A “loving” and “caring” mum died from a cancer which could not be treated – but delays by a hospital trust impacted on her heartbroken family, an inquest has heard.
Elaine Steven passed away at her home on Gillies Street in Walker, Newcastle, after vomiting blood and losing consciousness. The 60-year-old was previously found to have a large, cancerous tumor near her liver.
An inquest into her death heard how she went to the Royal Victoria Infirmary (RVI) in Newcastle in June 2020 with stomach pain and constipation and she was transferred to specialists at the Freeman Hospital. Elaine was told she had cancer and she was unable to undergo surgery to remove the tumour.
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The hearing, sitting at Newcastle Coroner’s Court on Friday, heard how she was referred to the oncology department to see if she was able to undergo chemotherapy to prolong her life. However the referral was not picked up for 18 days.
Consultant Medical Oncologist Dr Jane Margetts dealt with Elaine’s referral, which had been sent on July 27, on August 14 and she allocated her an appointment for four weeks later.
During her follow up appointment on September 14, Elaine was told that her cancer was terminal and it would be too dangerous for her to undergo chemotherapy. She passed away after falling ill at her home de ella on October 3, 2020.
During her evidence, Dr Margetts said she worked part time and would look at her referral letters once a week. She said: “All cancer referrals are important and we try to see everyone in a timely manner. We can’t see everyone at once, I have to prioritize.”
She said Elaine’s referral wasn’t marked as urgent and she used the information available to her on the referral to make the decision. Dr Margetts told the inquest that two medical problems and an element of frailty meant that it would be difficult for her to have chemotherapy.
She said she also read that she had had a stroke and a number of other medical problems whilst in hospital. The consultant told the court: “If I had seen the disease’s progression on the CT scan I would have allocated it an urgent appointment, within two weeks.”
Dr Margetts said she thought Elaine was still in hospital when she received the referral – but she had already been discharged. She admitted that she could have found out the information.
The consultant told the inquest, at the Civic Center in Newcastle, how she has now made changes to the way she works. She said this includes being more careful when reading referrals, not trusting everything that is said and checking everything. Dr Margetts said: “If someone says they’re in hospital, I check if they are out rather than wait.”
Assistant Coroner Karin Welsh told Dr Margett: “It seems to me, please correct me if I’m wrong, that the chronology for Elaine certainly could have been far shorter and she could have been seen earlier than the 14th September. It wouldn’t have altered the situation, that you were never able to identify where this cancer had originated from.
Elaine’s family questioned why they were not informed about how serious her diagnoses were so they could make the most of their time together. Her daughter Vikki Carter, 35, told the coroner: “If they’d said: ‘In all honestly there’s nothing much we can do, there wasn’t a good option’ I would have had 98 days to spend with my mum – I got 15. That’s why I’m here today.”
The inquest heard how medics at the Freeman Hospital were unable to work out where the disease had originated from. Dr Margetts apologized to the family and told them that the conversations could have been had earlier as they didn’t have the information.
She said: “The CT scan actually showed this wasn’t coming directly from the liver but a nodal mass, a lymph node, a swollen gland near her liver. We couldn’t tell exactly where this was arising from. We weren’t positive what it was because of that, we still didn’t have a diagnosis, and understandably you’re all quite upset about that and I’m sorry, I completely understand why you’re angry and upset about that.”
Mr Gourab Sen, Consultant Hepatobiliary and Transplant Surgeon, also gave evidence to the inquest. He told the court how Elaine was unable to have surgery to remove the tumor due to it being close to a blood vessel. He said: “She did not have a surgical option.”
Mr Sen told the court how she was referred to the oncology department to see if she was able to undergo treatment. He said there was a “gap” in between the referral being sent by his team and the oncology department receiving it.
The consultant said a new procedure had now been brought in where by referrals are now sent to a generic email address for the oncology team rather than a named individual.
He said: “We send a generic one now. At that time, a name referral was being sent. I think there was a gap from the time the referral was sent and when the referral was actually received. I would have to say that is not the standard time we usually see.”
Dr Colin Saysell, Consultant Cellular Pathologist at the RVI, told the inquest, via video link, how he had carried out a post mortem examination and he was unable to identify where the cancer had started. He said the tumor was very large and had spread out into the tissue around the area and at some point a vessel had been compounded.
He said: “The tumor has eaten into it, the vessel has ruptured and Elaine was vomiting blood.” Dr Saysell found Elaine’s cause of death to be massive upper gastrointestinal haemorrhage due to bleeding from large portacaval carcinoma.
Assistant Coroner Welsh concluded that Elaine died as a result of natural causes. She said: “There’s certainly been opportunities where the chronology, the timetable for Elaine, could have been brought forward but my conclusion would be that that would not have altered the outcome of her from a medical point of view.
“However it may have altered what was happening with Elaine within the family. You as a family would have had the benefit of knowing that everything that was done was done in a timely manner.”
Following the inquest, a spokesperson for Newcastle upon Tyne Hospitals NHS Foundation trust said: “We are sorry for the loss experienced by Mrs Steven’s family and share our condolences at this very difficult time.
“The coroner has found there were elements of communication and information sharing which could have been handled differently during the three months she was under our care and for that we apologise. The coroner was also clear that none of these issues would have had an impact on the cause of death from cancer.”
Elaine’s husband Colin, 60, told Chronicle Live how they had been married for 36 years and they moved to Newcastle from Dunbar in Scotland in 2017 to be closer to their daughter Vikki. The fisherman said: “she She was always beautiful, she was too beautiful for me. I do n’t have a heart anymore because it’s been ripped out.”
Vikki, who is mum Elaine’s grandson Jamie, 10, said she used to refer to herself as “Oma”, which is German for Grandma. She said: “She never thought she was old enough to be a nana. She accepted Oma, it was the best she could cope with! She was loving and caring and she adored me and her grandson. She was beautiful and intelligent. She was always having fun.”
Vikki said she had to contact the hospital to chase up Elaine’s appointment due to the delay with the referral. She said: “I have got terrible guilt now. When she got out of hospital I should have been straight on the phone. If I had done could I have at least got more time with her?”
She said that two weeks after her mum died they were sent a copy of the referral in the post. Vikki said: “I asked the question, why were they sent to my mum two weeks after she died. They said ‘unfortunately it’s not possible to identify why the letters were sent’. So I think that was a whistle blower of some sort. “
Vikki has urged others to call up and ask questions if they feel treatment is taking too long. She added: “If you’ve got to change your procedures you admitting there’s a failure.”
Colin, who is devastated by his wife’s death, said he has lost faith in the trust all together. He said: “It can’t be changed and we didn’t do enough, we could have done so much more. I will never ever go near a doctor or a hospital from now until I die.”