Sarah Catherine Daniels, a 43-year-old mother of three, died from metastatic cancer in April 2025 following a nine-month delay in receiving pathology test results that prevented her from accessing potentially life-extending treatment sooner, an inquest has concluded. She passed away at her home on Wayne Street in Porth, Rhondda Cynon Taf, surrounded by family members. Coroner Rachel Knight found the delay in the pathology department "unacceptable" and determined it reduced the likelihood of successful chemotherapy.
The inquest hearing, held at Pontypridd Coroners' Court, examined how a mass discovered on Sarah's ovary in October 2021 was not definitively diagnosed as cancer until November 2022—a gap of nine months during which she remained unaware of her condition's true nature and did not receive appropriate oncological care.
How did Sarah's cancer go undetected for so long?
Sarah first consulted her general practitioner in October 2021 at age 39 with concerning gynaecological symptoms. Her doctor escalated the matter, leading to an ultrasound scan on 21 October 2021 that revealed a mass on one of her ovaries. She was subsequently referred to the gynaecology department at Cwm Taf Morgannwg University Health Board.
Presented with two surgical options—a total hysterectomy or a less invasive procedure to remove only the mass—Sarah chose the latter to avoid the early menopause and other complications that would have accompanied the more extensive operation. In February 2022, the mass was surgically removed. Although it did not display the typical appearance of cancer, tissue samples were sent to the pathology department for microscopic examination.
The pathology department was severely backlogged at that time. Martin Ludlam, a biomedical scientist who served as cellular pathology and mortuary service manager at the health board, explained to the inquest that workload had surged dramatically during late 2021 and 2022 as routine appointments postponed during the Covid-19 pandemic resumed. The department lacked sufficient capacity to manage both current demand and the accumulated backlog. By the end of 2022, the health board had begun outsourcing work to reduce the backlog, a practice that continued at the time of the inquest.
Coroner Knight acknowledged that initial aspects of Sarah's care—her GP referral and an MRI scan conducted on 10 November 2021—had been handled appropriately. At that stage, there was "low suspicion" of cancer, and it was "reasonable" that clinicians did not request a wider abdominal MRI that might have detected the appendix cancer. The coroner also found that the mass's appearance did not suggest malignancy and that sending samples to pathology was the correct procedure.
What did the pathology results eventually reveal?
When Sarah finally received her pathology results in November 2022, she was informed that her condition was terminal with an expected survival of approximately 12 months. The diagnosis was metastatic signet ring adenocarcinoma of the appendix—a rare and aggressive cancer that had already progressed to stage four by the time of her initial GP visit in October 2021.
Mohamed Khalifa, a consultant in obstetrics and gynaecology who leads gynaecological cancer multidisciplinary team meetings for the health board, testified about the significance of the nine-month delay. He stated that Sarah had lost critical time in her cancer treatment and that her Risk of Malignancy Index (RMI) score had been "incorrectly reassuring" to both her and her family.
When she died might have been different if the chemotherapy or other treatment had been started sooner. The delay of [nine] months between surgery and histology was unacceptable,he told the inquest.
What treatment did Sarah pursue after diagnosis?
Upon learning her diagnosis was terminal, Sarah demonstrated remarkable determination to fight her illness. Her husband, Ben, provided written evidence describing how she sought private treatment at the Christie cancer treatment centre in Manchester, which included surgical removal of her appendix. She subsequently received follow-up care at Velindre Cancer Centre in Cardiff, undergoing 10 rounds of chemotherapy and multiple scans.
Initially, the treatment appeared successful and Sarah received an all-clear result. However, several months later, scans revealed the cancer had returned. This time, her blood markers frequently fell outside the safe range required for regular chemotherapy, meaning her treatment became sporadic and inconsistent. Ben described how his wife "never gave up" in her battle against the disease, but by January 2025, her health had deteriorated progressively.
Dr Kein Yim, a consultant in clinical oncology at Velindre, determined in March 2025 that Sarah's condition was declining rapidly and that she had become too frail to tolerate further chemotherapy. Sarah died at home on 15 April 2025, surrounded by loved ones.
What did the coroner conclude about the delay's impact?
Coroner Knight found that the pathology department had been "completely overwhelmed by demand" due to staffing shortages and the massive backlog created by the Covid-19 pandemic and its aftermath. While she noted that the health board had begun outsourcing and had established a better framework, she stated there had been no comprehensive "overhaul" of the system at the time of the inquest.
Knight determined that the nine-month interval between Sarah's surgery and the receipt of her pathology results was "unacceptable." She found that Sarah had been living with stage four cancer since October 2021, and that the diagnostic delay had likely compromised her treatment options, quality of life, and life expectancy. Critically, she concluded that the delay reduced the probability of successful cancer control through chemotherapy.
The coroner recorded Sarah's medical cause of death as metastatic signet ring adenocarcinoma of the appendix, which was a naturally occurring condition. However, Knight opted for a narrative conclusion rather than a simple natural-cause finding to reflect the full circumstances surrounding Sarah's death. According to reporting on the inquest outcome, the narrative conclusion allowed the coroner to document how the pathology delay had contributed to the trajectory of her illness.
Addressing Ben and their children, Knight expressed her condolences:
I'm sorry you lost Sarah in the way you did. You have shown great dignity throughout the proceedings... What you went though must have been horrendous.She added,
it is clear how loved Sarah was and how missed she is.
What is the broader context of pathology backlogs in Wales?
Sarah's case emerged from a wider crisis in diagnostic services across Wales. According to health board records from November 2022, Cwm Taf Morgannwg University Health Board had already begun using outsourcing to clear its cellular pathology backlog, demonstrating the scale of post-pandemic diagnostic pressure. The Welsh Government acknowledged in March 2023 that the backlog at Cwm Taf Morgannwg remained "too high" even after some reduction, with 618 patients still waiting at that point.
Martin Ludlam told the inquest that the health board's experience had reinforced a critical lesson:
This case has highlighted the case that we can never go back to a position where we have a routine backlog again.
Key Facts
- Sarah Catherine Daniels was 43 when she died in April 2025, nearly four years after her initial GP consultation in October 2021.
- A nine-month delay between her February 2022 surgery and November 2022 pathology results prevented timely diagnosis and treatment of metastatic appendix cancer.
- The pathology department was severely backlogged due to Covid-19 pandemic effects, including staffing shortages and deferred routine work.
- Coroner Rachel Knight found the delay "unacceptable" and concluded it reduced the likelihood of successful chemotherapy and affected Sarah's quality and length of life.
- The coroner returned a narrative conclusion to document the full circumstances of Sarah's death, rather than a simple natural-cause finding.
