Dr Kein Yim, a consultant in clinical oncology at Velindre said that in March 2025 it was clear that her condition was declining and a decision was made that she was too frail for any more chemotherapy.
Sarah died at home in Porth on 15 April 2025, surrounded by loved ones.
Mohamed Khalifa, a consultant in obstetrics and gynaecology who leads gynaecological cancer multidisciplinary team (MDT) meetings for the Cwm Taf health board, gave evidence about the significance of the nine month pathology delay in Sarah’s case.
He said that Sarah had lost time in her cancer treatment due to the delay between surgery and histology. He also said her Risk of Malignancy Index (RMI) had been “incorrectly reassuring” to 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 said.
Knight told the inquest that initial aspects of Sarah’s care were dealt with in appropriate time, including her initial GP referral and her MRI scan on November 10.
The coroner said there was “low suspicion” that Sarah had cancer at that stage and that it was “reasonable” that medics did not seek an MRI scan of a wider area like her entire abdomen which may have revealed her appendix cancer.
She said evidence corroborated that the mass did not have the appearance of cancer, and that samples were sent “appropriately” to pathology for testing.
However, she noted that the pathology department was “completely overwhelmed by demand” due to pre and post-Covid factors including staffing and a huge backlog.
Drawing on evidence she stated that the department had begun outsourcing its backlog, but that this was in its infancy. At present she said there had been no “overhaul” of the system, but that a better framework had been established by the health board.
She said she found the nine month delay between Sarah’s surgery and result “unacceptable”, and noted that the issue was accepted by the health board. She said that Sarah had been living with stage four cancer since October 2021, and that the delay likely impacted her treatment as well as her quality and length of life.
She said the delay reduced the chance of success in cancer control through chemotherapy.
Sarah’s medical cause of death was recorded as “metastatic signet ring adenocarcinoma of the appendix”.
Although Knight noted that the medical cause of death was “naturally occurring”, she opted for a narrative conclusion to reflect the full circumstances of Sarah’s death.
Knight apologised to Ben and their children: “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”.