An investigation by England’s Health Ombudsman following the death of a 67-year-old woman has triggered a systemic review of cancer treatment and diagnosis wait times at Mid and South Essex NHS Foundation Trust.

The Parliamentary and Health Service Ombudsman (PHSO) recently investigated the care of Mrs S who was treated at Broomfield Hospital, run by the Trust, in 2023.

The retired history teacher and mother-of-two from Chelmsford, had terminal ovarian cancer and died in April that year. Her son, who was 29 when his mother died, raised concerns about her care. PHSO’s subsequent investigation found there had been a delay in diagnosing and treating his mother’s cancer.

Mrs S’s diagnosis took 49 days and her treatment did not start for 81 days after the referral. NHS England targets at the time were for cancer to be diagnosed within 28 days of referral and treatment to begin within 62 days. After her son complained about his mother’s treatment, the Trust said that it had improved its performance on cancer wait times. However, PHSO’s investigation found the Trust’s performance against its treatment targets had declined.

In 2023, at the time Mrs S was being treated, the Trust failed to meet all of the NHS England cancer wait time targets. Only 47.6% of patients were treated within 62 days, compared to the national target of 85%. By July 2025, that had dropped to 46.1%. Trust figures show that at the end of August, 664 patients were waiting longer than 62 days to confirm a cancer diagnosis, or rule it out, and begin treatment.

Following its investigation, PHSO took the unusual step of asking the Trust to systemically review its performance against national cancer wait time targets, and develop a robust plan to help it meet treatment targets. 

The action plan has been received and the Trust has committed to look at how it can better allocate resources and increase capacity to reduce wait times. The Trust will use new technology to improve efficiency by standardising and digitising processes, and specialist software to analyse cancer pathways and identify delays.

The Trust will also hold weekly meetings to track progress and ensure the longest waiting patients are prioritised and implement a one-stop menopausal bleeding clinic which will offers scans and a consultant review at the first appointment to help with timely diagnosis.

Paula Sussex, Parliamentary and Health Service Ombudsman, said, 

Every day, hundreds of people receive a diagnosis of cancer. It is vital that they can trust in the system to deliver the quality treatment they need for their survival, recovery, or, in terminal conditions, to allow them to spend precious time with loved ones.

 

“Learning from past failings and continually improving services should be the lifeblood of the NHS. I am aware that the Trust has faced organisational challenges that exacerbated pressures brought by the pandemic, and they have worked to find an effective operating model, including leadership changes and a new programme to better listen to frontline voices. 

 

“In this case, we recommended that the Trust should investigate its performance against national targets and make a robust plan for how it will improve. The Trust has committed to carrying out this work and will be rolling out new technology to help it allocate resources more efficiently and increase capacity for cancer appointments. 

 

“While this will sadly not change what happened in this case, it highlights how one complaint can make a difference. Because of this investigation, other patients and families should experience wait times that are in line with national guidance.”

Mrs S visited her GP in January 2023 as she had uncomfortable abdominal bloating. After receiving concerning blood test results, the GP referred her to the Trust. 

A CT scan on 16 February showed the presence of cancer but clinicians could not identify the type of cancer until a biopsy on 15 March. Mrs S was diagnosed with ovarian cancer on 21 March. She was told that while it was not survivable, chemotherapy may extend her life.

Chemotherapy was scheduled for 21 April but due to the delays in diagnosis and treatment, Mrs S was no longer fit for the treatment. This meant she lost the opportunity to engage in chemotherapy, and her family will never know whether or not this could have improved her quality of life or extended her life to give her more time with her family. This is a serious injustice to them.

PHSO found that had the Trust met the national cancer standard for referral to treatment, Mrs S’s palliative care should have begun on or before 3 April. At that point, her medical records indicate that she would have been fit for treatment. 

When the Trust told her that her cancer was not survivable, it should have considered starting a palliative care pathway. There is no evidence this happened and there was no coordination of her palliative care between the hospital and the hospice, delaying her access to this care.

The Ombudsman found further failings in care including delays draining her ascites (fluid build up in the abdomen) which caused avoidable distress. 

The Trust also unsafely discharged Mrs S from hospital on 18 April. She was readmitted three days later in a serious condition. She died the next day.

PHSO found the failings by the Trust caused distress to Mrs S and her family. The Trust had not acknowledged the extent of its failings or taken appropriate action to address them.

Along with the cancer wait times review, PHSO recommended the Trust create an action plan detailing how it will improve its discharge planning, palliative care planning, and communication between staff and patients approaching the end of their life. The Trust was also told to apologise to her family. The Trust has complied.

Mrs S’s son described his mother as someone who was heavily involved in the local community. She sang in two local choirs, played tennis twice a week and volunteered teaching English to female refugees in Chelmsford.

Her son, a 31-year-old chartered surveyor, said, 

I had trust in the NHS, so whenever they told us things, like scans, would happen we believed them. But it was just delay after delay. My mother and I kept asking questions and for updates but never got anywhere and the whole situation was just confusing and frustrating.

 

“There was clearly something wrong with my mum and we had a feeling it could be cancer, but we needed a diagnosis and this took too long to get. After we finally had the diagnosis, we were almost relieved and we expected treatment to start straight away. But again, it took too long to confirm the chemotherapy date. 

 

“Then there were issues with my mum being unsafely discharged from hospital. I was basically just handed a bag of medication with no instructions, advice or support. My mum was incredibly weak during that time and I feel like that week where she came home and I was trying to look after her with no support took 10 years off my life. I still have nightmares about it.

 

“There was nothing that could be done for my mum because her cancer was terminal. But if she had received the care she should have had, then her quality of life would have improved and we may have had more time together.

 

"I’m grateful the Ombudsman provided the answers I couldn’t get from the Trust, I just want the Trust to be held to account. I don’t want another family to go through something like this.

 

"The service failures the Ombudsman has identified should be another driver for the Government to address substantial reforms required in the NHS. Time and time again, we hear politicians go on about reducing wait times but nothing seems to be improving on the ground. I cannot fault the frontline staff but there seems a general consensus around the country that without a substantial shake-up by policymakers, the quality of NHS care will continue to decline.”

Dawn Scrafield, Chief Executive of Mid and South Essex NHS Foundation Trust, said:

We know that waiting for cancer diagnosis and treatment is a worrying time and we offer sincere apologies to Mrs S’s family for the delay in her treatment. Demand has increased, and we are reviewing how we manage the need for more diagnostic services. We have begun an integrated improvement plan, working with our health and care system partners to speed up treatment times and get patients to the right place at the right time.

 

“We have invested in new technologies to help us treat cancer faster and have recently opened new a Community Diagnostic Centre in Thurrock, which is improving access to scans and diagnostic tests.

 

 “Cancer care is one of our key priorities, and we can already see our wait times reducing in some cancers as we deliver extra clinics and theatre scheduling.”