Failings led to delay in cancer treatment - inquest

Systemic failings in information sharing across Jersey's healthcare system led to "neglectful" and "distressing" delays to the treatment of a cancer patient, an inquest has heard.

Victor Tinley, 84, died from a relapse of lymphoma (blood cancer) in Jersey Hospice in January 2025.

The inquest heard there was a four-month delay between his cancer being found and him being informed of his diagnosis, and while earlier treatment may not have saved Tinley's life, it could have improved the quality of it.

Dr John McInerney from Health and Care Jersey said changes had been made following Tinley's death, but there were still areas where "we need to do much better".

The inquest heard Tinley had been in remission from a lymphoma that was found in 2017, but a biopsy on a lesion on his leg in December 2023 showed it had returned.

He underwent a CT scan in January 2024.

The coroner, Deputy Viscount Matt Berry, said the cancer had spread, including a mass in Tinley's pelvis.

He said that his GP surgery and the haematology and dermatology departments at Jersey General Hospital were all informed.

However, Tinley and his wife were not told until an annual oncology check-up in May 2024, and he did not start comprehensive treatment until July 2024.

Advocate Berry said clinical staff failing to take ownership of patients was a "theme" in the case, and Tinley had got "lost in the system".

He identified "significant challenges" with different healthcare systems talking to each other and with record-keeping.

He said he would write to the health minister to recommend further work on the organisation of medical records in Jersey to prevent future deaths.

Professor of Pathology at Southampton University, William Roche, who completed an independent review of Tinley's care, told the inquest that the time and manner of Tinley's death were "contributed to by neglectful delays".

"Failure to control the tumour early on is likely to have given rise to very distressing complications," he added.

He said he had previously raised concerns about Jersey's lack of a clear, accessible medical record system, which posed a "very significant risk" to patients.

In a statement, Tinley's wife, Cherrie, said losing her husband had left a "deep and lasting void" in her life, and she had made a formal complaint to the health department.

She said it was "devastating" to find out about the delay in them being told about his cancer, which "stole precious time" and "shaped his illness in a way that could not be undone".

A health department serious incident report concluded that the underlying cause of the delay was "systemic".

Detailing the lack of a standard system for managing blood cancer patients, an out-of-date and underused cancer patient tracking system, inconsistent communication across health departments and staffing issues, meaning key clinicians were missing from treatment conversations.

It said the hospital's haematology department was run by consultants working on a short-term basis, and the consultant who conducted Tinley's CT scan resigned the next day, with no system in place for responsibility for the results to be transferred.

McInerney, who is the deputy medical director, apologised to Tinley's family.

"There were so many missed opportunities to tell you what was happening," he said.

He accepted Roche's findings and the serious incident review and said the department had made "some progress" on their recommendations.

He told the inquest there were still ongoing issues with staffing and the patient record systems.

"Ideally, we'd have one patient care record for the whole island," he said.

In a statement, a Health and Care Jersey spokesperson said: "I would like to extend my sincere condolences to Mr Tinley's family at this difficult time."

It said work was beginning on a Shared Care Record, accessible to GPs, hospitals, community and mental health teams and social services.

"This will enable faster clinical decisions, fewer gaps in a patient's medical history and less repetition for patients and families," it said.

It added that cancer care at Jersey General Hospital had been digitalised since 2024, allowing specialists to access up-to-date patient records and to communicate more effectively about treatment plans.

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