A CORONER has slammed the health service after a “catalogue of errors” contributed to a woman’s death in Hereford County Hospital.

Stella Baker died aged 42 after doctors failed to spot a cancer which caused the infection that killed her, an inquest was told on Tuesday.

Herefordshire’s deputy coroner Mark Bricknell said she was “badly let down by the system” and called delays in her treatment excessive and ridiculous.

Miss Baker, of Bromley Road, Ludlow, visited Station Drive Surgery in the town on November 16, 2006, with a number of complaints including diarrhoea and rectal bleeding. She was diagnosed with irritable bowel syndrome.

Miss Baker returned on December 18 with similar symptoms and, on January 3, 2007, was referred to Hereford County Hospital.

Dr Caron Morton, a partner at the Station Drive Surgery, told the inquest that rectal bleeding was not seen in irritable bowel syndrome and should have alerted the previous doctor to other possibilities.

The inquest heard that: ● Clare Cheek, a consultant surgeon at the county hospital specialising in colorectal surgery, saw Miss Baker on March 28 and found a large rectal cancer “the size of a tangerine”.

● On April 16 Miss Baker was brought into hospital by ambulance with a swollen right leg and suffering from shortness of breath.

The cancer had also caused the death of skin tissue.

● Miss Baker’s condition deteriorated and on April 18 doctors decided the only way she was going to survive would be to remove her leg, but they felt further surgery would reduce her quality of life and delay cancer treatment.

With the permission of Miss Baker’s family, treatment was withheld and she died that evening.

Forensic pathologist Edmund Tapp told the inquest the tumour had caused organisms, which were “innocuous” in the intestine, to get out and cause infection, which damaged the skin tissue.

He gave necrotising fasciitis as the cause of death.

Expert witness Brian Donkin, a police surgeon, gave evidence that the hospital “failed in its duty” to pick up on a malignant carcinoma.

“The system in Hereford failed this patient. It is unacceptable to have a malignancy without being seen,” he said Recording a verdict of death by natural causes, Mr Bricknell said there had been a catalogue of “significant and disturbing”

delays in the treatment of Miss Baker.

He said the referral by the general practice was slow and that by December 18 there was sufficient evidence of a possible carcinoma to have secured a hospital appointment within two weeks.

Mr Bricknell said he had not been given a satisfactory explanation by the hospital about why the referral, dated January 3, was not dealt with until January 16, and why a letter from Miss Cheek, asking to bring forward the date of Miss Baker’s appointment, was not actioned for upwards of 12 days.

“A catalogue of errors caused a delay in this lady’s treatment which was excessive and ridiculous. The system let her down,”

said Mr Bricknell.

* HEREFORD Hospital Trust said after the inquest that it was extremely sorry about the death of Miss Baker and confirmed it had made significant improvement in the booking process for cancer patients since her death.

Improvements, the Trust said in a statement to the Hereford Times, included: ● A complete restructuring of the supervisory arrangements for booking cancer patients.

● Improvements in procedures.

● The implementation of a full direct booking system which allows the GP or patient to directly book an appointment at the hospital via the internet or by making a phone call.

The booking centre has also undergone an external audit review.

Martin Woodward, chief executive of Hereford Hospital Trust, said he was personally overseeing the improvements in the processes to ensure the unacceptable delays which occurred in Miss Baker’s death did not happen again.

He added that the trust had consistently complied with referral to treatment targets for cancer patients and also seen them reduce significantly over the last 12 months.