Mother, 44 died of cancer after preventable delays in her diagnosis.

A mother of five died of endometrial cancer hours after being admitted to A&E following preventable delays in her diagnosis.

An inquest was told that a private clinic identified the cancer by ultrasound, but the report was never sent to her GP.

Kerri Mothersole, 44, from Swale in Kent, had a complex medical history including decades of depression and chronic back pain.

Her son, Jordan Dighton, 21, said: “My mum should have been taken more seriously. If she were, maybe she’d still be alive.”

In May 2020 Mothersole presented with symptoms of early menopause. Blood tests showed that she had low iron levels and her symptoms persisted. In March 2021 she told her GP at Green Porch Medical Centre that she had had vaginal bleeding for six weeks.

She could not attend her ultrasound appointments because she was the family’s only driver and was removed from the waiting list despite rescheduling two appointments.

In June 2020 her GP referred her for an NHS scan at HEM Clinical Ultrasound Service, Sittingbourne. A radiographer, who was new to the private clinic, found a suspected ovarian mass. 

However, the clinical lead deemed the scan results inaccurate, so they were never returned to the GP. Instead, Kerri Mothersole was asked to attend a second pelvic and abdominal scan. She was losing weight and in persistent pain. 

A second ultrasound suggested a diagnosis of adenomyosis, a condition where the lining of the womb starts growing into the muscle in the wall of the womb, but the scan report said: “more serious pathology couldn’t be ruled out.”

Kerri Mothersole received a referral to gynaecology, but the GP had made another referral to a colorectal team to treat colon and stomach cancers at the NHS Kent and Medway Cancer Alliance on the urgent two-week waiting list. 

Despite her symptoms being gynaecological, she underwent what turned out to be a clear colonoscopy. According to the coroner, had the first scan report been seen this would have led to an urgent referral to gynaecology.

Jordan Dighton, a law student at the University of Kent, took on an advocacy role and managed his mother’s declining health. He told The Times: “The system was so siloed, and her case was passed around from department to department. It’s only after her death that we’ve started to make sense of what pathways she should have been on.”

A large mass in her pelvis was eventually confirmed during a CT scan, and Kerri  Mothersole was referred to the multidisciplinary team at the Medway Maritime Hospital. John Dighton and his stepfather allegedly discussed the possibility of cancer with the secretary of the multidisciplinary team but were assured it was probably a benign fibroid. 

An appointment was booked to see a gynaecologist, but the family never received the letter. After being transferred to Maidstone Hospital, a hysterectomy to remove Mothersole’s uterus was booked. 

On the day of her surgery Kerri Mothersole was admitted to A&E, where she remained under the care of oncology until she was discharged home to the care of hospice nurses. 

During end-of-life care the GP is alleged to have erroneously prescribed double the amount of morphine she should have received. The inquest heard that the pharmacist spotted the mistake and refused to release the medication until it had been amended. 

John Dighton added: “We submitted the prescription to the inquest because I wanted to highlight the systemic failings. Her partner spoke with the GP and the replacement prescription was resolved over the phone.”

This error was not considered at the inquest. The GP has not commented, citing patient confidentiality. 

On the afternoon of August 19, 2022, Kerri Mothersole was admitted by ambulance to Medway Maritime Hospital, where she had a scan and was told she had two weeks to live. “We all thought she was coming home,” John Dighton said. 

Kerri Mothersole had developed brain metastasis and died at 2am the following day. In January 2024 an inquest ruled that her death was preventable and that she died due to a delay in diagnosis. It found that neither of her ultrasound reports had been uploaded to her clinical notes at Medway Maritime Hospital or Maidstone Hospital. 

A spokesperson for the Green Porch Medical Centre said: “We wish to pass on our deepest condolences and deepest sympathies to the family and friends of Mrs Mothersole. 

“The practice gave evidence as part of the inquest hearing in the coroner’s court, the outcome of which is available in the public domain; however, we are unable to comment further because of our duty of patient confidentiality.”

A spokesperson for the NHS in Kent and Medway said: “We would like to offer our condolences to Ms Mothersole’s family. We are committed to learning and have put steps in place to improve the system for how ultrasound scans are reported back to GP practices.”