A mother died after her referral for urgent medical treatment was left in a doctor’s pigeonhole by medical staff for a month.

An inquest heard how Maria Shafighian, 59, missed potential treatment after a letter for referral was put in a pigeonhole for internal mail.

At the inquest, the coroner heard how the letter from speech and language therapists (SALT) was left unread for a month by the Ear, Nose, and Throat (ENT) department.

Just six months later, Maria, from Caerphilly, Wales, died from throat cancer.

Following her death and an inquest, senior coroner Caroline Saunders ordered a prevention of future deaths report.

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The inquest found that while Maria died from natural causes opportunities had been “missed to identify and treat” her tumour earlier.

WalesOnline reported that after suffering from “persistent hoarseness”, Maria was initially diagnosed with vocal cord palsy after laryngeal cancer had been ruled by a specialist ENT trainee during a CT scan.

As her condition deteriorated, she started to have problems swallowing and an urgent assessment request was made.

She was initially referred to the speech and language department before having a video consultation in April 2020.

When the SALT team found Maria was having difficulty swallowing, they referred her for an urgent assessment.

The referral was later printed out and left in the ENT pigeonhole where it was left for a month.

Senior coroner Ms Saunders said: “During the inquest, I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system.

“Following assessment by SALT on May 4, 2020, a letter was written to the ENT team which was printed and left in a pigeonhole.”

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Ms Saunders added: “No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner.

“In Maria’s case, there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team.”

Maria was later diagnosed with oesophageal cancer and received palliative radiotherapy and chemotherapy.

She was not considered a candidate for surgical intervention and died in November 2020. At the inquest, Ms Saunders said opportunities had been missed to treat her.

Ms Saunders said: “In the inquest, I determined that there had been opportunities missed to identify and treat Maria’s tumour earlier but I could not determine on balance that this would have altered the outcome and hence the conclusion was death by natural causes.”

Speaking to Aneurin Bevan University Health Board, Ms Saunders added: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.”

In their response, the CEO of the health board, Ms Nicola Prygodzicz said the hospital has now developed an electronic referral form to try and prevent further tragedies.

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