A coroner is to write to the Health Minister following the death of a Jersey man who was “lost in the system” and left waiting 15 weeks to be told his cancer had returned.
Deputy Viscount Matt Berry said he would issue a prevention of future deaths report, warning that “insufficient personnel and inadequate systems” meant Victor ‘Vic’ Tinley was not informed of his diagnosis or treated promptly.
Mr Tinley, an 84-year-old keen sailor and much-loved family man, died at Jersey Hospice on 6 January 2025 from high-grade B-cell lymphoma.
An inquest into his death held at Morier House yesterday heard that a biopsy confirmed the return of his cancer in early January 2024, with a CT scan on 24 January identifying multiple tumours, including a large pelvic mass.
Despite this, he was not told his cancer had returned until mid-May.
“Just dumbfounded”
During that period, dermatology, haematology and his GP were all aware of the diagnosis, but none informed him.
His wife, Cherrie Tinley, told the inquest the family were “just dumbfounded” when they finally found out.
The coroner found that around 15 weeks passed between the scan confirming the cancer’s return and Mr Tinley being told, with further delays before treatment began.
While earlier treatment may not have saved his life, it could have reduced the severity of his symptoms and improved his quality of life, the Deputy Viscount said.
“Systemic” failings
A serious incident report identified “systemic” failures, including fragmented records, a lack of oversight and no safety-net systems to track results when clinicians left. Nearly five months of potential treatment time were lost.
Mrs Tinley said there had been multiple missed opportunities to inform her husband, adding: “Nobody would actually talk to us or see him.”
The coroner said his report would focus on how medical records are processed and shared, warning of the risk of similar failures in future.