“He wanted to make sure people were listened to”
The family of a Birmingham man who died after his cancer progressed during delays in his treatment say they remain “tormented” by what happened.
Ravinder Lally, from Sutton Coldfield, died at Good Hope Hospital on January 2.
An NHS patient safety investigation identified several failings in his care, including an inappropriate initial operation and delays in removing precancerous tissue.
A Birmingham coroner recorded a verdict of death by natural causes, due to rectal cancer and ulcerative colitis.
Ravinder had lived with ulcerative colitis for around 20 years before doctors identified precancerous changes in his rectum in 2023.
He was referred for surgery and underwent an operation in October 2023.
The procedure removed part of his bowel but left his rectum in place.
An NHS investigation later found this was not the correct choice in the circumstances. It said removing the rectum would normally have been expected given Ravinder’s condition.
The investigation did not conclude that treatment delays directly caused his death.
However, it found his condition progressed during the period before further surgery took place.
The coroner said delays may have contributed to Ravinder’s death but could not conclude that this was more likely than not.
Consultant colorectal surgeon Nuha Yassin told the inquest that the operation had been a shared decision between herself and Ravinder.
She said she had clearly explained the risks of leaving his rectum in place.
Yassin said she and Ravinder agreed that a three-stage operation was preferable at the time.
She accepted that her documentation could have been better but defended her clinical decision-making.
Another colorectal surgeon, Mr Tirumalaraju, reviewed Ravinder in April 2024.
He apologised for the delay and recommended that his rectum be removed.
He said earlier removal would likely have been beneficial.
He also recorded on the death certificate that treatment delays contributed to Ravinder’s death.
The NHS investigation found there was no robust contingency plan while Yassin was absent from the hospital between February and April 2024.
Dr Sarah Addison, who conducted the review, said a clearer clinic letter should have explained the available surgical options.
She said the trust had since introduced new guidance around clinic letters and other improvements.
Addison said she was confident lessons had been learned across the colorectal department.
The coroner also said clinic letters should clearly explain the risks, benefits and reasoning behind treatment decisions.
Ravinder underwent further surgery in May 2024, when cancer was confirmed.
The NHS investigation found his condition had progressed from precancerous dysplasia to advanced cancer between the operations.
Earlier treatment would likely have resulted in a less advanced stage of disease, according to the report.
Ravinder later underwent chemotherapy, radiotherapy and major surgery in London.
Despite treatment, his cancer spread, and he died in January.
His father, Satnam Lally, said the family remained disappointed following the inquest.
He said they believed Ravinder had not been given enough information about the risks involved with surgery.
Satnam said the family wanted wider improvements to clinical documentation and patient communication.
However, he said they took comfort from changes introduced by University Hospitals Birmingham.
He described his son as determined and optimistic throughout his illness.
Ravinder had planned to leave his job and campaign for patients before his condition worsened.
Satnam said: “He wanted to make sure people were listened to.”
He added that Ravinder wanted something positive to come from his experience.
University Hospitals Birmingham said it was saddened by Ravinder’s death and offered condolences to his family and friends.
The trust said it recognised that the family felt they had been let down.
It apologised for their loss and the distress they had experienced.
The trust said it would continue working with patients and families to improve the care it provides.
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