Coroner highlights missed opportunity to diagnose retired NHS doctor’s fatal cancer

Dr Adegbenle Adegbenro, a former NHS orthopaedic surgeon and A&E consultant, died on 17 October 2023 aged 73 having been diagnosed with a cancer termed gastrointestinal stromal tumour, several weeks previously. 

An inquest into Dr Adegbenro’s death was held over two days in January 2025 at Poplar Coroner’s Court, with the inquest conclusion held Friday 7 March. 

HM Assistant Coroner Melanie Lee found that the decision not to keep Dr Adegbenro under surveillance and not follow him up in 2021 was a missed opportunity to identify the cancer earlier. 

Dr Adegbenro had been investigated for symptoms of suspected cancer in 2020 and 2021. Scans at the time showed evidence of a lesion in the stomach and a biopsy was taken. It was not possible to make a definitive diagnosis on the basis of the investigations that were undertaken but Dr Adegbenro was discharged without a plan for follow up. 

Dr Adegbenro, who previously worked at Broomfield Hospital and had worked as a locum doctor at King’s College Hospital in the past, was admitted to Coptcoat Ward at King's College Hospital on 15 September 2023 with serious symptoms due to cancer, over two years after he was discharged from the Upper GI Cancer Pathway at the same hospital. A large mass in the stomach was found on admission. Dr Adegbenro was unable to maintain adequate oral nutrition, his  condition deteriorated, and he suffered gastric perforation leading to localised sepsis and death.  

Dr Adegbenro and his family, from London, raised concerns during the hospital admission and the inquest over alleged delays in diagnosis of the cancer. They  also raised concerns about the treatment that Dr Adegbenro received when he was admitted to King’s College Hospital in 2023 upon diagnosis of the cancer.   

Dr Adegbenro’s children said: 

“Our father gave over four decades of his life to the NHS, the very institution that we feel failed him in his most serious time of need.  

“In our view, discharging our father in 2021, without any plan for follow-up eventually led to his untimely death in 2023. Gastro Intestinal Stromal Tumours are rare, but curable cancers, if caught early enough. We feel our father was denied the opportunity for treatment and that he would still be with us today if he had been followed up. He had been seeking to return to NHS work in some capacity”.   

“The purpose of the coroner’s inquest was to establish the facts surrounding his death and give dad a voice. We hope it works to bring about change to prevent other individuals and families suffering similar injustice. However, we as the family feel that both dad and we have been let down by the coronial service as it has sadly become apparent that limited funding, lack of resources and pressures on the system often dictates the level of investigation and inevitably the outcome. We are very thankful to the team at Leigh Day and our barrister who have been with us through the process and helped us to navigate the system and gain some answers.”  

Dr Adegbenro’s family is represented by Ceilidh Robertson, medical negligence solicitor at law firm Leigh Day.   

Ceilidh Robertson said:  

“It is hugely concerning that Dr Adegbenro was not kept under surveillance and followed up by King’s College Hospital. He was a man in good health and had much, much more to contribute.”