A BELOVED family man and keen sailor was left waiting 15 weeks before he found out that his cancer had returned following a series of “systemic” failures within Jersey’s Health Department.
The catalogue of failings were outlined during the inquest of Victor Charles Francis Tinley, held at Morier House yesterday, and prompted a coroner to conclude that a prevention of future deaths report focused on how medical records are processed and communicated should be presented to the Health Minister.
Mr Tinley, known to friends and family as Vic, died on 6 January 2025 at Jersey Hospice,
The inquest heard that the 84-year-old, who had completed two Atlantic crossings and at least 12 races around the Isle of Wight, as well as racing in San Sebastián and La Rochelle, had previously been treated for lymphoma following a diagnosis in 2017 and was in remission.
In January 2024, a biopsy found his lymphoma had returned – but Mr Tinley wasn’t told the result, only finding out on 18 May that he had cancer.
In the meantime, a CT scan – which Mr Tinley believe to be a routine test – had also identified lymphoma, but neither the patient nor his family were informed.
His wife, Cherrie Tinley, told the inquest they were “just dumbfounded” when they found out.
Recalling the words of a doctor, she told an inquest yesterday: “He said: ‘You know you have lymphoma.’ Vic said: ‘No, I’m in remission.’ [The doctor] said: ‘I’m sorry, you have lymphoma.'”
Even after the diagnosis was finally communicated, there were further delays of several weeks before his treatment began. By then, the inquest heard, Mr Tinley was extremely unwell.
Deputy Viscount Matt Berry, the presiding coroner, described Mr Tinley as having been “lost in the system”, adding that the case raised serious concerns about delays.
According to his wife, there were 11 missed opportunities to tell Mr Tinley that he had cancer.
“Nobody would actually talk to us or see him,” Mrs Tinley said.
Appearing at the inquest as an expert witness, Professor William Robert Roche, a professor emeritus at the University of Southampton, described the delays as “neglectful” and Health’s failures as “systemic”.
While recurring lymphoma “does have a poorer prognosis”, he said that treating it earlier would have spared Mr Tinley from significant pain and would have saved his family from very difficult caring duties at home.
Mrs Tinley described how, in the autumn of 2024, Mr Tinley was discharged and she was in charge of dressing a wound she described as “astronomical”.
While Professor Roche said he did not think that issues with wound management “directly contributed to the death”, he noted that they “would have caused enormous distress for him and anyone involved in his care”, adding: “This was a rapidly-growing tumour.”
A serious incident report put together by the Health Department and referred to during the inquest found that Mr Tinley had lost out on up to five months of potential treatment. The consultant who ordered the CT scan had left Health soon after, it noted.
Professor Roche said that Mr Tinley should have had a treatment plan in place by February, but that it only began at the start of July.
“It seems that multiple systems have failed simultaneously and that those failures were devastating in terms of the amount of delay,” the expert said.
“I think, reading the serious incident report, there seems to have been a failure not just of one safety mechanism but of multiple safety mechanisms and these appear to be systematic failures.
Patient records are spread between different systems, he said, with some departments using paper notes, and others using different IT systems.
Professor Roche said this made it difficult, even for a clinician, to piece together a patient’s journey. It was something he said he had flagged before, adding that “significant dangers arise” when there are multiple records.
As the serious incident report was read out, Mrs Tinley asked: “He didn’t stand a chance, did he?”
Deputy Medical Director Dr John McInerney said all healthcare systems had to grapple with these problems, adding: “Some are more advanced. We need to do much better.”
The department had made some improvements already, he said, for example by having more permanent staff in haematology and improving the way multi-disciplinary teams are run.
During the inquest, tributes were paid to a man who the Deputy Viscount said “clearly had a very full life andracing career and it seems a much-loved family as well”.
His family told the JEP that he was a much-loved husband, father, son, uncle, and brother, as well as a “an avid sailor, an adventurer, a fair and honest man”.
“We have all truly been affected by this huge ordeal,” they said.
A Health and Care Jersey spokesperson said following the inquest that they extended their “sincere condolences to Mr Tinley’s family at this difficult time”.
“As this matter relates to an inquest and individual care, it would not be appropriate for us to comment on the specifics of the case,” they said.
However, addressing Professor Roche’s critiques of the department’s record-keeping, the spokesperson added: “…Work is beginning on the procurement and implementation of a Shared Care Record which will bring together patients’ medical information into one secure place, that will be accessible by GPs, hospital clinicians, community teams, and mental health and adult social care.”
This, they said, “will enable faster clinical decisions, fewer gaps in a patient’s medical history and less repetition for patients and families”.
“In 2024 the Somerset Cancer Register was introduced to Health and Care Jersey. This is a digital registry that facilitates better coordination of care by allowing all involved specialists to access up-to-date patient records and communicate more effectively about treatment plans, and which will align cancer tracking processes and care with UK best practice. We continued to improve and modernise the system, so it keeps pace with current best practice,” the spokesperson concluded.
