The tragic death of a 'great mum' just weeks after a terminal skin cancer diagnosis and the 'missed opportunities' to help her

Katie Cooper was 32 years old when she died on June 9, just weeks after discovering that the skin cancer she had previously fought had returned and her prognosis was terminal.

She was survived by her husband Daniel Cooper and their young daughter.

An inquest at Bolton Coroner’s Court heard Katie was diagnosed with metastatic malignant melanoma at Wigan Infirmary on April 27 and it was already “widespread” in her body.

But coroner Michael Pemberton said there were "missed opportunities” by staff at Kumar Family Practice, in Worsley Mesnes, when Katie had appointments there.

Speaking after the inquest, Daniel said: “She was fantastic. She was a great mum – that was everything she wanted to be. She was a good wife too.

"She was a friend to everyone. When she was in hospital, she was reaching out to her friends to see if they were alright. That summed her up really. She always went above and beyond for everyone.”

The court heard Katie, a civil servant from Goose Green, was first diagnosed with melanoma after finding a mole on her neck in 2018.

She had surgery to remove it, but in 2021 – a week before her daughter was born – Katie found a lump on her neck where the mole had been.

She again had surgery, followed by radiotherapy and targeted therapy at Clatterbridge Cancer Centre in Liverpool throughout 2022.

Katie then had regular scans – known as “high risk surveillance” – initially every three months and then every six, to check in case the cancer returned.

But the court heard she missed scans, including two when she informed the hospital she could not get there due to a broken bone in September 2024, and she was discharged from the service.

Letters were sent to Katie’s GP at Kumar Family Practice informing them of missed appointments, followed by one in October 2024 saying she had been discharged.

They were asked to contact Katie about resuming the scans and told she could email a secretary on the plastic surgery team to make arrangements.

Dr Michael Feeney, who appeared in court on behalf of Dr Ahmed Salem, said Katie was contacted by the practice and she said she would do so.

Katie saw a first contact practitioner – a physiotherapist – at the surgery on March 3 with back pain after twisting while putting her daughter into a car.

She was examined and it was thought to be muscular pain or a spasm, so she was given exercises and advised to request stronger pain relief from a GP. Dr Salem had a telephone appointment with Katie later that day and prescribed codeine.

Mr Pemberton questioned that while medical notes mentioned Katie’s history of melanoma, no concerns about it were raised and the missed scans were not highlighted.

Katie contacted the practice on April 8 asking for a referral back to the plastic surgery team for scans, which was done by Dr Feeney.

She then saw a GP on April 15 with nausea, vomiting and diarrhea, which was thought to be gastroenteritis.

She returned on April 22 after three weeks of nausea, fatigue and loss of appetite and it was considered the gastroenteritis was resolving.

An urgent blood test was requested and she was advised to monitor weight loss and look out for any suspicious lumps or skin lesions. The test results did not raise any serious concerns, the court heard.

Katie went to Wigan Infirmary’s A&E department on April 27 as the pain in her back was getting worse, she had lost weight, was not eating and felt nauseous.

Scans showed she had metastatic melanoma, which was “widespread”, including in her liver, lungs, bones and ovaries. She had impending spinal cord compression and a fracture in her spine.

She was admitted to the hospital for treatment before being transferred to Clatterbridge Cancer Centre on May 14 for palliative care, which included radiotherapy to her spine and immunotherapy.

Dr Shobha Silva, medical oncologist, was asked whether it was possible to say how quickly the cancer had spread, particularly as an ultrasound scan of her uterus and ovaries in December did not show any signs, but she said it varied with every patient and the cancer.

Katie’s health deteriorated and she was transferred to Royal Liverpool University Hospital on June 8.

She was “extremely ill” and in “profound multiple organ failure”, Dr Simon Rogers said.

Despite treatment, Katie died on June 9.

A post-mortem examination was carried out by Dr Patrick Waugh, who recorded Katie’s medical cause of death as metastatic melanoma and its treatment.

She had damage to her lungs – known as shock lung – caused by her body’s response to immunotherapy (hemophagocytic lymphohistiocytosis).

This was a “recognised complication” of the drugs, Dr Waugh said, and led to her going into respiratory depression, which led to her death.

The court heard a learning event at Kumar Family Practice after Katie’s death highlighted she could have been contacted sooner about missed appointments and that GPs should be on “constant high alert” with patients with multiple site symptoms and a history of melanoma.

Concluding the hearing, Mr Pemberton said he was “satisfied” that Katie being discharged after missing scans was “communicated appropriately” and she had the opportunity to resume them.

But regarding the medical appointments on March 3 and April 15, he said: “In my judgement, these were missed opportunities to consider the relevance of any cancer concern given the previous history and the missed scans that the surgery were aware of.”

However, he could not say if there was anything that could have changed the outcome.

Mr Pemberton recorded a narrative conclusion that Katie “died as a consequence of a combination of naturally occurring disease and a recognised complication of its necessary treatment”.