The death of a "loving" mum-of-five could have been prevented if her cancer diagnosis had not been delayed, a coroner has ruled.

An investigation following Kerri Mothersole’s death revealed results from an ultrasound clinic were not provided to any of her treating clinicians which delayed her treatment.

The 44-year-old, who lived in Eden Village near Sittingbourne at the time, died as a consequence of endometrial cancer with brain metastases in August 2022.

Her heartbroken son, 21-year-old Jordan Dighton, who now lives in Sheppey Beach Villas, Leysdown, spoke of his devastation at learning her death could have been avoided.

He said: “She left behind a four and a six-year-old that unfortunately will never be able to know who their mum was.

“The coroner made it quite clear there are thousands of other people potentially at risk and that is really concerning.

“There is a systematic and managerial failing across the whole of our NHS.

“This isn't just local, this is everywhere. Thousands and thousands of us are going to present to our GP with a lump or a bump or a cough or something that is going to be ignored because unfortunately the doctors are just overwhelmed.

“There needs to be more funding and more staffing urgently.”

Assistant coroner Catherine Wood has issued a report to prevent future deaths following her investigation into the circumstances surrounding Kerri’s death.

Jordan, a University of Kent law student said: “When she was younger mum was involved in a car crash which left her disabled and she hadn't worked for about 20 years. I also became her carer with my stepdad.

“Mum and I had a relationship like no other. She was family-orientated and loved her kids.

“Her kids were her world and she’d do anything for them, they were her main priority in life.

“And now, because I've got such a young brother and sister, it’s our job to try and take mum's journey over because she’d have given them everything they wanted.

“It might not have been money, mum certainly couldn't have given them a lot in that sense, but she’d certainly have given them those skills, that love and that attention they needed to become sensible, mature human beings.”

In May 2020 Kerri was seen by a doctor at Green Porch Medical Centre with symptoms of possible early menopause.

Five months later her GP also noted she had been suffering from tiredness and had irregular periods.

In March 2021, Kerri complained of having vaginal bleeding for six weeks and she was referred for an ultrasound.

Due to her underlying ill health, and the fact Kerri was the only driver in her family, she missed appointments as she had difficulty getting to them.

She was seen at Green Porch Medical Centre in June 2021 by her GP who noted abdominal tenderness and weight loss and she was again referred for an ultrasound.

An ultrasound was undertaken by a private firm, HEM Clinical Ultrasound in Sittingbourne, on June 28, 2021, but the report was not sent to Kerri's GP.

Her family understands that the medical report noted Kerri's right ovary was normal but her left ovary could not be seen and there was a large complex mass. A gynae referral with an MRI was recommended.

A second ultrasound three days later suggested a diagnosis of adenomyosis, a condition that causes endometrial tissue in the lining of the uterus to grow into the muscular wall of the uterus, but noted that serious disease could not be ruled out.

Only the second result was sent to the GP which led to a routine gynaecology referral. Kerri had already been referred to the colorectal team on the urgent two-week wait pathway.

The coroner said if the first report had been sent an urgent referral to gynaecology would have been made.

Due to Kerri’s ill health, there were several more missed appointments and a colonoscopy finally took place in October 2021.

The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged.

In October 2021, a CT scan demonstrated a large pelvic mass and Kerri was referred to the gynaecology team in early December. This led to a request for an MRI scan.

Further appointments were made for December 2021, January and February 2022 but Kerri did not attend. She eventually underwent an MRI in May 2022 which revealed a large mass.

She was referred to the gynae-oncology surgeons at Maidstone Hospital and was seen on June 1, 2022.

Kerri was booked for surgery on June 27.

However, she was too unwell for the procedure and further investigations revealed brain metastases – something that happens when cancer cells spread from their original site to the brain.

She was admitted to hospital, treated with steroids and referred to the oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but was too unwell to receive even palliative radiotherapy.

Kerri's health deteriorated further and she was taken to Medway Maritime Hospital on August 19, 2022.

Whilst plans were made to provide some care at home she remained overnight but died on August 20, 2022.

The coroner said: “During the inquest, the evidence revealed matters giving rise to concern.

“In my opinion, there is a risk that future deaths will occur unless action is taken.”

“Her kids were her world and she’d do anything for them, they were her main priority in life...”

In her report, Ms Wood explained her concerns regarding the two reports from HEM Clinical Ultrasound Ltd.

She said: “The reports and any images associated with them were not provided to any of the deceased's treating clinicians.

“Only the second report was sent to her GP and not the first report. Neither report was uploaded to her clinical notes at Medway Maritime Hospital or Maidstone Hospital.

“Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her GP and she may have been investigated and treated at a much earlier stage.”

Jordan added: “There are other reports out there that give us the same indications that women go to their GP practices with gynaecological issues and they are ignored and they are put to one side until things are too late and we end up losing our mums at an age when really their lives should only just be beginning.

“It's not the doctors, in my opinion. The NHS is severely underfunded, severely understaffed and because of that it has a devastating consequence.”

NHS England and HEM Clinical Ultrasound Ltd have been contacted for comment.

Kerri leaves behind her partner, Mark White, her sister, Claire Martin, and her children Kezlyn Mothersole, Jordan Dighton, Ryan Dighton, Shayden-Ray and Lexi-Lou Dighton-White.

Since her death, Kerri has also become a nan to Wynter-Rose Stack, one, and Frankie-Jai Stack who is three months old.