Milos Jankovic

I am Rachel Knight H M Coroner, for the coroner area of South Wales Central

On 26 November 2024 I commenced an investigation into the death of Milos JANKOVIC. The  investigation concluded at the end of the inquest on 18/09/2025. The narrative conclusion of the  inquest was that Mr Jankovic had been diagnosed with Barrett’s Oesophagus in 2014, but lost to  follow up surveillance due to a bowel cancer taking priority. Sadly, in 2024 he began to show  symptoms of cancer and testing established that he had developed brain metastases of a primary  oesophageal cancer.  Had Mr Jankovic been under surveillance, it is more likely than not that he would have by 2023, been seen by specialists in Barrett’s Oesophagus who would have been able to offer various options for ongoing surveillance and potential treatments. However, there is insufficient evidence that this would have changed the outcome for Mr Jankovic, given the nature of the disease and its known poor outcomes despite surveillance. 1a  Metastatic Oesophageal Cancer 1b  Barrett’s Oesophagus 1c II

The Inquest focused upon:- a. The practical aspects of administration of surveillance for Barrett’s patients in primary and secondary care; and b. Whether the outcome would have been different for Mr Jankovic if surveillance had occurred as it should have

During the course of 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. In the circumstances it is my  statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1)  There are two cases that have recently come to my attention within the Cardiff area where  patients have been diagnosed with Barrett’s, lost to follow-up and have gone on to die from  oesophageal cancers; (2) There are inadequate processes in place to address this lacuna, particularly in primary care  where a patient may not be a regular attender; (3) GPs frequently recall their patients with known, chronic issues such as asthma & diabetes, and there is a process for recalling women for smear tests for example, however Barrett’s does not  currently benefit from such a recall exercise/audit, even though it is well-established to be a pre-  cancerous condition; and (4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to  Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags  which may benefit from endoscopy rather than a course of medication, or whether they have  previously been diagnosed with the condition and ought to be under surveillance.

In my opinion action should be taken to prevent future deaths and I believe you and your organisations have the power to take such action.