Coroner lists ‘gross failures’ in care for nurse who died from cervical cancer

There were gross failures in the care of a nurse who died from cervical cancer after she was wrongly told by doctors a smear test and biopsy were normal, a coroner has concluded.

Avon Coroner Maria Voisin recorded a conclusion of “natural causes contributed to by neglect” following an inquest into the death of Julie O’Connor.

Mrs O’Connor, 49, died in February last year after being given the all-clear from a smear test and a later biopsy.

Addressing the court, Mrs Voisin said: “In assessing the evidence it is clear there are a number of failures in her care, that her condition should have been known and action should have been taken when it was not.

  • The failure to report the smear test accurately in September 2014
  • The failure to report the endometrial biopsy accurately in October 2015
  • The failure to recognise the clinically obvious cancer of the cervix or a failure to recognise the need of further assessment in August 2016
  • The failure to recognise the clinically obvious cancer of the cervix or a failure to recognise the need of further assessment in November 2016

“In the context of considering a finding of neglect I have concentrated on the failures which based on the expert view of causation could have caused or contributed to Julie’s death.

“Firstly, the failure to report the smear test accurately in September 2014; secondly, the failure to report the endometrial biopsy accurately in October 2015; thirdly, the failure to recognise the clinically obvious cancer of the cervix or a failure to recognise the need of further assessment in August 2016; and fourthly, the failure to recognise the clinically obvious cancer of the cervix or a failure to recognise the need of further assessment in November 2016.

Julie O’Connor inquest
Kevin O’Connor holds a picture of his wife Julie outside Avon Coroner’s Court in Flax Bourton, near Bristol (Rod Minchin/PA)

“I consider that based on the evidence I have heard the failure to report the smear test accurately was a gross failure and the further assessments in both August and November 2016 were also gross failures.”

Mrs O’Connor repeatedly went to see her GP over a 14-month period complaining of gynaecological problems and was referred three times – twice under the two-week cancer pathway – to Southmead Hospital in Bristol for further tests.

Gynaecologists told Mrs O’Connor, from Thornbury, South Gloucestershire in October 2015 that an endometrial biopsy was negative.

The hospital had also provided a “false positive” result to a routine smear test carried out the previous year.

One expert said Mrs O’Connor would have had less than 1% chance of developing cervical cancer had she received the appropriate treatment when she was wrongly given the all-clear from the smear test.

A second said there was clear evidence of cancer in Mrs O’Connor’s October 2015 biopsy and a third said had Mrs O’Connor’s cancer been diagnosed and treated in August 2016 she most likely would have survived for over five years.

Avon Coroner’s Court heard that by August 2016 Mrs O’Connor had returned to her GP with the same symptoms and was referred back to Southmead questioning cervical cancer and the nurse was seen within two weeks but told her cervix “looked normal”.

By November she was still unwell and her GP made a third referral to the specialists who saw her in February 2017.

She was due to undergo further tests at Southmead the following month but decided to instead to see a consultant at a private hospital.

On examining Mrs O’Connor, they immediately suspected cervical cancer, which was later confirmed.

Further tests showed signs her cancer had spread and she underwent chemotherapy and radiotherapy.

She died in a hospice less than 12 months after the cancer was confirmed.

North Bristol NHS Trust has accepted the findings of both the smear test and later biopsy were wrong.

Consultant gynaecologist Professor Robert Hammond said if the smear test had been acted upon, Mrs O’Connor would had the affected cells removed – giving her less than 1% chance of developing cervical cancer in the future.

Ms Voisin asked Prof Hammond: “Is it fair to say she would not have died in February, if she did?”

He replied: “Yes.”

Expert witness Professor Sir Nicholas Wright said he had examined the endometrial biopsy undertaken in October 2015 and concluded it showed the presence of cervical cancer.

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A general view of Southmead Hospital, Bristol (Ben Birchall/PA)

“Most pathologists reviewing these sections with due care should have seen them,” he said.

Another expert witness, Professor John Tidy, said that if the cancer had been diagnosed in August 2016, she would have undergone surgery and her prognosis would have been good.

“I would have expected the majority of women with Stage 1B cervical cancer to have survived for over five years,” he told the court.

“By that time a train of events had developed and given the inexperience of the doctors that saw her then it would have been quite challenging for them to come to a different opinion.”

Prof Tidy said doctors examining the nurse’s original smear test failed to detect the presence of a severe dyskaryosis, a condition which if left untreated can lead to cervical cancer.

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