There were gross failures in the care of a nurse who died from cervical cancer after doctors wrongly told her a smear test and biopsy were normal, a coroner has concluded.
The Avon coroner, Maria Voisin, said neglect contributed to the death of 49-year-old Julie O’Connor, who died in a hospice in February last year 12 months after the cancer was finally confirmed.
Voisin said: “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.” She spelled out four failures and three gross failures from September 2014 to November 2016.
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.
One expert said O’Connor would have had less than a 1% chance of developing cervical cancer had she received the appropriate treatment when she was wrongly given the all-clear from the smear test in 2014.
A second said there was clear evidence of cancer when O’Connor had a biopsy in October 2015 and a third said had O’Connor’s cancer been diagnosed and treated in August 2016 she most likely would have survived for at least five years.
The inquest heard that by August 2016 O’Connor had returned to her GP with the same symptoms and was referred back to Southmead. She was seen within two weeks but told her cervix “looked normal”.
In 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 see a consultant at a private hospital instead.
On examining 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.
Consultant gynaecologist Prof Robert Hammond said if the smear test had been acted upon, O’Connor would had the affected cells removed – giving her less than 1% chance of developing cervical cancer in the future.
Voisin asked Hammond: “Is it fair to say she would not have died in February, if she did?” He replied: “Yes.”
During the inquest, O’Connor’s husband, Kevin, 50, who works for the Civil Aviation Authority, expressed concern at her inquest that there could be many other “victims”.
He said there were “systemic failures” by North Bristol NHS trust in the care of his wife and raised concerns about the investigations into what went wrong.
“I am concerned about the trust’s ability to learn from past mistakes. The root cause analysis does not look at the root underlying cause,” he said. “The root cause analysis does not account for further potential victims. I am extremely concerned that a proper wider independent investigation has not taken place.
“This negligence is of serious public concern. There may be other victims who have received false negative pathology reports, and false gynaecology clinician examinations, at the North Bristol NHS trust, who need to be reviewed.”
North Bristol NHS Trust deputy medical Director Tim Whittlestone said: “Firstly I would like to repeat on behalf of North Bristol NHS Trust our sincere apology for the mistakes we made in failing to diagnose Julie’s cancer.
“I would also like to say how sorry we are to her loving family and friends for causing them pain, distress and loss.
“North Bristol has investigated these errors and more importantly that we have learnt lessons from our mistakes.
“I would like to reassure patients that as a result of Julie we have improved the way we examine patients and diagnose cervical cancer.”
