Source · Prevention of Future Deaths

Julie O’Connor

Ref: 2020-0129 Date: 30 Jan 2020 Coroner: Maria Voisin Area: Avon Responses identified: 1 / 2 View PDF

There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the need for further assessment over several months.

Date 30 Jan 2020
56-day deadline 6 Nov 2020 est.
Responses identified 1 of 2
Community health care and emergency services related deaths

Coroner's concerns

AI summary
There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the need for further assessment over several months.
View full coroner's concerns
Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, 8S48 lUL

In this case as well as the fact that the smear test was incorrectly reported there were also 2 occasions when there was a failure to recognise a clinically obvious cancer of the cervix or a failure to recognise a need for further assessment in August and November 2016. In addition the evidence of the experts was that the abnormal appearance of the cervix should also have been diagnosed in February 2017. The North Bristol NHS Trust have developed a guide for "the management of abnormal cervix, ectropian, and post coital bleeding"* and it is the view of the trust that if this guide had been in place at the time that Julie's medical condition would have been picked up earlier.
*I attach a copy of the guide produced by the Trust. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, B548 lUL

Responses

1 respondent
Royal College of Obstetricians and Gynaecologists Education
13 Mar 2020 PDF
Action Planned

The RCOG will be updating the article in The Obstetrician & Gynaecologist (TOG) entitled Nonmenstrual bleeding in women under 40 years of age and will work with the BGCS to review the training materials for suspected cervical cancer. (AI summary)

View full response
Dear Sir/Madam,

Re: Julie Sandra O’Conner – deceased

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Julie O’Connor dated 31 January 2020. I would like to begin by expressing my sincere condolences to Julie’s family.

In order to provide a full response, I have been in contact with colleagues in the British Gynaecological Cancer Society (BGCS) and the British Society for Colposcopy and Cervical Pathology (BSCCP).

The President of the BGCS has given some context to this issue and highlighted that Cancer Research UK presents data on cervical cancer incidence as being approximately 3000 new women each year; https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer- type/cervical-cancer/incidence#heading-Zero. However, she also states that junior staff in the obstetric and gynaecology specialty will see a patient with cervical cancer very uncommonly; but that post-coital bleeding is an extremely common symptom and that there is a risk that a woman presenting with cervix cancer can therefore be missed.

In order to improve awareness for junior staff, we will be updating the article in The Obstetrician & Gynaecologist (TOG) entitled Nonmenstrual bleeding in women under 40 years of age that was first published in 2004. TOG provides all health professionals working within the field of obstetrics and gynaecology with an up-to-date, peer-reviewed information resource delivered through a range of educational articles. The journal provides UK consultants with CPD-creditable questions, where TOG questions can be answered and used as part of the knowledge-based assessment, and is also relevant to all trainees and health professionals working in the field of obstetrics and gynaecology (O&G) across the world.

The President of the BSCCP has highlighted that updated colposcopy guidelines and referral indications have recently been published which can be found at the following link:

management/2-providing-a-quality-colposcopy-clinic

We all agree that having guidance on senior review of a patient with a suspected cervical abnormality is useful to have at Trust level. If this Trust had had their guidance in place, it may well have prompted the clinician to seek a more senior review which may have picked up Julie’s condition at an earlier stage. However, guidance alone may not be sufficient and we will work with the BGCS to review the training materials for suspected cervical cancer, as this is a very visual diagnosis.

The RCOG is committed to improving the standard of care delivered to women and working collaboratively with others to prevent such tragedies from occurring in the future.

Report sections

Investigation and inquest
On 17/04/2019 I commenced an investigation into the death of Julie Sandra O'Connor. The investigation concluded at the end of the inquest 30th January 2020. The conclusion of the inq.uest was natural causes contributed to by neglect. Her medical cause of death was recorded as: la) metastatic squamous cell carcinoma of the cervix
Circumstances of the death
The brief circumstances were ... Julie O'Connor had a smear test in September 2014 which was reported as normal when it was not; she was examined by gynaecologists who did not diagnose her condition in August and November 2016. It was not until she was seen in March 2017 that she was appropriately diagnosed and treate.d for cervical cancer. Unfortunately despite treatment at that time her condition deteriorated, she developed metastatic disease due to the delayed diagnosis and she died on 4th February 2019 at St Peter's Hospice from metastatic squamous cell carcinoma of the cervix.
Action should be taken
In my opinion action should be taken to prevent future deaths and I believe you have the power to· take such action.

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Report details

Reference
2020-0129
Date of report
30 January 2020
Coroner
Maria Voisin
Coroner area
Avon

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Nov 2020 (estimated).

Sent to

Department of Health and Social Care
Royal College of Obstetricians and Gynaecologists

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