Coroner blasts ‘neglect’ that led to nurse’s cancer death
Mum of two ‘would have survived’ if smear test had been read accurately
THE family of a nurse who died after her cervical cancer was missed six times say they are ‘relieved’ and ‘reassured’ after a coroner ruled there were gross failures in the care she received.
Julie O’Connor, 49, repeatedly visited her GP complaining of gynaecological problems and was referred three times to Southmead Hospital in Bristol.
But she was forced to wait almost three years for a diagnosis after a smear test and biopsy were incorrectly reported as normal. It was only when she went to see a private consultant that the mother-oftwo, who died in February last year, learned she had a tumour.
Yesterday, following a four-day inquest into her death, the senior coroner for Avon, Maria Voisin, concluded that Mrs O’Connor died of ‘ natural causes contributed to by neglect’.
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 coroner listed four examples:
▪ 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 ‘clinically obvious’ cancer in August 2016; and
▪ The failure to recognise ‘clinically obvious’ cancer in November 2016.
Speaking publicly for the first time since their daughter’s death, Mrs O’Connor’s parents, Brian and Lesley Pleavin, said the coroner’s conclusion was ‘exactly what we wanted’.
They told the Mail: ‘The coroner thought long and hard about this and she did a superb job. She has said everything that we’ve been saying from the very beginning.
‘We just hope that what she has said, the hospital take on board and, most importantly, actually do something about.
‘We really hope that this could save other girls’ and women’s lives. We want to encourage people to go and have smear tests still. But if you feel you still have symptoms and you’ve not been given the right advice then challenge, challenge, challenge. That is what Julie would say.
‘The people that made the mistakes reading the smear should be told about the mistake they made and the effect it has had, if they haven’t already.’
During the inquest, Mrs O’Connor’s husband, Kevin, 50, expressed concern that there could be many other ‘victims’. He said there were ‘systemic failures’ by North Bristol NHS Trust in the care of his wife.
Mrs O’Connor, who worked for the NHS for 13 years, had attended a routine smear test in September 2014, which was reported as normal. But it is now recognised that the sample was actually ‘plentiful’ with abnormal cells and Mrs O’Connor should have been referred for further tests.
The inquest heard that had this happened it was highly likely Mrs
O’Connor would have survived. Following the 2014 smear, Mrs O’Connor repeatedly visited her GP due to irregular bleeding.
As a result she was referred on numerous occasions to specialists, but following gynaecologist examinations in October 2015 and August 2016, she was told everything was ‘normal’.
During her hospital visit in October 2015, a biopsy was taken and reported as normal, though – again – this was not the case. Mrs
O’Connor eventually attended a consultation at the private Spire Hospital in March 2017 where a specialist immediately suspected cervical cancer.
Tim Whittlestone, of the North Bristol NHS Trust, apologised to Mrs O’Connor’s family for the errors made in her care. He added: ‘I would like to reassure patients that as a direct result of Julie, we have improved the way we examine patients and indeed in our ability to diagnose cervical cancer.’