Nurse’s widower calls for inquiry after coroner rules medics were guilty of gross failures when they failed six times to spot cervical cancer that killed the 49-year-old mother-of-two
- Julie O’Connor died despite being given all-clear from smear test and biopsy
- Died aged 49 from ‘natural causes contributed to by neglect’, coroner ruled
- North Bristol trust gave her a one per cent chance of developing cervical cancer
Medics were guilty of gross failures in the care of a nurse who was killed by cervical cancer who should have had a 99 per cent chance of survival, a coroner ruled.
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.
Widower Kevin O’Connor, 50, said he believed more women could have developed cancer after suffering the same level of care as his wife Julie.
The 49-year-old mother of two died in February last year after being given the all-clear from a smear test and a later biopsy.
Mr O’Connor, who works for the Civil Aviation Authority, spoke out after Avon Coroner Maria Voisin highlighted three gross failings and concluded she died from ‘natural causes contributed to by neglect’.
Julie O’Connor (pictured with her husband, Kevin) died despite being handed the all-clear
He said: ‘We are satisfied with the conclusion of neglect by the coroner. We hope this will go a long way to help and protect other women in the future. For Julie this was never about blame. Julie strove in her final years to give women the confidence to question the professionals.
‘We hope that by the actions and recommendations barriers and safeguards are put in place to protect all women. Cervical screening does save lives. We want to ensure we have a safe cervical screening and gynaecological service.’
Mr O’Connor said he believed his wife was not the only victim and added: ‘We need to have a wider review now and consider other victims.
‘In order to go forward we put safeguards and barriers in place, but to do so we do need to look backwards and consider whether there are other victims out there.’
Pictured: Kevin O’Connor holds a photo of his wife outside Avon Coroner’s Court at the inquest into her death
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.
‘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.
How did medics miss the cervical cancer?
Mrs O’Connor consulted her GP over a 14-month period about gynaecological problems, only for medics to miss her cancer as the timeline lays out:
September 2014: North Bristol NHS Trust fails to report smear test accurately
October 2015: Failure to report the endometrial biopsy accurately
August 2016: Fails to recognise the clinically obvious cancer of the cervix
Also misses the need of further assessment
November 2016: Failure to recognise the clinically obvious cancer of the cervix for a second time
Failure to recognise the need of further assessment for a second time
‘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.
‘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 per cent 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.
Pictured: Southmead hospital where Julie O’Connor was told she was all-clear only to die of cancer aged just 49
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 per cent 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.
‘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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