Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0129, written 30 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jan 2020 |
|---|---|
| Reference | 2020-0129 |
| Deceased | Julie O’Connor |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M. E. Voisin Her Majesty's Senior Coroner Area of Avon 30th January 2020 REF: 13847 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health 2. Royal College of Obstetricians and Gynaecologists 1 CORONER I am M E Voisin Senior Coroner for Area of Avon 2 CORONER'S LEGAL POWERS I make this report under paragra ph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www. I egis I ation .gov. u k/ u kpga/2009 /25 / sch ed u le/5 / pa ragra ph/7 http://www. legislation .gov. uk/u ksi/2013/1629/pa rt/7 /made 3 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 4 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. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, 8S48 lUL Telephone 01275 461920 The MATTERS OF CONCERN are as follows. - In this case as well as the fact that the smear test was incorrectly reported there were also 2 occasions when there was a fai lure to recognise a clinically obvious cancer of the cervix or a failure to recogn ise 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 prod uced by the Trust. Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, B548 lUL Telephone 01275 461920 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 March 2020. I, the coroner, may extend the period. th Your response must contai_n details of action taken or proposed to be taken, setting out the timetable for · action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the chief coroner and to the following interested persons - the family of Julie O'Connor, North Bristol NHS Trust. Spire Bristol and - I am also under a duty to send the chief coroner a copy of your response. The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the chief coroner. 9 30/01/2020 s;gnoMe L , ' . M E voynior Coroner Area of Avon Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com . The Coroner's Court, Old Weston Road, Flax Bourton, BS48 lUL Telephone 01275 461920
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon The Coroner’s Court Old Weston Road Flax Bourton BS48 1UL Dear Sir/Madam, Re: Julie Sandra O’Conner – deceased 13th March 2020 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: https://www.gov.uk/government/publications/cervical-screening-programme-and-colposcopy- 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. Yours sincerely, President, Royal College of Obstetricians and Gynaecologists
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