The widower of a nurse who died from cervical cancer after she was wrongly told by doctors a smear test and biopsy were normal has called for an inquiry into other potential victims.
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”.
“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,” said Mr O’Connor, from Thornbury, South Gloucestershire.
“For Julie this was never about blame.
“Julie strived 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.”
The inquest heard 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.
Doctors told Mrs O’Connor in October 2015 that an endometrial biopsy was negative and the hospital had also provided a “false positive” result to a routine smear test carried out the previous year.
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 who immediately suspected cervical cancer.
Further tests showed the cancer had spread and she underwent chemotherapy and radiotherapy.
She died in a hospice less than 12 months after the cancer was confirmed.
Addressing the court, the coroner said she had focused on the failures that could have caused or contributed to Mrs O’Connor’s death.
“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 Voisin said she would also be writing to the Department of Health and Social Care, as well as the Royal College of Obstetricians and Gynaecologists, with her findings.
Tim Whittlestone, of the North Bristol NHS Trust, apologised to Mrs O’Connor’s family for the errors made in her care.
“Furthermore, we are so very sorry to her family and friends for the distress we caused them,” he said.
“I would like to reaffirm that North Bristol NHS Trust investigates mistakes and does learn from those mistakes.
“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.”