Recurring concern

Failure to reliably detect cervical cancer through screening and assessment

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First reported 30 Jan 2020•Latest report 11 Aug 2025

Definition

What this concern includes

Includes failures of cervical-cancer detection controls, including timely and clinically appropriate cervical screening, recognition of abnormal cervical findings, further assessment and referral where these are directly intended to identify cervical cancer or significant cervical disease.

Not included

Excludes generic cancer-screening deficiencies where cervical cancer or cervical findings are not materially identified.
Excludes delays or deficiencies in cervical-cancer treatment after detection unless the asserted concern is also a failure of screening or diagnostic assessment.
Excludes generic appointment, staffing or documentation deficiencies unless they directly impair cervical-cancer screening or assessment.
Excludes screening and assessment for non-cervical cancers or unrelated gynaecological conditions.

Reports: 2
Individual concerns: 9
Date range: 2020–2025
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

National Institute for Health and Care Excellence1

NHS England1

Royal College of Obstetricians and Gynaecologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

11 Aug2025
Essex
Concerns raised8
1. Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular
2. Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations
3. Failure to account for women who have not received HPV vaccination in cervical cancer screening
1. Unavailability of staffing for cervical screening appointments
2. Failure to identify early-stage cervical cancer without bleeding symptoms
3. Failure to distinguish post-partum bleeding from abnormal bleeding
4. Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk
5. Failure to provide timely post-partum cervical smear testing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Notify Agilio Software of the concerns about cervical screening information.
  Stated by National Institute for Health and Care ExcellenceStated planned
2. Action
  Conduct research on the safety, accuracy and reliability of cervical screening within three months after birth.
  Stated by NHS EnglandStated in progress
3. Action
  Consider the research findings when available and assess their implications for national cervical screening guidance.
  Stated by NHS EnglandStated planned
Respondent positions 4
1. Position
  Existing guidance is considered sufficient: symptomatic women should seek GP advice, screening is non-diagnostic, and screening should be delayed for three months after birth.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  Postnatal screening would probably not have prevented the death because the cancer was aggressive, metastatic at presentation and incurable.
  Stated by NHS EnglandDisputes the concern
2. Position
  The recommendation to delay cervical screening for women under 12 weeks postpartum does not originate from NICE guidance.
  Stated by National Institute for Health and Care ExcellenceDisputes the concern
3. Position
  NHS England’s NHS Cervical Screening Programme is best placed to address the concerns about postpartum cervical screening.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
AI-generated summary

QUY THI PHAM · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Quy Thi Pham died at Basildon Hospital on 3 September 2024 after an extremely rare and rapidly progressing early-stage cervical cancer caused metastatic pulmonary hypertension and irreversible cardiac arrest. She had been advised to wait until 12 weeks post-partum for cervical screening, and a later appointment was cancelled because of staff shortages and not rebooked. Concerns were raised about the application of national cervical screening guidance to post-partum women and whether it may exclude some women from timely diagnosis.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular
Wider context from the report
“(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding v. Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations
Wider context from the report
“(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding v. Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to account for women who have not received HPV vaccination in cervical cancer screening
Wider context from the report
“(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding v. Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of staffing for cervical screening appointments
Wider context from the report
“(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear. This appointment was then cancelled due to staff shortages. (3) The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum, especially if a patient had not had a previous smear test, as in the case of Ms Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify early-stage cervical cancer without bleeding symptoms
Wider context from the report
“(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding v. Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to distinguish post-partum bleeding from abnormal bleeding
Wider context from the report
“(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding v. Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk
Wider context from the report
“(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding v. Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide timely post-partum cervical smear testing
Wider context from the report
“(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear. This appointment was then cancelled due to staff shortages. (3) The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum, especially if a patient had not had a previous smear test, as in the case of Ms Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures. ”
Source location
QUY THI PHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Notify Agilio Software of the concerns about cervical screening information.

Verbatim wording from the response
“We will make Agilio aware of the concerns you raise so that they can check for any updates to the NHS Cervical Screening Programme when they next update this topic.”

Source location
Response from NICE
Page 1 · response
Published 15 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct research on the safety, accuracy and reliability of cervical screening within three months after birth.

Verbatim wording from the response
“There is research underway supported by the cervical screening programme to collect evidence on whether it is safe, accurate and reliable to report cervical screening tests within 3 months of birth. This research is expected to conclude by September 2027. When the findings of this research are available, NHS England will consider them and update national guidance accordingly.”

Source location
Response from NHS England
Page 2 · response
Published 15 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consider the research findings when available and assess their implications for national cervical screening guidance.

Verbatim wording from the response
“There is research underway supported by the cervical screening programme to collect evidence on whether it is safe, accurate and reliable to report cervical screening tests within 3 months of birth. This research is expected to conclude by September 2027. When the findings of this research are available, NHS England will consider them and update national guidance accordingly.”

Source location
Response from NHS England
Page 2 · response
Published 15 August 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing guidance is considered sufficient: symptomatic women should seek GP advice, screening is non-diagnostic, and screening should be delayed for three months after birth.

Verbatim wording from the response
“The aim of the national cervical screening programme is to detect asymptomatic cell changes in the cervix that could, if left untreated, develop into cervical cancer in the future. The screening programme guidance for patients with unusual bleeding or gynaecological symptoms they are concerned about is always to seek advice from their GP. A cervical screening test is not an appropriate tool to investigate these concerns as it is not a diagnostic test.”

Source location
Response from NHS England
Page 1 · response
Published 15 August 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Postnatal screening would probably not have prevented the death because the cancer was aggressive, metastatic at presentation and incurable.

Verbatim wording from the response
“Based on the clinical history provided which has been reviewed by clinical experts who support NHS England’s cervical screening team, Quy suffered from an aggressive form of cervical cancer which metastasised to the lungs at presentation. It is accepted that unusual and rapidly developing cervical cancers are unlikely to be prevented by screening. Even if Quy had received post-natal screening in July 2024, on the balance of probabilities, Quy would still have had an aggressive cervical cancer with lung metastases which, sadly, would still have been incurable.”

Source location
Response from NHS England
Page 2 · response
Published 15 August 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The recommendation to delay cervical screening for women under 12 weeks postpartum does not originate from NICE guidance.

Verbatim wording from the response
“Firstly, it may be helpful for me to clarify that the recommendation that cervical screening should be delayed for women who are less than 12 weeks post-partum does not come from guidance produced by NICE, but from Public Health England (PHE) guidelines, ‘Ceasing and deferring women from the NHS Cervical Screening Programme (PHE, 2019)’. We believe that the issues raised within your report are therefore best addressed by NHS England’s NHS Cervical Screening programme, and I note that your report has also been sent to them.”

Source location
Response from NICE
Page 1 · response
Published 15 August 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England’s NHS Cervical Screening Programme is best placed to address the concerns about postpartum cervical screening.

Verbatim wording from the response
“Firstly, it may be helpful for me to clarify that the recommendation that cervical screening should be delayed for women who are less than 12 weeks post-partum does not come from guidance produced by NICE, but from Public Health England (PHE) guidelines, ‘Ceasing and deferring women from the NHS Cervical Screening Programme (PHE, 2019)’. We believe that the issues raised within your report are therefore best addressed by NHS England’s NHS Cervical Screening programme, and I note that your report has also been sent to them.”

Source location
Response from NICE
Page 1 · response
Published 15 August 2025
Open published response
30 Jan2020
Avon
Concerns raised1
1. Failure to recognise and appropriately assess an abnormal cervix
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Work with the BGCS to review training materials for suspected cervical cancer.
  Stated by Royal College of Obstetricians and GynaecologistsStated planned
AI-generated summary

Julie Sandra O'Connor · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Julie Sandra O'Connor had a smear test in September 2014 that was reported as normal when it was not, and her cervical cancer was not diagnosed during examinations in August and November 2016. She was diagnosed and treated in March 2017, but her condition deteriorated and she died from metastatic squamous cell carcinoma of the cervix. The report identified concerns about the incorrect smear result and failures to recognise the cancer or the need for further assessment on several occasions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to recognise and appropriately assess an abnormal cervix
Wider context from the report
“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. ”
Source location
Julie Sandra O'Connor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the BGCS to review training materials for suspected cervical cancer.

Verbatim wording from the response
“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 the guidance in place, it may well have prompted the clinician to seek a 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.”

Source location
2020-0129-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists_Published.pdf
Page 2 · response
Published 11 September 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised8

Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular

Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations

Failure to account for women who have not received HPV vaccination in cervical cancer screening

Unavailability of staffing for cervical screening appointments

Failure to identify early-stage cervical cancer without bleeding symptoms

Failure to distinguish post-partum bleeding from abnormal bleeding

Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk

Failure to provide timely post-partum cervical smear testing

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to recognise and appropriately assess an abnormal cervix

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 3

Respondent positions 4

Actions described in response 1