11 Aug 2025 QUY THI PHAM · Prevention of Future Deaths report Essex
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Concerns raised 8
Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular View source Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations View source Failure to account for women who have not received HPV vaccination in cervical cancer screening View source
Unavailability of staffing for cervical screening appointments View source Failure to identify early-stage cervical cancer without bleeding symptoms View source Failure to distinguish post-partum bleeding from abnormal bleeding View source Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk View source Failure to provide timely post-partum cervical smear testing View source See 5 more concerns
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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.
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× 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
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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
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
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
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
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
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
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
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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
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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
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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
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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
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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
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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
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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
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30 Jan 2020 Julie Sandra O'Connor · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to recognise and appropriately assess an abnormal cervix View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.