Barbara Rawlinson · Prevention of Future Deaths report

Barbara Rawlinson died on 16 July 2015, aged 58 years, from complications arising from a diagnosis of uterine sarcoma. An inquest into her death was heard on 11 November 2015, at which I recorded a narrative conclusion (see attached).

Mrs Rawlinson presented to her GP in 2014 with post-menopausal bleeding and was referred to the gynaecology team at Barnet Hospital (part of the Royal Free Trust). She underwent ultrasound examinations and hysteroscopies to investigate the cause of this bleeding, which was presumed to be resulting from a fibroid. She was concerned that the diagnosis was cancerous and, in order to reassure her that this was not the case, she underwent a hysterectomy in early 2015. Unfortunately histology of her uterus demonstrated that the cause of the bleeding was a uterine sarcoma.

She was referred to UCLH to receive further treatment of this cancer and underwent a further procedure to remove additional tumour mass which had been demonstrated on CT scanning. Unfortunately, following this procedure she developed a perforated stomach and subsequently a perforated gallbladder. She died after attempts to treat these and further complications.

Mrs Rawlinson’s family raised a concern that no CT scanning had been undertaken prior to the hysterectomy being performed. Mr Broadbent, Consultant Gynaecologist at Barnet Hospital, had been appraised of this concern in writing before the inquest and had provided a supplementary written statement to address this. He set out that he had been reassured by the findings of repeated ultrasound scanning. As such, I did not call him to give evidence.

However, at the inquest I heard from ████████, Consultant Gynaecologist at UCLH who had undertaken Mrs Rawlinson’s second operation. She set out that, in her opinion, a CT scan should have been undertaken prior to the hysterectomy to address the possible (but rare) diagnosis of sarcoma in a post-menopausal woman with ongoing bleeding.

I decided that I could conclude the inquest but that this issue warranted a report to prevent future deaths, in order to allow the Royal Free Trust the opportunity to reflect on and respond to these concerns.

(1) The lack of CT scanning prior to hysterectomy, with reliance only on ultrasonography, raises the concern that the diagnosis of uterine sarcoma could be missed in the future and consideration should be given as to whether steps can be taken to address this risk.