PFD report

Julie Sandra O'Connor · Prevention of Future Deaths report

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Issued 30 Jan 2020•Avon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Failure to accurately report smear test results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
  2. Failure to recognise and appropriately assess an abnormal cervix
    Part of recurring concern: Failure to reliably detect cervical cancer through screening and assessment
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

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

    Stated by Royal College of Obstetricians and GynaecologistsStated plannedThe respondent said that this action was planned when they made their response on 11 September 2020.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to accurately report smear test results

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. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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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. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure to reliably detect cervical cancer through screening and assessment.

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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Update the TOG article on nonmenstrual bleeding in women under 40 to improve junior staff awareness.

    Stated by Royal College of Obstetricians and GynaecologistsStated plannedThe respondent said that this action was planned when they made their response on 11 September 2020.

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

Update the TOG article on nonmenstrual bleeding in women under 40 to improve junior staff awareness.

Verbatim wording from the response

“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.”

Source location

2020-0129-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists_Published.pdf
Page 1 · response
Published 11 September 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026