検死官 名簿（に載せる）／表（にあげる）s `甚だしい／１２ダース 失敗s´ in care for nurse who died from cervical 癌
There were 甚だしい／１２ダース 失敗s in the care of a nurse who died from cervical 癌 after she was wrongly told by doctors a smear 実験（する） and 生体検査 were normal, a 検死官 has 結論するd.
Avon 検死官 Maria Voisin 記録，記録的な／記録するd a 結論 of “natural 原因（となる）s 与える／捧げるd to by neglect” に引き続いて an 検死 into the death of Julie O’Connor.
Mrs O’Connor, 49, died in February last year after 存在 given the all-（疑いを）晴らす from a smear 実験（する） and a later 生体検査.
演説（する）／住所ing the 法廷，裁判所, Mrs Voisin said: “In 査定する／（税金などを）課すing the 証拠 it is （疑いを）晴らす there are a number of 失敗s in her care, that her 条件 should have been known and 活動／戦闘 should have been taken when it was not.
“In the 状況 of considering a finding of neglect I have concentrated on the 失敗s which based on the 専門家 見解（をとる） of causation could have 原因（となる）d or 与える／捧げるd to Julie’s death.
“Firstly, the 失敗 to 報告（する）／憶測 the smear 実験（する） 正確に in September 2014; secondly, the 失敗 to 報告（する）／憶測 the endometrial 生体検査 正確に in October 2015; thirdly, the 失敗 to recognise the clinically obvious 癌 of the cervix or a 失敗 to recognise the need of その上の 査定／評価 in August 2016; and fourthly, the 失敗 to recognise the clinically obvious 癌 of the cervix or a 失敗 to recognise the need of その上の 査定／評価 in November 2016.
Kevin O´Connor 持つ／拘留するs a picture of his wife Julie outside Avon 検死官´s 法廷，裁判所 in Flax Bourton, 近づく Bristol (棒 Minchin/PA)
“I consider that based on the 証拠 I have heard the 失敗 to 報告（する）／憶測 the smear 実験（する） 正確に was a 甚だしい／１２ダース 失敗 and the その上の 査定／評価s in both August and November 2016 were also 甚だしい／１２ダース 失敗s.”
Mrs O’Connor 繰り返して went to see her GP over a 14-month period complaining of gynaecological problems and was referred three times ? twice under the two-week 癌 pathway ? to Southmead Hospital in Bristol for その上の 実験（する）s.
Gynaecologists told Mrs O’Connor, from Thornbury, South Gloucestershire in October 2015 that an endometrial 生体検査 was 消極的な.
The hospital had also 供給するd a “誤った 肯定的な” result to a 決まりきった仕事 smear 実験（する） carried out the previous year.
One 専門家 said Mrs O’Connor would have had いっそう少なく than 1% chance of developing cervical 癌 had she received the appropriate 治療 when she was wrongly given the all-（疑いを）晴らす from the smear 実験（する）.
A second said there was （疑いを）晴らす 証拠 of 癌 in Mrs O’Connor’s October 2015 生体検査 and a third said had Mrs O’Connor’s 癌 been 診断するd and 扱う／治療するd in August 2016 she most likely would have 生き残るd for over five years.
Avon 検死官’s 法廷，裁判所 heard that by August 2016 Mrs O’Connor had returned to her GP with the same symptoms and was referred 支援する to Southmead 尋問 cervical 癌 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 予定 to を受ける その上の 実験（する）s at Southmead the に引き続いて month but decided to instead to see a 顧問 at a 私的な hospital.
On 診察するing Mrs O’Connor, they すぐに 嫌疑者，容疑者／疑うd cervical 癌, which was later 確認するd.
その上の 実験（する）s showed 調印するs her 癌 had spread and she underwent chemotherapy and 放射線療法.
She died in a hospice いっそう少なく than 12 months after the 癌 was 確認するd.
North Bristol NHS 信用 has 受託するd the findings of both the smear 実験（する） and later 生体検査 were wrong.
顧問 gynaecologist Professor Robert Hammond said if the smear 実験（する） had been 行為／法令／行動するd upon, Mrs O’Connor would had the 影響する／感情d 独房s 除去するd ? giving her いっそう少なく than 1% chance of developing cervical 癌 in the 未来.
Ms Voisin asked Prof Hammond: “Is it fair to say she would not have died in February, if she did?”
He replied: “Yes.”
専門家 証言，証人／目撃する Professor Sir Nicholas Wright said he had 診察するd the endometrial 生体検査 undertaken in October 2015 and 結論するd it showed the presence of cervical 癌.
A general 見解（をとる） of Southmead Hospital, Bristol (Ben Birchall/PA)
“Most 病理学者s reviewing these sections with 予定 care should have seen them,” he said.
Another 専門家 証言，証人／目撃する, Professor John Tidy, said that if the 癌 had been 診断するd in August 2016, she would have undergone 外科 and her prognosis would have been good.
“I w ould have 推定する／予想するd the 大多数 of women with 行う／開催する／段階 1B cervical 癌 to have 生き残るd for over five years,” he told the 法廷，裁判所.
“By that time a train of events had developed and given the inexperience of the doctors that saw her then it would have been やめる challenging for them to come to a different opinion.”
Prof Tidy said doctors 診察するing the nurse’s 初めの smear 実験（する） failed to （悪事，秘密などを）発見する the presence of a 厳しい dyskaryosis, a 条件 which if left untreated can lead to cervical 癌.
