The widower of a 49-year-old mother of two, who died from cervical cancer after being repeatedly failed by the NHS, has spoken out about a report into his wife’s death. Julie O’Connor tragically passed away in February 2019 following a late diagnosis of cervical cancer.
Mrs O’Conner first went for a smear test in September 2014 which came back negative. After persistent symptoms, and five further visits to an NHS hospital over two years, Mrs O’Connor saw a private Consultant who finally identified a tumour. There had been a clear misdiagnosis and, rightly, an independent report was commissioned by the Trust. However it unfortunately appears that – once again – an NHS Trust has missed the mark, with Mr O’Connor describing it as “lamentable from start to finish”.
Unfortunately this sad tale is all too common and something which we have been talking about for far too long.
HOW SHOULD MEDICAL MISTAKES BE DEALT WITH?
This question can apply to all walks of life and is not hard to answer. We are taught as children how to deal with mistakes: acknowledge them, apologise and learn from it so that it doesn’t happen again. It cannot be right to consistently provide caveated and diluted apologies and then carry on with the practice that led to the mistake in the first place. I do not mean to be flippant, and I acknowledge that it is not simple to implement change within such a huge organisation, but the current practise is not good enough. In Mrs O’Connor’s case, the investigation was limited to after she was diagnosed (it reportedly did not look into the repeated misdiagnoses) - this surely must be incredibly frustrating to the family. Mr O’Connor made his feelings clear “It just doesn’t seem serious – it just comes across as if s*** happens”.
This common approach to investigations is partly attributable to lack of resource. But it is in no small part due to fear. As Kate Rohde recently wrote, often when patients are striving to discover the truth, they are met with fear and a lack of transparency. That fear and lack of transparency comes from the stigma that can be attached to medical accidents. This is, in part, because of a lack of understanding of what the law is. This creates fear of the unknown that can leave medics feeling isolated, distressed and even, very regrettably, shamed. When those feelings expand to be organisational, you get a locked-down environment of corporate damage limitation.
The aim must be to avoid, not fear mistakes and as James Titcombe has campaigned, to “prioritise safety over fear”. As a loved one wanting answers, Mr O’Connor confirmed he is “not out to nail anybody, crucify anyone, I can’t change the past – just God forbid if anything happened to anyone else.”
WHAT IS THE AIM OF THE REPORT / INVESTIGATION?
As already pointed out, the aim of any investigation following an error is to ensure that such failings are avoided next time. But a secondary aim should be to address the questions and concerns of those hurt. There must be a willingness to listen to and hear the narratives of all of the people involved - particularly the patient but also the staff involved. Too often, those who are the subject of the failing (and their loved ones) are left to feel as a side issue. In Mrs O’Connor’s case, the report was reportedly promised to have been concluded before her death: the least that could be done you might think. But unfortunately it was delayed seven months and Mrs O’Connor was not able to receive answers before she passed away.
As is often the case, the first problem probably feeds into the second. Much of why patients often feel ignored and left without a proper apology is because Trusts and staff are often fearful of being open and transparent. Medical professionals can’t easily be accused of being un-empathetic (after all, they generally go into the profession to help people), but, sometimes the current culture makes it very difficult for an individual (or a Trust) to acknowledge, apologise and learn.
Hope shouldn’t be entirely lost - it can work (see for example the Cappuccini Test) - but more still needs to be done.