Death of nurse mistakenly given cancer 'all-clear' was 'avoidable', coroner concludes

• Video report by ITV Wales reporter Ian Lang.

The death of a woman whose ovarian cancer was misdiagnosed was avoidable, a coroner has concluded.

Coroner John Gittins was speaking at the end of a five-day inquest into the death of nurse Catherine Jones, who died in 2016 from cancer and recorded a narrative verdict.

Mr Gittins said he would be issuing a prevention of future deaths report that revolved around communication within the board saying he still had concerns that the "right hand did not know what the left hand was doing."

The inquest heard Mrs Jones’s consultant had made a handwritten note on a scan in 2012 proposing that she be placed on a waiting list for removal of the right ovary and fallopian tube.

It “would have prevented the catastrophic outcome which ensued,” the coroner said. 

But due to the absence of “cohesive” recording the planned procedure didn’t happen. 

“The failure to require scans before surgery in 2013, given an interval of eight months, is below an acceptable standard of both care and practice,” the coroner said.

He added that not seeing patients in the clinic before the day of surgery to discuss consent also represented “poor practice.” 

Mrs Jones was just 35 years old when she died, three years after undergoing surgery at Wrexham Maelor Hospital, where she also worked.

A previous hearing was told Betsi Cadwaladr University Health Board had accepted that a biopsy was reported wrongly as “benign” when it had been “borderline” cancerous.  

Its medical director Dr Nicks Lyon said: “The issues raised within this inquest have given us a further opportunity to reflect on how we investigate failures in care.

“With this is mind, the Board has already instigated a review of several hundred investigations liable for reporting to His Majesty’s Coroners across North Wales.

“It is important to all of us we are confident in the processes we use and that the findings we make are of the highest quality.

“Only by doing this can we be assured we are fulfilling our Duty of Candour.

“In this case, we unreservedly accept the findings of the Coroner. We will respond to his specific concerns and list the actions we will take to guard against such failings, in due course.

“Most importantly, I would like to offer my condolences to Catherine’s family and apologise for the failings in her care.”

The inquest heard how a biopsy sample should have been flagged as borderline cancerous, meaning Mrs Jones would have been offered surgery and other treatment. But instead, she wasn't called up for treatment and she assumed she was in the clear.

But she did have cancer which progressed unchecked. The inquest in Ruthin heard how she fell ill in 2016 and was referred for an urgent hysterectomy after which cancer was discovered in her right ovary.

She was given the all-clear following that operation and told she did not need further treatment. But she died of cancer four months later.

David Jones promised his wife that he'd hold to account those responsible for her care. Over the past five days, his legal team has questioned a series of medical professionals.

David Jones' solicitor Richard Jones from Mackenzie and Jones

His solicitor Richard Jones, who has been in the profession for 35 years, told ITV Wales: "I've dealt with many, many tragic cases but this by far and away is the saddest of all."

Mr Jones continued: "The day that I sat around the desk in my office with David, once we had completed the obtaining of all our expert evidence and we had established that the hospital's negligence had caused Catherine's death, was one of the saddest moments of my life.

"Firstly he (David) wanted to set out to expose the truth.

"Secondly, he wants those who caused or contributed to Catherine's death to be brought to account. And thirdly he wants to expose the wider failings of the health board and potentially healthcare for female patients in the whole of Wales."

Following the conclusion of evidence being shared with the Ruthin's Coroner Court, Mr Jones shared a statement with the inquest, he said: "It is with profound regret, deep sadness and immense sorrow that I could not protect her (Catherine) from her ordeal." 

He continued: "Catherine had enormous potential, so much to offer and so many plans for 2017 and beyond.

"She captured the unbelievable nature of this catastrophe in her own words, ‘At 35, I have not yet lived my life’."

Mr Jones thanked the coroner for listening to his concerns after her death and opening an inquest.

He said: "Catherine wanted to see those responsible held to account and ensure that actions were taken to prevent others being let down and put at risk."

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