Nurse mistakenly given cancer all-clear was 'catastrophically let down’, says husband

The husband of a nurse who died from cancer three years after it was misdiagnosed as benign has said she was "catastrophically let down" and believes there is a "catalogue of questions to be answered”.

Coroner John Gittins concluded that Catherine Jones' death in 2016 was "avoidable" and recorded a narrative verdict on Friday 8 December.

He said he would be issuing a prevention of future deaths report that revolved around communication within the Betsi Cadwaldr University Health Board.

Mrs Jones' husband David Jones read out a statement at the inquest in Ruthin saying "due to the number of professionals involved in the care" of his wife "patient safety has been and continues to be compromised."

He said: "To have witnessed my wonderful 35-year-old wife being catastrophically let down was appalling.

"To have watched her endure immense pain was horrendous. To have seen her suffer colossal emotional turmoil was heartbreaking.

"To know that this situation could have been avoided is overwhelming and unbearable."

Mr Jones described how he had promised her that he would find out what had gone wrong and make sure those responsible were held accountable.

Mrs Jones underwent surgery at Wrexham Maelor Hospital to remove an ovarian cyst in July 2013.

A previous hearing was told that a biopsy sample from the cyst should have been identified as borderline cancerous.

This meant Mrs Jones would have been offered surgery to remove the cancerous ovary which together with other treatments meant she would have survived.

Instead, she was given the all-clear. The cancer returned in the summer of 2016 and Mrs Jones, who worked as a staff nurse on the cardiology ward, was rushed back to hospital.

Tests revealed a cancerous tumour and she underwent a hysterectomy. She was told she had the all-clear, but, it had spread and she died a few months later.

Mr Jones, who has been fighting to find out the truth about his wife's care for seven years, said: "On 10 November 2016, I lost Catherine, my soul mate, my friend and my wife, whose dignity in adversity astounded me, whose consummate professionalism amazed me, whose love had sustained me, whose pain I could not take away and whose life I could not save.

"It is with profound regret, deep sadness and immense sorrow that I could not protect her from her ordeal."

Mr Jones thanked the coroner, in his statement to the inquest, for listening to his concerns after his wife's death.

He said: "My perception is that there are a catalogue of issues and questions to be answered regarding the recent death of Catherine.

"A number of these issues include senior clinicians not taking responsibility for listening topatients, informing them of pertinent facts, reading clinical notes, following up on clinical notes, reading scan requests properly, reading/reviewing/checking scan reports properly and not following appropriate guidelines, policies and procedures.

"My fear is that based upon the number of issues that I have encountered and been made aware of to date together with the number and breadth of professionals involved, then patient safety has been and continues to be compromised."

He revealed how "devastating" it was to tell his wife that her cancer had spread.

He said: "The words that I had to say to Catherine on the 9 November 2016, just a few moments before the doctors spoke to her, were words that no husband should ever have to say to his beloved wife and certainly not words that a wonderful wife should ever have to hear from her doting husband."

He continued: "The news was devastating and she had not been expecting it. Her surprise and sheer look of disbelief at what I had to tell her will haunt me for the rest of my life. Up until this point, Catherine thought that she would be receiving Chemotherapy when an ‘infection’ was under control.

"The emotional, physical and mental harm that Catherine suffered included untenable fear, excruciating pain, physical implications and immense distress."

He continued: "She died an avoidable, undignified, uncomfortable and premature death in the Hospital where she both worked in and had trained."

Mr Jones described how his wife was "dedicated to her vocation, passionate about caring for people in need and was proud to serve the public as a team member of the NHS".

He said she was a "brightly shining star" who had "achieved a great deal, had saved lives and had made everybody smile".

"Catherine was an incredible, kind and loving person," he said. Their hopes of "entertaining family in their home" and so many other occasions will now never materialise.

"All of our dreams to see as much of the world as possible together will now never be realised."

Mr Jones ended the statement saying: "No longer will I be able to see her smile, take her hand in mine or dance with her. She is sorely missed and warmly remembered for the lovely soul she was by all those whose lives she touched.

"Catherine could have shone even brighter, fulfilled her ambitions, saved more livesand offered so much more, if, she had only been allowed the time on this earth to realise her full potential and live her full life."

Following the conclusion of the five-day inquest in Ruthin, Betsi Cadwaladr University Health Board's 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.”

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