An NHS trust has apologised over the death of a 27-year-old events manager after a locum gynaecologist mistook aggressive cervical cancer for a hormonal or bowel problem.
The family of Porsche McGregor-Sims, who died a day after being admitted to Queen Alexandra hospital in Portsmouth, told her inquest that she had felt she was not listened to and that the misdiagnosis had robbed them of a chance to say goodbye.
The area coroner Rosamund Rhodes-Kemp said the case was one of the most “shocking and traumatic” she had dealt with and she would write to Portsmouth hospitals university NHS trust expressing her concern.
In December 2019, McGregor-Sims’ GP referred her to a consultant after she complained of abdominal pain and vaginal bleeding.
She saw Dr Peter Schlesinger, an agency locum at the Queen Alexandra hospital, at the end of January 2020. He did not physically examine her and believed her symptoms were linked to changing hormones or irritable bowel syndrome (IBS).
After the UK went into lockdown two months later, McGregor-Sims continued to report symptoms but was prescribed antibiotics over the phone and was seen in person only after a GP thought she might have Covid because she had shortness of breath.
McGregor-Sims was finally diagnosed with an aggressive form of cervical cancer and on 13 April was taken to hospital, where she died a day later.
During the inquest, her family accused Schlesinger of having denied them their chance to say goodbye. Her mother, Fiona Hawke, told him: “You robbed us of the opportunity to prepare for her death and say goodbye to her.”
Hawke said that when her daughter finally went into hospital she was “scared and alone”, adding: “She knew it was going to be a fight and she knew she probably was not going to survive it in the long run but she did not expect to die … days after being diagnosed. She expected to be listened to and helped but that is not what happened.
“Had the examination been done in January we would have still had some time with her. A few weeks more would have made an indescribable difference to that experience for all of us – including Porsche.”
Schlesinger insisted McGregor-Sims’ symptoms – including bleeding after sex – did not lead him to think she had a serious illness.
Dr Claire Burton, a consultant gynaecologist, said Schlesinger should have physically examined McGregor-Sims, and apologised for the care she received at the trust.
Burton said: “If [Scheslinger] had examined her then she would have been referred for a colposcopy [cervix examination] more quickly, where diagnosis would have been made. I would like to express our condolences to Porsche’s family and friends, and to apologise for the care she had.”
Liz Rix, the chief nurse at Portsmouth hospitals university NHS trust, said: “I would like to express our condolences to the family of Porsche McGregor-Sims. When we were aware of concerns around her care, we immediately investigated these and ensured we learnt from the experience of Porsche and her loved ones.”
The coroner said she would write a letter of concern to the trust. Rhodes-Kemp said: “We see hundreds and hundreds of cases every year – and I have done about 6,000 inquests – but this one is particularly sad.
“It is not clear that a referral in January would have altered the tragic outcome, but an earlier diagnosis would have allowed her and her family more time to prepare themselves.” She concluded McGregor-Sims died of natural causes.
The inquest heard the trust had reviewed protocols following the case, which had led to it deciding to employ more in-house consultants rather than using locums.
All patients seen by Schlesinger had now had consultations with another doctor, the inquest heard.
McGregor-Sims had studied drama at Havant and South Downs college in Hampshire before going to the University of Plymouth to study events management. She met her fiance, Mark Chappel, while at university, and the pair moved back to Portsmouth after finishing their studies.
