A CORONER has said the death of a hospital nurse from ovarian cancer was “avoidable.“

It followed her widower’s “seven-year battle to expose the truth.” 

At the inquest held in Ruthin, John Gittins, senior coroner for North Wales East and Central, recorded a narrative conclusion following the November 2016 death of 35-year-old Catherine Jones, of Hawarden.

He said 2012 scans had identified an ovarian abnormality and she underwent surgery. But a biopsy was then “wrongly classified as benign” and there was no follow-up. 

In June 2016 it was identified that there was development of a malignant disease process “which would probably have been identified sooner if the 2013 sample had been correctly classified.” 

Mrs Jones had further surgery “but the presence of a soft tissue ovoid lesion was not identified either in surgery or on a subsequent scan, and she didn’t undergo chemotherapy.” 

Mr Gittins said the aggressive cancer had spread and while in Wrexham Maelor Hospital in October 2016 Mrs Jones contracted an infection which accelerated her deterioration. 

The five-day 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 remarked. 

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. Not seeing patients in clinic prior to the day of surgery to discuss consent also represented “poor practice.” 

Dr Nick Lyons, acting deputy CEO, Betsi Cadwaladr University Health Board, said they were reviewing their investigations awaiting inquests and the Ombudsman. Access to patient records had been an issue during the inquest. Dr Lyons said there still weren’t fully electronic patient records, perhaps the “gold standard.” 

The coroner said: ”The risk of future deaths still applies.” He would raise the “slow” progress of an electronic records system in Wales with the Welsh Government. A second prevention of future deaths concern involved BCUHB and “the right hand not knowing what the left was doing.”

Widower David Jones had told the coroner: ”My perception is that there are a catalogue of issues and questions to be answered regarding the death of Catherine.

"A number of these issues include senior clinicians not taking responsibility for listening to patients, 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.   

“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 heart-breaking. To know that this situation could have been avoided is overwhelming and unbearable."

The Leader: PIC: Wrexham Maelor Hospital.

Paying tribute to Catherine, he added: "Catherine attended Hawarden High School, was chosen as a representative to meet the Queen and went on to attain her Diploma in Nursing at Wrexham University.  

“Catherine’s first post as a qualified nurse was at Wrexham Maelor Hospital. She subsequently moved to Glan Clwyd Hospital and worked on the Acute Medical Unit before returning to Wrexham Maelor Hospital to work on the Acute Cardiology Unit. Catherine 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.

"Catherine was kind-hearted, extremely generous, very bubbly and exhibited exemplary qualities. She was an outstanding, proud and talented young woman. Catherine had achieved a great deal, had saved lives and had made everybody smile. She was a brightly shining star."

After the inquest, Mr Jones said that ”very many risks” remained.

He said: “We have exposed a catastrophic catalogue of failings.” 

He thanked Richard Jones, a lawyer with Mackenzie Jones, who’d been “on the journey” for the truth. 

Dr Nick Lyons, said after the inquest: “The issues raised within this inquest have given us a further opportunity to reflect on how we investigate failures in care.

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

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“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.”