Quy Thi Pham
11 Aug 2025 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. delayed cervical screening post-partum
“Ms [name redacted] had received 2 alerts for a routine smear test when pregnant and attended the GP surgery. Ms [name redacted] was informed that she should wait until she was post-partum according to the National Cervical Screening Guidance.”
2. missed early detection of cervical cancer
“The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum, especially if a patient had not had a previous smear test, as in the case of Ms [name redacted] who had an early-stage cervical cancer with no infiltration into surrounding organs or structures.”
3. inadequate symptom criteria for post-partum cervical cancer detection
“The national guidance to identify post-cotidal bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus”
4. misinterpretation of post-partum bleeding as normal
“Post-partum lochia can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal”
5. lack of clear bleeding criteria for post-partum women
“Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern”
6. asymptomatic early-stage cervical cancer
“Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding”
7. unequal HPV vaccine coverage
“Not all women residing in the UK have had the HPV vaccine”