The NHS has apologized to the family of an aspiring model who died from cervical cancer after her symptoms were mistaken for IBS – as a coroner described the case as one of the most ‘shocking and traumatic’ she has ever dealt with.
Porsche McGregor-Sims, 27, died at Queen Alexandra Hospital in Portsmouth on April 14, 2020, after ‘aggressive’ cancer spread to her lungs – causing breathing problems before she suffered a fatal heart attack.
An inquest into her death at Portsmouth Coroner’s Court today heard she had been referred to the hospital by her GP after presenting with abdominal pain and bleeding in December 2019 – four months earlier.
The events manager was seen on January 24, 2020, by locum gynaecologist Dr Peter Schlesinger, but he dismissed the likelihood of her having cancer, the court heard.
He instead told her that the issues could be linked to the side effects of having stopped taking birth control or irritable bowel syndrome.
Dr Schlesinger, 71, earlier told the court he did not think a physical examination was ‘needed’, but Ms McGregor-Sims later complained he ‘hadn’t listened’ and had ‘talked over’ her.
Ms McGregor-Sims underwent further examinations in early April – when cervical cancer was first suspected – and was referred to the oncology department on April 9.
She was later admitted to Queen Alexandra Hospital with ‘severely’ short breath, caused by the cancer, and died a day later on April 14 2020.
Ms McGregor-Sims (pictured), a graduate who was engaged to be married, had been an aspiring model before her death
Fiona Hawke, mother of Porsche, and twin brother Deucalion at the inquest in January
Porsche’s fiance Mark Chappel kisses her in this poignant picture of the engaged couple
Cervical cancer was not discovered until a day before death
2017 – Miss McGregor-Sims has her first smear test, which uncovers no cancerous cells – although some are abnormal. No action is taken.
2019 – December she is referred by a GP to a consultant after complaining of abdominal pain and bleeding.
2020 – In late January a doctor says her condition is hormonal, believing it to be related to her stopping taking birth control injections.
2020 – March sees Miss McGregor-Sims have two phone consultations and was prescribed antibiotics after feeling ‘short of breath’.
2020 – April 13 – she is brought into Westlands Medical Center in Portchester, near Portsmouth, for a face-to-face consultation. She was found to be ‘severely’ short of breath and was rushed to Queen Alexandra Hospital.
2020 – April 14, 2020 – Miss McGregor-Sims dies in hospital.
Doctors told the inquest that Ms McGregor-Sims should have been properly examined by Dr Schlesinger and, if her cancer had been diagnosed, then she may have lived for several more months.
The family said Ms McGregor-Sims had requested a second opinion in January, describing it as ‘very out of character for her to complain’, but she felt she was ‘not listened to.’
In a statement read to the court, they said: ‘None of us, including Porsche, thought that she would not make it out of hospital on April 13.
‘We didn’t even have a chance to adjust to the knowledge that it was stage four cancer and therefore we were not going to have much time.
‘Every step of the way she was being told it was IBS, and from what we can see, nobody was entertaining it (the idea that it could have been cancer).
‘You can’t have come to terms that she was going to go to hospital and come out in a body bag because we didn’t even know it was cancer. There’s no way we could have prepared for it. ‘
Dr Claire Burton, a consultant gynaecologist at Portsmouth Hospitals NHS Trust, apologized for the care she received at the trust.
She said: ‘If [Dr Scheslinger] had examined her [in late January] then she would have been referred for a colposcopy 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 here.’
Concluding her inquest, Area Coroner Rosamund Rhodes-Kemp today said the young woman’s untimely death in 2019 was one of the most ‘shocking and traumatic’ cases she had ever dealt with.
She said the early diagnosis would not have changed the outcome for Ms McGregor-Sims, but she and her family would have been saved the ‘shock and trauma’ of finding out about her cancer just before she died.
Giving a narrative verdict, she told the court: ‘It’s not clear that a referral in January would have altered the tragic outcome, but an earlier diagnosis would have allowed more time for her and her family to prepare themselves.’
Ms Rhodes-Kemp said that a mass of 5.3cm was only detected on April 6 following a CT scan, and a PET scan three days later found the cancer was ‘widespread and inoperable’ and ‘chemotherapy was the only option’.
She continued: ‘The appointment planned for a detailed discussion of these issues with the family was due on April 13.
‘This meant that the family and Porsche were unaware of the details of the cancer diagnosis and the severity.’
Porsche with fiance Mark Chappel in a heartbreaking photo before her cancer was found
Porsche and her twin brother Deucalion on their 24th Birthday three years before she died
The coroner added: ‘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.
“I think an appropriate conclusion in this case is natural causes.
“In no way am I trying to belittle the suffering of the family, but there is no evidence that an earlier diagnosis would have altered the outcome.”
The coroner said she will be writing a ‘letter of concern’ to the trust responsible for her care.
Portsmouth Hospitals NHS Trust says it reviewed protocols following Porsche’s case, which had led to the trust deciding not to employ any locum doctors in the future and instead hire more in-house consultants.
All patients seen by Dr Schlesinger have now been seen again by another doctor, the inquest heard.