“Ms Pham had received 2 alerts for a routine smear test when pregnant and attended the GP…”

The coroner’s concerns

– (1) Ms Pham had received 2 alerts for a routine smear test when pregnant and attended the GP surgery. Ms Pham was informed that she should wait until she was post-partum according to the National Cervical Screening Guidance. (2) Ms Pham attended the GP surgery at approximately 9 weeks postpartum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear. This appointment was then cancelled due to staff shortages. (3) 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 Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures. (4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded: i. ii. 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 Post-partum lochia can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal 2 iii. iv. v. 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 Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding Not all women residing in the UK have had the HPV vaccine Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0425

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0