Heartbroken family 'denied opportunity' to say goodbye to 'beautiful and talented' 27-year-old from Portsmouth who died from cervical cancer as inquest finishes
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Today, a coroner found Porsche McGregor-Sims's tragic passing to be the result of natural causes.
However, Porsche's family say that a locum doctor's failure to give her a physical examination could have meant an earlier diagnosis, which would have bought time and made an 'immeasurable' difference to their family.
Just two days previously, Porsche had been told she had cervical cancer, which was at stage four - meaning the metastatic disease was widespread and affecting other parts of her body.
Before her diagnosis, Porsche was seen in January of that year by Dr Peter Schlesinger, a locum gynaecologist for nine weeks at QA.
Porsche's family raised questions over actions during this appointment, saying he failed to carry out a vaginal assessment and the meeting had left the young woman in tears.
Mother Fiona Hawke and Porsche's fiance Mark Chappel were present at the inquest at Winchester Coroner's Court.
Mum Fiona said: 'She was smart, funny and beautiful.
'But today I want to talk about one of her other qualities, which is that she was very understanding.
'She accepted failings in other people. She accepted that nothing is perfect in life.
'So that she chose to file an official complaint says a lot about how badly she felt. She left the appointment in tears. That was not usual for Porsche.
'She was at the tail end of nearly two years of illness. Two years of feeling that she hadn't been listened to. She was in pain a great deal of the time. She was looking for answers. She was scared and alone.
'She went to the doctor's expecting to be listened to and heard.'
Fiona said that her daughter felt 'talked over' and had her pain downplayed by some medical staff over a period of two years.
She continued: 'She knew it wasn't good. She knew it was going to be a fight. But she did not expect to die two days after being diagnosed with cervical cancer.
'What we do know is that time taken to diagnose and assess her cost us what time we had to adjust to the idea that we were going to lose her, to be there with her, to be there for her, and in any way prepare for the massive loss we were about to experience.
'If the exam had been done in January we would still have had time.
'A few weeks more of knowledge would have made an indescribable amount of difference.
'Anything would have been better than what we had. Not any of us, including Porsche, thought she would not come out of hospital.'
Coroner Rosamund Rhodes-Kemp said that the inquest could serve as a 'learning exercise' to prevent future deaths, and that although it was too late for 'beautiful and talented' Porsche, 'the consequences of excluding [the physical examination] are very serious'.
While it is standard practice to do such an examination, Dr Schlesinger said that Porsche's smear test and ultrasound were normal and did not believe her symptoms to be a sign of cancer.
Claire Burton, consultant gynecologist at Portsmouth Hospitals NHS Trust said that an investigation into the case had been made.
She said: 'It was clear there had been a delay in the diagnosis of the cancer.
'The consultant should have performed an examination at the time.'
Dr Schlesinger had previously told the court that he had not done a vaginal inspection as there had not been a chaperone available, but Dr Burton said that 'it was not felt there was a problem with chaperones' and one would have been available.
Portsmouth Hospitals NHS Trust set out an 'action plan' for the gynaecology clinic, involving 'reminding staff of the basics' and reinforcing the current protocols in place.
The plan includes no longer using agency staff 'but to increase consultant numbers'.
Dr Burton added: 'There was an opportunity missed.
'It would have given her a little bit longer.'
While the court heard that it is possible that if Porsche had had the chance to undergo chemotherapy she may have survived for further weeks or months, she already had advanced disease.
The coroner concluded that while 'earlier diagnosis would have given the more time for the family to prepare', it 'would not have altered the outcome'.
Outside the court, Fiona said: 'This has been heartbreaking and devastating for all of us in ways I cannot even describe.'
Afterwards, Liz Rix, chief nurse at Portsmouth Hospitals University NHS Trust, said: ‘On behalf of Portsmouth Hospitals University NHS Trust, 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.
‘I would like to reassure patients that their safety is of utmost importance to us and should they have any concerns or questions regarding their care, encourage them to raise these with the team caring for them.
‘Our thoughts are with Porsche’s family at this difficult time.’
A message from the Editor, Mark Waldron
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