Trust missed two opportunities to diagnose cervical cancer, leading to an unnecessary hysterectomy

Organisation we investigated: The Newcastle Upon Tyne Hospitals NHS Foundation Trust

Date investigation closed: 31 October 2019

The complaint 

Complainant P complained that they received two false negative results following cervical cancer screening (smear tests) before going on to develop cervical cancer. They also complained that the Trust took too long to respond to her complaint.

What we found 

The Trust accepted that the smear tests were reported incorrectly. The Trust said that if these tests had been reported correctly, Complainant P would have been referred for further investigations. However, the Trust had not considered the impact of these failings on Complainant P in its response to their complaint. 

We found that if Complainant P had been referred for further investigations following the first wrongly reported test, the cancer would probably have been picked up within 18 months. Treatment at that stage would have been much less intensive, and they would have been continually monitored for 10 years. 

We also found that if the second wrongly reported result had been reported correctly, further investigation would have identified a pre-cancerous area or early invasive cancer. Treatment at this stage would also have been much less intensive and Complainant P would have been unlikely to need a hysterectomy. 

We found the Trust did not keep Complainant P updated following their complaint. It could have given at least a partial response while it waited for the other organisation to provide additional information. This compounded the distress Complainant P experienced. 


Complainant P had three smear tests, four years apart. The Trust reported these as negative, meaning that there were no abnormalities that would prompt further investigation.  

Complainant P was then diagnosed with cervical cancer after a positive smear test. As a result, they had a hysterectomy. 

The Trust later completed an audit of Complainant P’s two smear test results before the positive result, as part of the National Cervical Screening Audit. The audit found both test results showed abnormalities in the cells.  

Complainant P complained to the Trust. The Trust sought information from another organisation.

Putting it right 

We recommended the Trust write to Complainant P to acknowledge and apologise for the failings in reporting of the smear tests and in how it handled the complaint.  

The Trust told us the process for reporting smear test results had changed since the events in this case. All tests are now checked by two people and both checks are documented. We were satisfied this reduced the risk of the same mistakes occurring in future. 

We recommended the Trust develop a plan to ensure complaints are responded to promptly and complainants are kept updated. 

We did not recommend a financial recommendation in this case, as NHS Resolution was involved and was discussing an appropriate financial remedy. 

The Trust complied with our recommendations.

This case summary is featured in the Ombudsman's Casework Report 2019.