Quy Thi Pham
PFD Report
Partially Responded
Ref: 2025-0425
Coroner's Concerns (AI summary)
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women and delaying crucial cancer diagnosis.
View full 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 post-partum 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. 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
ii. Post-partum lochia can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. 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
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. 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.
(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum 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. 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
ii. Post-partum lochia can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. 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
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. 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.
Responses
Action Planned
NHS England is funding research expected to conclude by September 2027, to collect evidence on the safety and reliability of cervical screening tests within 3 months of birth, after which national guidance will be considered and updated accordingly. (AI summary)
NHS England is funding research expected to conclude by September 2027, to collect evidence on the safety and reliability of cervical screening tests within 3 months of birth, after which national guidance will be considered and updated accordingly. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Quy Thi Pham who died on DATE.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 August 2025 concerning the death of Quy Thi Pham on 3 September 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Quy’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Quy’s care have been listened to and reflected upon.
Your report raised concerns relating to the existing National Cervical Screening Guidance for pregnant women. In particular, you highlighted the Trust Consultant’s concerns that the Guidance may mean that a cohort of women may be excluded, specifically in relation to bleeding as a symptom of concern. This is because not all post-partum women have resumed coitus (leading to post-coital bleeding), post- partum bleeding can persist or be misinterpreted and therefore not understood to be abnormal, and women in general may not have a regular menstrual cycle making it difficult to diagnose bleeding. In addition, rare complications of early stage cervical cancer may not always manifest with bleeding symptoms.
The Cervical Screening Programme
The aim of the national cervical screening programme is to detect asymptomatic cell changes in the cervix that could, if left untreated, develop into cervical cancer in the future. The screening programme guidance for patients with unusual bleeding or gynaecological symptoms they are concerned about is always to seek advice from their GP. A cervical screening test is not an appropriate tool to investigate these concerns as it is not a diagnostic test.
Based on the information within your Report, it appears that the NHS Cervical Screening Programme guidance was followed in Quy’s situation. The guidance is that National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
6 October 2025
screening should be delayed if it is less that 3 months since the person gave birth, as the results may not be reliable due to the disruption to the epithelium of the cervix during birth and so could be falsely reassuring if a normal result is issued.
Screening programme advice on the management of abnormal bleeding is available: Abnormal vaginal bleeding in women under 25: clinical assessment - GOV.UK and Cervical screening: programme and colposcopy management - GOV.UK (individuals with symptoms and cervical screening in pregnancy).
Based on the clinical history provided which has been reviewed by clinical experts who support NHS England’s cervical screening team, Quy suffered from an aggressive form of cervical cancer which metastasised to the lungs at presentation. It is accepted that unusual and rapidly developing cervical cancers are unlikely to be prevented by screening. Even if Quy had received post-natal screening in July 2024, on the balance of probabilities, Quy would still have had an aggressive cervical cancer with lung metastases which, sadly, would still have been incurable.
There is research underway supported by the cervical screening programme to collect evidence on whether it is safe, accurate and reliable to report cervical screening tests within 3 months of birth. This research is expected to conclude by September 2027. When the findings of this research are available, NHS England will consider them and update national guidance accordingly.
GP Surgery Key Learnings
I understand that Quy’s GP Surgery undertook a comprehensive review of her records and completed a Significant Event Analysis.
The key learnings highlighted by the surgery include the introduction of mandatory prompts during postnatal checks to ask and record bleeding symptoms. Whilst completing new baby registrations, administrators will now check and book maternal postnatal and cervical screening appointments. Training on screening has also been undertaken, including the clarification of the referral pathway for abnormal bleeding which should trigger urgent gynaecological referral and not screening.
In addition, the surgery will flag vulnerable groups in their records (e.g. language barriers, never-screened, immunocompromised) and apply tailored communication strategies to ensure equitable access to screening.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Quy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 August 2025 concerning the death of Quy Thi Pham on 3 September 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Quy’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Quy’s care have been listened to and reflected upon.
Your report raised concerns relating to the existing National Cervical Screening Guidance for pregnant women. In particular, you highlighted the Trust Consultant’s concerns that the Guidance may mean that a cohort of women may be excluded, specifically in relation to bleeding as a symptom of concern. This is because not all post-partum women have resumed coitus (leading to post-coital bleeding), post- partum bleeding can persist or be misinterpreted and therefore not understood to be abnormal, and women in general may not have a regular menstrual cycle making it difficult to diagnose bleeding. In addition, rare complications of early stage cervical cancer may not always manifest with bleeding symptoms.
The Cervical Screening Programme
The aim of the national cervical screening programme is to detect asymptomatic cell changes in the cervix that could, if left untreated, develop into cervical cancer in the future. The screening programme guidance for patients with unusual bleeding or gynaecological symptoms they are concerned about is always to seek advice from their GP. A cervical screening test is not an appropriate tool to investigate these concerns as it is not a diagnostic test.
Based on the information within your Report, it appears that the NHS Cervical Screening Programme guidance was followed in Quy’s situation. The guidance is that National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
6 October 2025
screening should be delayed if it is less that 3 months since the person gave birth, as the results may not be reliable due to the disruption to the epithelium of the cervix during birth and so could be falsely reassuring if a normal result is issued.
Screening programme advice on the management of abnormal bleeding is available: Abnormal vaginal bleeding in women under 25: clinical assessment - GOV.UK and Cervical screening: programme and colposcopy management - GOV.UK (individuals with symptoms and cervical screening in pregnancy).
Based on the clinical history provided which has been reviewed by clinical experts who support NHS England’s cervical screening team, Quy suffered from an aggressive form of cervical cancer which metastasised to the lungs at presentation. It is accepted that unusual and rapidly developing cervical cancers are unlikely to be prevented by screening. Even if Quy had received post-natal screening in July 2024, on the balance of probabilities, Quy would still have had an aggressive cervical cancer with lung metastases which, sadly, would still have been incurable.
There is research underway supported by the cervical screening programme to collect evidence on whether it is safe, accurate and reliable to report cervical screening tests within 3 months of birth. This research is expected to conclude by September 2027. When the findings of this research are available, NHS England will consider them and update national guidance accordingly.
GP Surgery Key Learnings
I understand that Quy’s GP Surgery undertook a comprehensive review of her records and completed a Significant Event Analysis.
The key learnings highlighted by the surgery include the introduction of mandatory prompts during postnatal checks to ask and record bleeding symptoms. Whilst completing new baby registrations, administrators will now check and book maternal postnatal and cervical screening appointments. Training on screening has also been undertaken, including the clarification of the referral pathway for abnormal bleeding which should trigger urgent gynaecological referral and not screening.
In addition, the surgery will flag vulnerable groups in their records (e.g. language barriers, never-screened, immunocompromised) and apply tailored communication strategies to ensure equitable access to screening.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Quy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Noted
NICE clarifies that the recommendation to delay cervical screening post-partum comes from Public Health England (PHE) guidelines, not NICE guidance, and that NICE guidance recommends a suspected cancer pathway referral for a cervix with an appearance consistent with cervical cancer. (AI summary)
NICE clarifies that the recommendation to delay cervical screening post-partum comes from Public Health England (PHE) guidelines, not NICE guidance, and that NICE guidance recommends a suspected cancer pathway referral for a cervix with an appearance consistent with cervical cancer. (AI summary)
View full response
Dear Ms Hayes
Re: Regulation 28 Prevention of Future Deaths Report (Quy Thi Pham)
I write in response to your regulation 28 report dated 11 August 2025 regarding the very sad death of Quy Thi Pham. I would like to express my sincere condolences to Quy’s family.
The patient safety leads at NICE have carefully considered the content of your report and understand that your request relates to cervical screening post-partum.
Firstly, it may be helpful for me to clarify that the recommendation that cervical screening should be delayed for women who are less than 12 weeks post-partum does not come from guidance produced by NICE, but from Public Health England (PHE) guidelines, ‘Ceasing and deferring women from the NHS Cervical Screening Programme [PHE, 2019]’. We believe that the issues raised within your report are therefore best addressed by NHS England’s NHS Cervical Screening programme, and I note that your report has also been sent to them.
As background, this recommendation is referred to in the clinical knowledge summaries (CKS) section on cervical screening on the NICE website. CKS are developed by an external company called Agilio Software and are designed to summarise the evidence on the treatment of specific health conditions, however they do not constitute NICE guidance. We work with the publisher to make the CKS available on our website and, while they may refer to NICE guidance (if there is any that is relevant), they also use many other sources. They are written for health professionals working in primary care (usually GPs) however the guidance is freely available for anyone to access.
We will make Agilio aware of the concerns you raise so that they can check for any updates to the NHS Cervical Screening Programme when they next update this topic.
Although not directly mentioned in your report, it may be helpful for us to also highlight our guideline Suspected cancer: recognition and referral (NG12). Section 1.5 deals with
[Insert footer here]
2 of 2
gynaecological cancers and discussed cervical cancer in recommendation 1.5.13 which recommends: 'Consider a suspected cancer pathway referral for women if, on examination, the appearance of their cervix is consistent with cervical cancer’.
The rationale for that recommendation is on page 169 of the full guideline: 'The GDG noted that a cervix with an appearance consistent with cervical cancer is likely to be a symptom of cervical cancer. The GDG agreed, based on their clinical experience, that had this symptom been studied it would have had a positive predictive value of 3% or above. The GDG therefore agreed to recommend a suspected cancer pathway referral for this symptom. The GDG also discussed the likely PPVs for other symptoms, such as inter-menstrual bleeding, post-coital bleeding and vaginal discharge. However, the GDG agreed that these were likely to be extremely low as these symptoms are very common and cervical cancer is relatively rare. The GDG therefore decided not to make any further recommendations based on symptoms. Due to the lack of evidence and the fact that there is no other obvious test for a cervix with an appearance consistent with cervical cancer in primary care, the GDG were not able to recommend a particular test beyond visual inspection for the primary care investigation of cervical cancer.'
The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory for the NHS to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
I hope that the information above is helpful and would like to reiterate my sincere condolences to Quy’s family.
Re: Regulation 28 Prevention of Future Deaths Report (Quy Thi Pham)
I write in response to your regulation 28 report dated 11 August 2025 regarding the very sad death of Quy Thi Pham. I would like to express my sincere condolences to Quy’s family.
The patient safety leads at NICE have carefully considered the content of your report and understand that your request relates to cervical screening post-partum.
Firstly, it may be helpful for me to clarify that the recommendation that cervical screening should be delayed for women who are less than 12 weeks post-partum does not come from guidance produced by NICE, but from Public Health England (PHE) guidelines, ‘Ceasing and deferring women from the NHS Cervical Screening Programme [PHE, 2019]’. We believe that the issues raised within your report are therefore best addressed by NHS England’s NHS Cervical Screening programme, and I note that your report has also been sent to them.
As background, this recommendation is referred to in the clinical knowledge summaries (CKS) section on cervical screening on the NICE website. CKS are developed by an external company called Agilio Software and are designed to summarise the evidence on the treatment of specific health conditions, however they do not constitute NICE guidance. We work with the publisher to make the CKS available on our website and, while they may refer to NICE guidance (if there is any that is relevant), they also use many other sources. They are written for health professionals working in primary care (usually GPs) however the guidance is freely available for anyone to access.
We will make Agilio aware of the concerns you raise so that they can check for any updates to the NHS Cervical Screening Programme when they next update this topic.
Although not directly mentioned in your report, it may be helpful for us to also highlight our guideline Suspected cancer: recognition and referral (NG12). Section 1.5 deals with
[Insert footer here]
2 of 2
gynaecological cancers and discussed cervical cancer in recommendation 1.5.13 which recommends: 'Consider a suspected cancer pathway referral for women if, on examination, the appearance of their cervix is consistent with cervical cancer’.
The rationale for that recommendation is on page 169 of the full guideline: 'The GDG noted that a cervix with an appearance consistent with cervical cancer is likely to be a symptom of cervical cancer. The GDG agreed, based on their clinical experience, that had this symptom been studied it would have had a positive predictive value of 3% or above. The GDG therefore agreed to recommend a suspected cancer pathway referral for this symptom. The GDG also discussed the likely PPVs for other symptoms, such as inter-menstrual bleeding, post-coital bleeding and vaginal discharge. However, the GDG agreed that these were likely to be extremely low as these symptoms are very common and cervical cancer is relatively rare. The GDG therefore decided not to make any further recommendations based on symptoms. Due to the lack of evidence and the fact that there is no other obvious test for a cervix with an appearance consistent with cervical cancer in primary care, the GDG were not able to recommend a particular test beyond visual inspection for the primary care investigation of cervical cancer.'
The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory for the NHS to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
I hope that the information above is helpful and would like to reiterate my sincere condolences to Quy’s family.
Sent To
- National Institute for Health and Care Excellence
- NHS England
Response Status
Linked responses
2 of 3
56-Day Deadline
6 Oct 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 24 September 2024 , I commenced an investigation into the death of QUY THIS PHAM, AGE 29 . The investigation concluded at the end of the inquest on 5 August 2025. The conclusion of the inquest was 1a Metastatic Pulmonary Hypertension 1b Cervical Carcinoma. Narrative: Natural Causes: Quy Thi Pham died of an extremely rare but recognised and rapid progression of an early-stage cervical cancer resulting in tumour cells impacted within the small pulmonary vasculature that caused her death.
Circumstances of the Death
Quy Thi Pham died on 3 September 2024 at Basildon Hospital of Metastatic Pulmonary Hypertension due to Cervical Carcinoma approximately 5 months post-partum. Ms Pham had been called for routine cervical screening during her pregnancy on 2 occasions and was informed according to guidance that she needed to wait until she was 12-weeks post-partum, and this was repeated on 6 June 2024 when Ms Pham again attended. The GP surgery made an appointment for 5 July by text that was not acknowledged. A rescheduled appointment for 25 July 2024 was cancelled by the surgery due to staff shortages and was not rebooked. Ms Pham attended her GP surgery on 2 September 2024 with a several days history of pleuritic chest pain and shortness of breath and Ms Pham was sent to Basildon Hospital where she was treated for suspected pulmonary embolism. Ms Pham had low blood pressure with tachycardia and tests confirmed signs of right heart strain with suspicion of pulmonary embolism with sub-optimal scan due to breathing difficulties. Ms Pham continued to deteriorate and was admitted to intensive care on 3 September where she went into cardiac arrest that did not respond to treatment including thrombolysis. Ms Pham was found on post-mortem to have a heavy load of metastatic tumour cells that had impacted in the pulmonary vasculature that had spread from an early-stage cervical primary tumour that caused right heart strain. This led to cardiac arrest that was irreversible. Natural Causes: Quy Thi Pham died of an extremely rare but recognised and rapid progression of an early-stage cervical cancer resulting in tumour cells impacted within the small pulmonary vasculature that caused her death.
Copies Sent To
Mid & South Essex NHS Trust
: Care Quality Commission Royal College of General Practitioners Pathologist
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.