What Does a Coroner’s Conclusion of Neglect mean?

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We acted for Julie O’Connor and her husband Kevin in connection with Julie’s claim against North Bristol NHS Trust for delayed diagnosis of her cancer.   Sadly Julie passed away in February 2019.

The inquest into Julie’s death finished last week with the Coroner giving a neglect conclusion in respect of the care which North Bristol NHS Trust provide to Julie.  She said:

‘I consider that based on the evidence I have heard the failure to report the smear test accurately was a gross failure and the further assessments in both August and November 2016 were also gross failures’

And she concluded that Julie’s death was due to ‘natural causes contributed to by neglect’



A gross failure is one which was substantial and not trivial.  It is a failure which is more than a basic failure.


In an Inquest, neglect has a very narrow, specific meaning – much narrower than the duty of care in the law of negligence.  It is not to be equated with negligence or gross negligence.

It is limited in a medical context to cases where there has been a gross failure to provide basic medical attention to someone obviously in need of it, and where that gross failure has played a part in the death..

In a medical context it is not the role of an inquest to criticise every twist and turn of a patient’s treatment. Neglect is concerned with the consequences of, for example, failing to make simple (“basic”) checks, or do something the patient very obviously needed.

The critical point is “the opportunity of rendering care … which would have prevented death”. It is not enough to show that there was a missed opportunity to render care which might have made a difference; it must be shown that care should have been rendered and that it would have made a difference, and saved or prolonged life.


The fact that the Coroner concluded that there was neglect, a failure to provide basic medical care, due to several gross failures in the care provided to Julie highlights the severity of her concerns about the care which Julie received.

The coroner has indicated that she will write to the Department of Health and Social Care and to the Royal College of Obstetricians and Gynaecologists with her findings.

The Trust indicated that it had learned from the mistakes made in Julie’s care and has improved their ability to diagnose cervical cancer.

Julie’s husband Kevin O’Connor is continuing Julie’s fight to ensure that ensure that recommendations and safeguards are put in place to protect all women, and for there to be a safe cervical screening and gynaecological service. He is keen that there should be a wider review of past cases to consider if there are other victims who have had their cervical cancer diagnosis delayed.