Gynaecologist failed to carry out exam that may have detected cervical cancer in woman (77), inquiry hears

Seán McCárthaigh

A consultant gynaecologist who recommended Ann Summers products to an elderly patient with vaginal bleeding, but who failed to carry out a thorough medical examination of the woman that might have detected she was suffering from cervical cancer, has been found guilty of poor professional performance.

A fitness-to-practise inquiry by the Medical Council found an allegation proven that Dr John Bermingham, a consultant gynaecologist at University Hospital Waterford, had inappropriately diagnosed the 77-year-old female as suffering from atrophic vaginitis – an inflammation and thinning of the vaginal lining – during a consultation on July 10th, 2018.

The inquiry heard the patient was subsequently diagnosed with Stage IV cancer of the cervix and uterus in November 2018 and died two months later.

As part of the allegation, the fitness-to-practise committee found that the consultant had failed to conduct an abdominal palpation as well as both a manual and speculum examination of the patient’s vagina.

The inquiry heard that Dr Bermingham had relied solely on a letter from the woman’s GP to reach his working diagnosis that she had atrophic vaginitis for which he prescribed a HRT medication.

It also emerged that the consultant had discussed “sexual activity and male drive” with the patient as well as the use of Ann Summers products for her “personal comfort.”

In addition, the gynaecologist recommended a book entitled Intimacy Through the Ages to the elderly woman.

Dr Bermingham, who did not attend the inquiry, made admissions through his legal representative about the allegation and also accepted that it constituted poor professional performance.

The inquiry arose after the woman’s daughter made a complaint to the Medical Council in July 2019 about what her family believed were “very obvious mistakes” in the diagnosis and treatment of their mother by Dr Bermingham.

The patient had experienced vaginal bleeding in June 2018 and attended her family doctor who referred her to the consultant.

An ultrasound carried out on the woman before her consultation with Dr Bermingham on July 10th, 2018 had found no overt sign of any disease.

She visited the gynaecologist again on October 9th, 2018 after she experienced severe pain in her back and pelvic area when she was referred for another ultrasound.

Later that month, the woman’s daughter said she was told by Dr Bermingham that he did not know what was causing the problem with her mother who had been suffering “excruciating” pain by that stage.

The patient was referred by Dr Bermingham to an oncologist who diagnosed that she had an advanced form of cancer following further specialised tests.

Her daughter said they had “lost a vibrant, kind, loving wife, mother, grandmother and sister who had a lot more living to do.”

In reply to the complaint, Dr Bermingham, said the result of the ultrasound performed before he first saw the patient had been “reassuring” while she had also appeared well and her GP had found “little of note.”

The consultant told the Medical Council there was no clinical basis for ordering a CT or MRI scan or referring the patient to an oncologist.

He also pointed out that he never shied away from “discussing intimate matters” with his patients.

Dr Bermingham said he told the woman’s GP that he would review her again in three months but to return earlier if she had any issues.

The inquiry heard the GP wrote to the consultant on August 15th, 2018 to expedite a follow-up as the patient was passing clots.

Dr Bermingham said he also observed clots when he examined her in his clinic on October 9th, 2018 and ordered another ultrasound to determine the next course of action.

The patient’s care was passed over to an oncologist a few weeks later after Dr Bermingham was concerned that her clinical symptoms were not fitting the findings of his examination.

Offering his condolences to the woman’s family, the consultant said an endometrial carcinoma was “not a major consideration” and he never suspected such a condition.

Dr Bermingham told his regulatory body that he had treated the patient at all times with dignity and at no time was dismissive or inconsiderate of her concerns.

He pointed out that he was anxious to avoid performing any unnecessary exploratory surgeries on the woman given her age and other medical conditions.

The consultant said he was “personally distressed” that the advanced carcinoma was not evident during his assessments of the patient.

Counsel for the Medical Council, Neasa Bird BL, said a report by an expert witness, Cliona Murphy, noted that postmenopausal bleeding was considered “a significant or red flag symptom.”

Dr Murphy explained that 10-15 per cent of cases of postmenopausal bleeding were due to endometrial cancer.

The gynaecologist said the usual work-up for the treatment of postmenopausal bleeding should be abdominal and pelvic examinations including one with a speculum.

Dr Murphy said an ultrasound should also be carried out to check the endometrial thickness with possible further tests dependent on its results.

She said it would have been “quite reasonable” to diagnose the patient with atrophic vaginitis if at least manual and speculum examinations of her vagina had been performed.

However, Dr Murphy also acknowledged that even if the consultant had conducted a proper examination of the patient it was possible he might not have detected the carcinoma as some are not easily visible even with a speculum examination.

She said the GP’s letter to Dr Bermingham in August 2018 should have triggered an earlier appointment with the consultant before she was actually seen on October 9th, 2018.

However, Dr Murphy also stated that she believed it was unlikely that it would have made “a difference to the ultimate outcome” apart from making an earlier diagnosis.

The expert witness concluded that there were “perturbing” elements to Dr Bermingham’s treatment of the patient which she considered “serious failings.”

On the issue of sanction, Ms Bird said it might be appropriate for conditions to be attached to the consultant’s registration in order to address “the underlying, serious clinical failures.”

Counsel for Dr Bermingham, Cathal Murphy BL, described the subject matter of the inquiry as “an isolated incident” and he believed the sanction of censure “would meet the circumstances of the case.”

Confirming the finding of poor professional performance, the inquiry’s chairperson, Marie Culliton,said the recommended sanction, which would not be made public, would be conveyed to the Medical Council to consider.