A woman died from cervical cancer after abnormalities were missed following two routine smear tests, an inquest heard.
Mother-of-two Linda Strode, 54, of Pontblyddyn, Flintshire, died on 2 January 2023 after being diagnosed with untreatable stage four cancer.
This was after an earlier negative smear, while she also received clear results in 2016.
Public Health Wales apologised to the family after an inquest in Ruthin, Denbighshire.
Dr Andrew Evered, a consultant biomedical scientist for Cervical Screening Wales, took part in a review of both Ms Strode’s test results in an inquiry following her death.
He told the inquest that looking for abnormal cells was “subjective” and a “difficult process”, but that the original screeners had “made mistakes” and abnormalities had been “missed”.
His review of the cells taken in 2016 found they were abnormal in the “very earliest stage of cancer”, and added: “Clearly classifying it as normal was a mistake.”
Talking about the 2021 test, he said the slide did not contain enough cells to make an accurate assessment, and it should have been reported as ” inadequate”, with Ms Strode recalled for a repeat smear test.
Gareth Powell, head of programme for Cervical Screening Wales said the team examines about 25,000 slides a year and latest figures, from January 2021 to August 2023, showed an accuracy rate of 98.93%, compared with 95% UK-wide.
But he said “mistakes can happen”.
Ms Strode’s test in 2016 was examined by two screeners, and in 2021, by three separate screeners, but in nether case were abnormalities or concerns found or flagged.
Mr Powell said screeners were “continually monitored” for performance.
Cervical Screening Wales said its thoughts were with the family and Powell said: “I would like to apologise to the family for the mistakes and we will do our best as a service to learn.”
Ms Strode’s oncologist at Ysbyty Glan Clwyd, Denbighshire, Dr Nikhil Oommen, said cervical cancer at stage three or below can be treated with chemotherapy, but by the time she was referred to him, it was too late for anything other than palliative care.
Giving his narrative conclusion to the hearing, senior coroner John Gittins said her smear test in 2016 did not identify the presence of abnormal cells, and in 2021, the slide was incorrectly reported, which meant she did not have further tests at a stage when curative treatment could have been an option.
He added it was “hard to get his head around it happening twice,” but he said he would not be making a prevention of future deaths report.
“The reality is I am not comfortable with what happened here because there were two mistakes, which have been devastating,” he said.
“However, I have to balance that with the data I have been provided with. It reassures me there is a process, and largely a good process.
“It is a valuable process and valuable resource which largely works properly.”
Addressing Ms Strode’s family, he said: “The reality of 99% is there will always be 1%, and in your case it’s Linda, mum, sister.
“This is devastating for you as a family but also has an impact on those involved in the process. It is not taken lightly by Public Health Wales.”
After the hearing, Linda Strode’s daughter Sharna Shwenn said: “We are devastated. It shouldn’t have happened.”
She described her mum as a “positive person who loved life”.
“I truly believe she would have been here today if treated correctly,” she said.
“It makes me so angry she died because her results weren’t checked properly,” she added.