A woman who died following a cancer misdiagnosis felt she was 'not listened to' by her doctor.
Porsche McGregor-Sims died on 14 April 2020 - one day after being admitted to Queen Alexandra hospital in Portsmouth.
The 27-year-old events manager and aspiring model was initially referred to a consultant in December 2019 after complaining to her GP about abdominal pain and vaginal bleeding.
She was seen on 24 January 2020 by locum gynaecologist Dr Peter Schlesinger, who deemed a physical examination unnecessary, believing her symptoms were linked to hormonal changes caused by contraception or irritable bowel syndrome (IBS).
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McGregor-Sims continued to report symptoms over the following months and was prescribed antibiotics over the phone; she was only seen in person after a GP suspected she may have Covid-19, due to her shortness of breath.
A 5.3cm mass was detected on 6 April and a further scan on 9 April found that the cancer was widespread and inoperable.
McGregor-Sims was admitted to hospital with severely short breath on 13 April - with the cancer having spread to her lungs - and a day later she suffered a fatal heart attack.
Speaking at her inquest, the family said she felt she had not been listened to, and she was 'scared and alone' when she was finally admitted to hospital.
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Her mum, Fiona Hawke, told Dr Schlesinger: "You robbed us of the opportunity to prepare for her death and say goodbye to her."
She continued: "She knew it was going to be a fight and she knew she probably was not going to survive it in the long run but she did not expect to die days after being diagnosed.
"She expected to be listened to and helped but that is not what happened.
"Had the examination been done in January we would have still had some time with her. A few weeks more would have made an indescribable difference to that experience for all of us - including Porsche."
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The inquest heard Portsmouth Hospitals NHS Trust had reviewed protocols following the case, with the trust deciding not to employ any locum doctors in the future. All patients seen by Dr Schlesinger have now been seen again by another doctor, the inquest heard.
Coroner Rosamund Rhodes-Kemp concluded McGregor-Sims died of natural causes, adding that her death was one of the most 'shocking and traumatic' cases she had ever dealt with.
"We see hundreds and hundreds of cases every year - and I have done about 6,000 inquests - but this one is particularly sad," she said.
"On 24 January she was seen by a consultant locum gynaecologist who didn't examine her nor refer her for a colposcopy (an examination of the cervix). She was instead advised on [symptoms of] IBS.
"It is not clear that a referral in January would have altered the tragic outcome, but an earlier diagnosis would have allowed her and her family more time to prepare themselves."
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Liz Rix, the chief nurse at Portsmouth hospitals university NHS trust, said: "I would like to express our condolences to the family of Porsche McGregor-Sims.
"When we were aware of concerns around her care, we immediately investigated these and ensured we learnt from the experience of Porsche and her loved ones."
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