Simonne Renvoize was misdiagnosed by Dr John Brennan in 1990, one of the two consultant radiologists whose work has been called in question in the current breast screening scare at the Royal Devon and Exeter hospital. Although her cancer was later detected by other doctors, she received inadequate treatment delivered too late, according to specialists who dealt with her case, and died a gruesome death in 1995.
It can never be proved that earlier treatment would have prolonged her survival, but the knowledge that she had been misdiagnosed added greatly to her suffering, according to her cousin, Judith Barnes. "Simonne died knowing she could have had better treatment from the NHS in which she had had great faith. It shattered her trust in the health service as it did for all the family," she said.
On Thursday, the Royal Devon and Exeter NHS trust announced that Dr Brennan and fellow consultant radiologist Dr Graham Urquhart have been asked to undergo retraining after a review found decisions they had made led to delayed diagnosis of nine women with breast cancer. Mammography films for 1,900 women are to be re-examined to check for microcalcification - minute traces of calcium in the breast which can indicate that cancer is developing.
Angela Pedder, chief executive of the trust, said screening for breast cancer was not an exact science. "Any consultant in any specialty will on occasion miss something. The question is whether it is within the scope of normal practice - because no one is perfect - or whether it is outside normal practice.
"Our review suggested that in terms of the particular interpretation of microcalcification there seems to be a need for re-training of these consultants in this area."
Documents seen by The Independent show that this is not the first time that Dr Brennan's judgement has been criticised. In April 1990, Simonne Renvoize, then aged 45, was referred to him at Treliske hospital, Cornwall, in April 1990, where he was then working, for breast screening after she had consulted her GP about lumps in both her breasts.
Dr Brennan told her that the lumps were not cancerous and were caused by hormonal problems and wrote in his report that there were "no suspicious features in either breast". Four months later she returned to her GP complaining the lumps were bigger. She was referred to a surgeon at the hospital. Breast cancer was diagnosed and she had a mastectomy in September 1990.
Because of further shortcomings in her treatment, the cancer in her other breast was not diagnosed until the following year and she had a second mastectomy in March 1991 - 11 months after it should have been detected.
Dissatisfied with her treatment, Ms Renvoize sought a second opinion from the Royal Marsden cancer hospital in London when the disease recurred in 1993. Ms Barnes said: "The specialist at the Marsden didn't hold out much hope. By 1994 she was told she wouldn't recover. The disease spread to her lungs and invaded her chest. The end was truly gruesome."
A medico-legal report on the case by Graham Whitehouse, professor of diagnostic radiology at Liverpool University, in June 1994, criticised Dr Brennan's failure to spot the tumours on the original mammography film. He wrote: "The carcinoma in the right [breast] should certainly have been observed by the radiologist ... I would have anticipated that a radiologist experienced in mammography would also have seen the left breast lesion."
Ms Renvoize had lived for 11 years in Australia, where she married a writer on a surfing magazine. After her marriage failed she returned to Newquay, Cornwall where she lived in a flat beneath her parents. When her cancer developed she became a campaigner for improved understanding of the disease.
Ms Barnes said: "I don't think her mother will ever get over it. She was an only daughter and they were very close. They both lived with a sense of anger that Simonne didn't get the best possible chance. They knew women in Newquay who had got breast cancer and had poor treatment and died but who did not want to make a fuss.
"Right to the end she kept her sense of humour and was very dignified but she was also very angry."
Before she died, Ms Renvoize wrote about her illness in the hope that her experience would serve as a warning to other women. She urged them to seek a second opinion and insist on treatment in specialist centres, not local hospitals.
She added: "We are referred to as cancer victims but are we victims of the disease or of the NHS? In the light of my experience I ask whether the NHS is failing British women. Something is seriously wrong."