A coroner has warned an NHS trust over its “neglect” of a patient, after failing to identify her fatal cancer sooner, despite monitoring her condition for more than three years.
Anne Lorraine Dyson, 68, died in St Benedict’s Hospice in Sunderland on February 24, after being diagnosed with terminal metastatic lung cancer some four months earlier.
She had been under investigation for lung disease by South Tyneside and Sunderland NHS Foundation Trust since September 2021, while scans showed she had an increased growth in the organ from October 2023.
A CT scan was also wrongly interpreted on March 25 2024, which meant diagnosis of a malignancy in her lung was delayed by many months, by which point it could no longer be successfully treated.
An inquest into Ms Dyson’s death concluded that she died of “natural causes contributed to by neglect”.
David Place, senior coroner for the City of Sunderland, said evidence heard at the inquest had shown there was “no consistent approach” for radiologists interpreting medical scans at the trust, which could unintentionally lead to “confirmation bias”.
“The evidence indicated that radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period,” the coroner said.
“I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted, not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed.”
Copies of the coroner’s prevention of future deaths report were sent to the trust, Ms Dyson’s family and the Care Quality Commission.
Mr Place added: “I shall be glad to be told of any learning arising from this death and timescales and results of your review.”
Ben Hall, clinical director of diagnostic imaging at South Tyneside and Sunderland NHS Foundation Trust, said: “We offer Anne’s family our heartfelt condolences following their loss. We understand this has been a very difficult time for her loved ones.
“We know from the review we have carried out that we missed a vital warning sign she had developed lung cancer. This should not have happened and we apologise for this.
“We have thoroughly investigated this and shared learnings with our wider radiology team with the aim this will not happen again.”
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