Woman died after one-year delay in cancer diagnosis

An NHS trust has been told it must take action after a woman's cancer diagnosis was delayed for about one year before she died.

Gloria Monte, 79, died of lung cancer at Nottingham City Hospital on 2 May 2025.

An inquest at Nottingham Coroner's Court, which concluded in August, heard a nodule was discovered on her lung in February 2024, and although she was told it "could be" a primary lung tumour, it was never investigated. She was diagnosed with cancer the following year.

The inquest found there had been a delay in her diagnosis "due to individual and systemic omissions in her medical care" by Nottingham University Hospitals (NUH) NHS Trust, which has apologised to Monte's family.

Coroner Laurinda Bower issued a prevention of future deaths report - a notice by coroners to highlight areas where action is needed to stop similar deaths - to NUH over concerns raised during the inquest.

Manjeet Shehmar, NUH medical director, said the trust was "deeply sorry for the missed opportunities identified during the inquest", and said staff were committed to improving patient safety.

The inquest - detailed in the coroner's report, which was published on 19 October - heard Monte had been to the emergency department (ED) in February 2024 after a fall and underwent a chest X-ray and CT scan.

A report of the scan found injuries and a 14mm nodule on Monte's lung, which was described by a radiologist as "likely incidental but could be a primary lung tumour".

The ED doctor noted the incidental finding and referred Monte to the major trauma unit, with an expectation she would be referred to the multi-disciplinary team that dealt with lung nodules.

However, the major trauma doctor determined Monte did not need to be admitted, and no referral was made.

Her GP was also not tasked with actioning a referral or follow-up, according to the coroner's report.

A number of follow-up appointments took place throughout the year, but no reference was made to the lung nodule.

In February 2025, the report said Monte attended her GP with chest symptoms. When she did not improve with antibiotics, her GP arranged her admission to hospital.

It was then that chest imaging found suspected lung cancer, and it was concluded after a comparison with the imaging from 2024 that the nodule noted at the time was probably cancer.

In her report, Bower said there had been a known risk of incidental imaging findings being "overlooked" by NUH for years.

She wrote: "There has been a long-standing failure to adequately mitigate this risk, and there is ongoing dispute about who is responsible for actioning incidental imaging findings; ED (as the investigation originator to whom the results/reports will always be sent) or the admitting team."

The coroner said there was a "failure" to have in place a clear policy identifying who was responsible for acknowledging and actioning incidental findings from ED imaging.

She noted that this issue had been raised at an earlier inquest, which had "similar themes".

Bower said it was "disappointing" that the trust had no agreed standard operating procedure to address the risk, despite it being raised "consistently since 2007" in national patient safety alerts - high-level communications issued to providers to instruct them to take action to prevent serious harm.

The coroner also raised concerns over what she called an "over-reliance" on an automated alerting system used in the radiology department to identify and safety net incidental findings.

NUH medical director Shehmar added: "We would like to offer our sincerest condolences to Gloria's family, and we are deeply sorry for the missed opportunities identified during the inquest.

"The trust has taken the coroner's concerns seriously, and we have already revised the Radiology Alert Standard Operating Procedure to make it clearer to colleagues which findings require an alert and to align the process with national professional guidance.

"We will continue to engage with Gloria's family and provide the coroner with six-monthly updates on the progress of the improvements and actions being implemented in response to the concerns raised.

"We remain committed to improving patient safety across our hospitals."

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