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NHS Trust Must Act After Year-Long Cancer Diagnosis Delay
27 Oct
Summary
- Woman's cancer diagnosis delayed nearly one year, leading to her death.
- A lung nodule was overlooked for investigation despite radiologist concerns.
- Coroner issued report highlighting systemic issues at Nottingham NHS Trust.
An NHS trust has been mandated to implement changes following a significant delay in diagnosing a woman's lung cancer, which occurred approximately one year before her passing. Gloria Monte, aged 79, died at Nottingham City Hospital on May 2, 2025. An inquest concluded in August revealed that a lung nodule identified in February 2024 was never investigated, despite warnings it "could be" a primary lung tumour.
The Nottingham University Hospitals (NUH) NHS Trust was found responsible for delays due to individual and systemic failures in Monte's medical care. Coroner Laurinda Bower issued a prevention of future deaths report to NUH, highlighting concerns that incidental findings on scans were overlooked. The trust's medical director expressed deep apologies for the missed opportunities and affirmed a commitment to improving patient safety.
The inquest detailed how Monte underwent imaging in February 2024 after a fall, revealing a nodule on her lung. Although flagged as potentially significant, no referral was made to the appropriate teams. Subsequent medical appointments throughout the year failed to address the lung nodule. It was only in February 2025, when Monte presented with chest symptoms, that imaging confirmed suspected lung cancer, confirmed as likely originating from the previously overlooked nodule.
Coroner Bower noted a long-standing failure at NUH to mitigate the risk of overlooking incidental imaging findings, with ongoing disputes about responsibility between departments. The trust lacked a clear policy for actioning such findings, a known issue since at least 2007, despite national patient safety alerts. Concerns were also raised about over-reliance on an automated system for flagging incidental findings.
