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.