Anne Dyson died following “neglect” by a hospital trust, a senior coroner has found
City Hall in Sunderland(Image: Sunderland City Council)
A woman died due to “neglect” that saw her lung cancer missed until it was too late for it to be treated, a coroner has warned. Anne Dyson, 68, died in St Benedict’s Hospice in Sunderland on February 24 this year.
Sunderland’s senior coroner David Place heard during a hearing which ended on August 15 this year how she had been monitored by medics at the South Tyneside and Sunderland NHS Trust for more than three years. Despite this she wasn’t diagnosed until just months before she died, the inquest heard.
Evidence also revealed how, in October 2023 and more than a year before her diagnosis- a scan showed an “increased growth” on her lung. It was also heard how in March 2024 a CT scan was “misinterpreted” and this led to delays in diagnosing her cancer.
In fact, she was not diagnosed until November 20 2024. By this time her cancer had spread and could not be cured. In a formal “prevention of future deaths” notice issued to the NHS trust, the senior coroner has said how 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”.
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At the inquest, senior coroner Mr Place found Ms Dysons’s death had been due to “natural causes contributed to by neglect”. In his formal warning letter, he has urged the NHS trust to ensure such a case cannot reoccur. The trust has apologised to Anne’s family and said this action had been taken with the aim of ensuring this could not be repeated.
M Place wrote: “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.
“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.”
Ms Dyson’s death is the second case in the region where a cancer diagnosis has been delayed due to issues with scans. Earlier this year – as reported by ChronicleLive – a Gateshead coroner found Jim Johnson’s lung cancer had also been diagnosed too late – when healthcare staff did not act on “red flags” which were apparent on his scans.
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.”
The trust now has until October 21 2025 to formally respond to the coroner’s concerns.
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