A man died of lung cancer after doctors at Gateshead’s Queen Elizabeth II Hospital didn’t act upon a suspicious X-ray, meaning his disease was left to progress for over a year.
John Johnson was admitted to the hospital’s emergency department on 8 April 2022, after fracturing his leg in a fall at home. Ahead of planned surgery on his fracture, because of his age and the potential need for a general anaesthetic, he underwent a chest X-ray.
The results of this scan reported a suspicious lesion in his right lung which was red-flagged by a radiographer. It was recommended in the X-ray report that Johnson should be referred to the respiratory team as soon as possible.
But following his transfer to an orthopaedic ward, nobody looked at his test results, meaning they were missed and no respiratory referral was made. He was soon discharged.
In May 2023, Johnson returned to hospital with severe breathing difficulties and the results of the earlier chest X-ray were noted. Further investigations were carried out and he was diagnosed with lung cancer. He died on 22 November 2023.
A new policy
A patient safety incident case review report by the Trust found there was a “lack of ownership” for the test results of patients who transfer from the emergency department to other speciality care areas.
This meant there was a “missed opportunity” to refer Johnson for specialist care the previous year.
An inquest concluded that he had died of natural causes contributed to by neglect.
Assistant coroner James Thompson ruled that when Johnson went back to hospital in May 2023 treatment options to cure his cancer were unavailable.
Understandably they have a number of concerns regarding whether more could have been done to help Jim once his lesion was identified on an X-ray,” said Stuart Bell, the expert medical negligence lawyer at Irwin Mitchell representing the family.
The Trust has now introduced a policy where test results, which highlight possible suspicions of lung cancer, are sent straight to specialists for discussion.
