Anne Dyson

I am David Place, His Majesty’s Senior Coroner for the City of Sunderland

On 7 th March 2025 I commenced an Investigation into the death of Mrs Anne Lorraine Dyson, who died in St Benedict’s Hospice, Sunderland on 24 th February 2025 aged 68 years. The Investigation  concluded at the end of the Inquest on 15 th August 2025.  I gave a conclusion ‘Natural causes contributed to by neglect.’ The medical cause of death was: –  Ia Non Small Cell Lung Cancer (Metastatic)

Anne Lorraine Dyson died at St Benedict’s hospice on 24th February 2025 having been diagnosed  with metastatic lung cancer on 20th November 2024 despite being under investigation for lung  disease since September 2021 and scans showing an increased growth from October 2023. An  incorrect interpretation of a CT scan of 25th March 2024 led to a significant delay of many months in diagnosing a malignancy which had progressed to be terminal and could no longer be  successfully treated.

During the course of the Inquest the evidence revealed a matter giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.  The MATTERS OF CONCERN are: – The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies in quality and level of detail, and there is no consistent approach, with  Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken.  I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to  confirmation bias or satisfaction of search by the Radiologist when providing a report.  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.  I shall be glad to be told of any learning arising from this death and timescales and results of your review.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.