Incidental lung nodule missed for a year before fatal cancer diagnosis
A 79-year-old woman died of lung cancer after an incidental nodule seen on imaging was not followed up for about a year, exposing a dangerous gap in how abnormal scans are tracked across hospital teams. The case has now prompted a coroner to order action from Nottingham University Hospitals NHS Trust after finding failures at both the individual and system level.
Gloria Monte died at Nottingham City Hospital on 2 May 2025, after a delay that began when a lung nodule was identified in February 2024 during an emergency department assessment after a fall. The scan report described the 14mm nodule as “likely incidental but could be a primary lung tumour.” In practice, those words should have triggered a closed-loop escalation: someone had to own the finding, ensure review, and confirm follow-up. None of that happened.
The consequences were abrupt and final.
How the nodule slipped through the follow-up chain
Monte’s February 2024 emergency visit led to a chest X-ray and CT scan, which captured injuries from the fall and the lung lesion. The emergency department doctor documented the incidental finding and referred her to the major trauma unit with an expectation that the lung nodule would be passed on to the multidisciplinary team responsible for such findings. Instead, the major trauma doctor decided she did not need admission, and no referral followed. Her GP was not instructed to arrange follow-up either, leaving the abnormality without a designated owner.
Over the next year, multiple appointments took place, but the lung nodule was never raised again. That is the sort of failure that can happen when systems rely on memory, assumptions, or team boundaries instead of a defined pathway. Incidental findings on imaging are clinically important precisely because they often emerge in urgent care settings, where the immediate focus is trauma, infection, or pain rather than cancer surveillance. If no one is assigned to act, the abnormality can vanish into routine care.
By February 2025, Monte presented to her GP with chest symptoms. Antibiotics did not help, and she was admitted to hospital. New chest imaging then raised concern for lung cancer, and comparison with the 2024 scan showed the earlier nodule was probably malignant.
Coroner cites individual and systemic omissions
The coroner concluded that the diagnosis was delayed because of “individual and systemic omissions” in Monte’s care. The report described a broader trust-wide risk: incidental imaging findings had been overlooked for years, and there was still no clear policy identifying who must acknowledge and action them when they arise from emergency department imaging.
That failure is especially troubling because the issue had already surfaced in earlier inquests and had been raised consistently in national patient safety alerts since 2007. Those alerts are intended to drive hospitals toward standardised safeguards when a recurring hazard can lead to serious harm. Here, the hazard was not a subtle radiology error. It was the absence of a dependable process to make sure an incidental finding traveled from scan report to clinical action.
The coroner also criticised an over-reliance on an automated alerting system in radiology to identify and safety-net incidental findings. Automation can support safety, but it does not replace accountability. If a system depends on software flags without a hard-wired clinical workflow, the alert may be generated while the patient still falls through the gap between departments.
Why incidental cancer findings need a closed-loop pathway
A 14mm lung nodule described as possibly a primary tumour is not a trivial observation. In real-world cancer care, the earliest imaging clue may appear outside oncology entirely, in an emergency scan ordered for a fall, chest pain, or infection-like symptoms. That makes the handoff as important as the radiology read. If the finding is left in a report with no named clinician responsible for review, follow-up becomes vulnerable to shift changes, discharge decisions, and competing priorities.
This case shows why incidental findings need a formal closed-loop system: radiology identifies the lesion, the responsible clinical team acknowledges it, follow-up is ordered, and the patient’s primary care record reflects the next step. Without that chain, the lesion may remain visible only on paper until symptoms finally force re-imaging. By then, disease may have progressed from a potentially earlier-stage discovery to a far more advanced and less treatable cancer.
The bedside implication is direct. Patients can leave hospital believing that a scan finding has been “noted,” while in fact no referral has been made and no appointment is pending. Families often assume that another team is handling it. Clinicians assume the other service will take ownership. The coroner’s report shows how dangerous those assumptions can be.
Trust response and continuing safety concerns
NUH’s medical director said the trust was deeply sorry for the missed opportunities identified during the inquest and apologised to Monte’s family. The trust said it had already revised its Radiology Alert Standard Operating Procedure to make it clearer which findings require an alert and to align the process with national professional guidance. It also said it would continue engaging with the family and provide six-monthly updates on improvements and actions.
Those revisions matter only if they produce reliable behavior at the point of care. A policy can exist on paper while the real-world workflow still depends on informal understanding. The coroner’s criticism suggests the trust had not yet solved the basic question of who is responsible for actioning incidental imaging findings from emergency department scans. Until that is fixed, the same failure mode remains available.
The case is not about a single missed report line alone. It is about a preventable delay in cancer diagnosis, the absence of a clear ownership model, and a safety system that appears to have depended too heavily on alerts rather than accountable follow-through. For patients, that difference can determine whether a suspicious nodule is investigated when it is first seen or only after disease has already declared itself through symptoms.