Overview

• An inquest found Anne Lorraine Dyson, 68, died of natural causes contributed to by neglect following a delayed lung cancer diagnosis.
• Evidence highlighted a lack of a consistent approach to scan interpretation and no routine symptom summaries for radiologists, raising risks of confirmation bias.
• Dyson was investigated for lung disease from September 2021; a scan showed increased growth in October 2023; a CT was misread on March 25, 2024; diagnosis came on November 20, 2024; she died on February 24, 2025.
• The coroner sent the Prevention of Future Deaths report to the trust, the family, and the Care Quality Commission, requesting details of learning and review timelines.
• The trust acknowledged a missed warning sign, apologized to the family, and said it had investigated and shared learning, and it has until October 21, 2025 to formally respond.