Prevention of future deaths report: Gloria Monte (19 October 2026)

Summary

Gloria Monte died on 2 May 2025, at the City Hospital, Nottingham, as a result of cancer. There was a delay in diagnosing Gloria’s cancer of approximately one-year. She had initially attended the emergency department (ED) following a fall in February 2024, where a nodule was discovered on her lung which she was told could be a primary lung tumour. The nodule was not subsequently investigated.

Gloria attended her GP in February 2025 with chest symptoms. She was treated with antibiotics but when she failed to improve, her GP arranged an admission to hospital. There, chest imaging showed findings suspicious of lung cancer and comparison with the February 2024 imaging led to the conclusion that the nodule noted the year prior probably was cancer.

In their findings the Coroner states that if diagnosis had been achieved as expected in 2024, Gloria would have been counselled on the available treatment options. If she had accepted those options, it is possible that she may have lived for longer than she in fact did, but the Coroner has been unable to determine whether her life would probably have been extended because there are many variables to the success of, and side effects of, cancer treatment.

Content

The coroner highlights the following matters of concern:

A failure to have in place a clear policy identifying the clinician responsible for acknowledging and actioning incidental findings from ED imaging

• This prevention of future deaths report follows the report issued at the conclusion of the inquest touching the death of David Marriott, at which similar themes were explored.

• Gloria’s death is a further example of the Trust’s failure to have in place a clear policy on who holds responsibility for taking action following a report of incidental findings on imaging requested by ED teams.

• The Coroner expressed concerns that there is a risk of future deaths presented by the current standard operating procedure in the following scenarios:

  • A patient might be referred to a speciality by the ED doctor holding a mindset that the patient is going to be admitted, only to find that the speciality has not admitted the patient. Where does responsibility rest then? If the speciality is being requested to provide a specialist opinion relevant to their expertise (and out of hours this is likely to be an incredibly stretched junior doctor covering the wards/theatre, as well as ED admissions and the on-call phone), is it reasonable to expect the speciality to pick up and action incidental findings arising from imaging request by ED?

  • A patient might be admitted by a speciality, only to find that they have a more urgent medical concern which requires urgent transfer to another speciality. Where does responsibility rest then?

  • Despite referral to a speciality, the patient might self-discharge before being seen by the speciality or admitted if accepted. Where does responsibility rest then?

The Coroner states that requests for investigations come with results, and those results need to be acknowledged and actioned in a timely and appropriate manner. NHS England guidance proposes that responsibility should rest with the originator.

An over-reliance on consensus alerts to identify and safety net incidental findings and a lack of clarity of language in the Trust’s Radiology Guidelines

• The Coroner states that they have heard evidence that there is a division of opinion amongst radiology colleagues as to whether a 14mm pulmonary nodule should trigger a cancer alert via consensus.

• The policy states “5.2 New cancer imaging expected or unexpected. This includes expected or unexpected imaging findings that suggest new or probable new cancer and new or probable new cancer recurrence within the report.”

• Later the policy provides a non-exhaustive list of examples, including, “An unexpected lung nodule or a solid renal mass suspicious of a new carcinoma”

• There are three different standards mooted within the guidance – suspected,  probable and suspicious – which the Coroner deems unhelpful. Whether the threshold of  suspicious applies only to a solid renal mass is also open for debate.

• In Gloria’s case, the radiologist reported the nodule as “likely incidental but  could be a primary lung tumour”. 

• The British Thoracic Society Guidelines (2015) identify pulmonary nodules of  greater than 5-6mm as requiring follow up (the degree of action then increases based on size). In which case, the Coroner asks in their report might this be a clear trigger for an alert?