Inquest into the death of an Ollerton man from lung cancer concluded Major Oak Medical Practice, Edwinstowe, missed opportunities to diagnose him
A coroner identified ‘missed opportunities’ to save a 39-year-old man who died after a delayed stage four lung cancer diagnosis.
David Pickering, 39, died on August 21, 2024, at his home in Ollerton, of metastatic lung cancer.
The inquest into his death concluded in Nottingham on Friday when coroner Dr Elizabeth Didcock identified a ‘significant missed opportunity’ for a referral in October 2023.
In her narrative conclusion, Dr Didcock said: “I find on the balance that had the referral to the respiratory team been made by the practice by October 2023, David would not have died when he did.”
David had first gone to the Major Oak Medical Practice in Edwinstowe in April 2023 with a persistent cough that had started in January.
He had no known chronic chest condition but was a long-term smoker and had a family history of asthma.
Following the GP appointment, he had chest X-rays in April, May, August and October 2023 and again in May 2024.
The April X-ray didn’t raise any concerns, but the results showed a density change in the lung tissue. Doctors suspected it was an infection and prescribed him antibiotics.
The May X-ray was described as being stable, however, David still had a persistent cough.
The inquest heard from Dr Emad Gabrawi, a GP partner at the Major Oak Medical Practice, who started following David’s case in August 2023.
The inquest heard that the term inflammatory used in the radiology reports may have been misunderstood by GPs, with the coroner finding that they had not recognised that it could indicate malignancy.
Over the following months, David returned several times with a persistent cough and in August 2023, he began coughing up blood, and a further X-ray showed a progression of the abnormal area.
Despite this, no referral to a respiratory specialist was made.
Doctor Gabrawi said it was believed the continuous cough was due to asthma and that the blood could be related to prolonged covid symptoms so David was prescribed more antibiotics and an inhaler.
In October 2023, David again reported blood in his sputum and another X-ray was done but no action followed.
The coroner found this was a key moment when a two-week wait referral to respiratory medicine should have been made.
She said: “I find it was the role of general practice to review David's symptoms and to use the chest x-ray reports to assist in the assessment and management of their patients.
“I find there is no documented review of this chest x-ray, and no further chest x-ray arranged as should have occurred. This was a missed opportunity to book a further chest X-ray.
“There was also a significant missed opportunity to refer to respiratory medicine when he came back again on the 13th of October 2023.”
In January 2024, David’s symptoms were getting worse and he started having shortness of breath.
By April, he had developed a lump in his neck and although the GP referred him for an ultrasound, the request was declined. The lump was said not to be affecting his daily routine, but it was still uncomfortable.
It was heard that at this time, David was constantly coughing, had joint aches, a lump in his neck for about six weeks and had been losing weight over six months.
After another X-ray in May 2024, an urgent referral was finally made and a CT Scan confirmed advanced stage four lung cancer.
Doctor Yutaro Higashi, a consultant radiologist at Sherwood Forest Hospitals, reviewed the X-rays at the inquest. He said that, given the persistence of the cough, a recommendation for CT scanning and a respiratory specialist could have been suggested by the radiologist in August 2023.
Regarding the May 2024 X-ray, Dr Higashi said: “I would be extremely worried about this X-ray. There has been a substantial change, and there is definitely something there.”
Dr Nicola Downer, a respiratory consultant at Sherwood Forest Hospitals, who saw David in June, said the disease was already incurable and had spread to other parts of his body.
She believes that from the first X-ray in May 2023, the right upper side area that was mentioned throughout was the tumour, and it progressed from there.
Both Dr Downer and Dr Higashi said they probably would have referred David to a respiratory specialist in October 2023.
Dr Downer said: “On the balance of probabilities, it is probable that he would have had better chances of being treated if treated earlier.
“If we had done a CT in November and it was a stage one disease, then yes, he would have had radical treatment, which would have been potentially surgery.”
The cure rate for lung cancer is 65%. The doctor said if the cancer had been detected earlier, he would have had those chances of curability at a stage one stage, rather than a 5% chance at a stage four diagnosis.
The coroner's narrative conclusion read: “The lack of referral by the GP surgery to the respiratory team for further investigation and management in October 2023 made a more than minimal, negligible or trivial contribution to his death on balance.”
The coroner also criticised the delay in reflective learning by the GP practice as a reflective document was submitted at 9.51pm on Thursday (August 7) - 14 months after David’s death.
She noted that the document could not be considered in her findings, as it was received too late.
The coroner did not issue a formal Prevention of Future Deaths document, but she requested Dr Higashi to share the findings of the inquest with the radiology colleagues to form a discussion about terminology used in radiology.
She has asked Major Oak Medical Practice to hold a meeting reflecting on the missed opportunities in David’s care and submit it to her by the end of October 2025.