The death of a patient, who was diagnosed with lung cancer, might have been 'avoidable' if a hospital trust in Cumbria had not 'failed to act' on two X-rays, a report has found.
The Parliamentary and Health Service Ombudsman (PHSO) has revealed a series of failings by North Cumbria University Hospitals Trust, which runs hospitals in Carlisle and Whitehaven.
The patient, referred to in the report as Mr C, was admitted twice to hospital with stroke-like symptoms in 2014 and 2015. He underwent X-rays on both occasions.
The first scan showed abnormalities in lungs described as "unexpected demonstration of a new oval soft tissue mass".
The second showed an 'irregular round opacity' which was 'larger than on the previous image’, suggesting a slowly growing tumour in the right lung.
The report found the Trust failed to take action in relation to both chest X-ray findings.
In July 2017, Mr C was admitted to the Trust where they performed another chest X-ray. It showed a lung mass which was untreatable. He died one month later on 1 August 2017.
The report also found North Cumbria University Hospitals NHS Trust failed to correctly handle a complaint submitted by Mr C's daughter.
Findings show she complained about the care provided to her father and said their failure to act on chest scans delayed his diagnosis, leading to his death.
It says she also formally complained about the Trust's handling of her original complaint. The response is said to have been delayed and failed to answer her questions which caused 'additional distress at an already difficult time'
The report said: "Miss C has told us how she has struggled to grieve knowing her father’s death could have been avoided, and we can understand why this would be the case."
After his death, the Trust completed a Serious Incident Report which found the 'root cause of the failure' in 2014 was an 'outdated paper reports system.'
It said there was no evidence to suggest the report had ever reached the requesting physician.
The PHSO say North Cumbria University Hospitals NHS Trust has acknowledged it did not review the X-rays and has apologised that this occurred.
The PHSO has also asked the Trust to compensate Mr C's daughter £10,000 in recognition of the distress caused by his "avoidable death."