A father-of-two sadly died just a few months after being diagnosed with advanced cancer.
Paul Johnson, 54, from Sheffield, died at the Macmillan Palliative Care Unit at Sheffield’s Northern General Hospital on January 18, 2023, just a few months after being diagnosed with advanced cancer. An inquest into his death found there were multiple ‘missed opportunities’ that could have saved or prolonged his life and that neglect was a contributing factor.
Plasterer, Johnson, rushed to Northern General Hospital’s A&E department in November 2020 and despite a CT scan identifying a lump, which could have represented cancer, this was never followed up.
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This led to coroner Carl Fitch concluding that neglect contributed to Mr Johnson’s death. He also said seven separate medical professionals had the opportunity to arrange further investigation and treatment, especially those who dealt with Mr Johnson’s discharge.
Suffering with abdominal pain and jaundice, plasterer Mr Johnson – who had a medical history of alcoholic hepatitis, decompensated alcohol liver disease, chronic pancreatitis, and type 1 diabetes – attended A&E. An ‘orange alert’, which is used for urgent or unexpected significant findings, was not attached to a report of the CT scan’s findings by radiologists, the inquest, that took place in Sheffield on Wednesday, heard.
(Image: Paul Johnson)
Mr Johnson’s condition gradually improved and he was discharged in December 2020. In November 2022, he was admitted to Sheffield’s Royal Hallamshire Hospital to investigate left-sided weakness. An MRI scan confirmed Mr Johnson had at least 18 lesions in his brain and a CT scan showed the lump reported on the scan two years earlier had more than trebled in size.
A biopsy of the lump confirmed Mr Johnson had non-small cell lung cancer, which had spread to other parts of his body, including the brain, and was incurable. He was transferred to the Macmillan Palliative Care Unit at Northern General Hospital in December 2022.
Mr Johnson’s sister Kay Hemming, brother-in-law Christopher Hemming, mum Janet Johnson and dad Mac Johnson said: “It has been extremely difficult re-living Paul’s final two years and hearing that there were multiple chances where his lung cancer could have been diagnosed and treated, which could have extended his time with us.
“To us, it always felt like medical professionals believed Paul wasn’t worth treating and that his health issues were entirely his fault due to how he suffered with alcohol problems. It breaks our heart knowing that in the lead up to his death, Paul felt completely worthless.
“Life will never be the same for us without Paul; losing him has left a huge void in our family and while nothing can ever bring him back to us at least he is now at peace and no longer suffering.”
James Anderson, clinical negligence legal director, and Ikhira Thandi, litigation legal assistant, both of Lime Solicitors, have assisted Mr Johnson’s family in preparation for the inquest and are currently looking into whether legal action against Sheffield Teaching Hospitals NHS Foundation Trust, which runs the hospital, is appropriate.
James said: “The inquest highlighted multiple missed opportunities to investigate the lump that was picked up on the CT scan back in 2020. Proper investigation could have led to a timely diagnosis and provided Mr Johnson with much-needed treatment to give him the best chance of surviving cancer.
“No follow up was arranged and no ‘orange alert’ was attached to the report. Furthermore, in February 2021, a hepatologist viewed the CT scan during a telephone consultation with Mr Johnson, but the lump was not commented on and no further action was carried out.
“The inquest heard there were seven separate medical professionals who had the opportunity to raise the follow up, especially those who dealt with Mr Johnson’s discharge. These errors meant that over the next two years, the nodule significantly increased in size and spread to Mr Johnson’s brain, which was found when it was properly investigated at the Royal Hallamshire Hospital. However, at this point, there were no curative treatment options.
“While a CT scan is unable to show whether a nodule is cancerous or not, it is important to be proactive because early detection of lung cancer can make a huge difference to a patient’s outcome. Further testing should have been carried out and its growth should have been monitored over time.
“The court also heard that those with signs of early lung cancer have a 75% chance of survival if treated promptly. The coroner said there were a number of missed opportunities and, had they been caught earlier, Mr Johnson’s life could have been saved or prolonged.
“While the inquest won’t bring Mr Johnson back, it is hoped his family’s concerns have been listened to and lessons have been learned to prevent others from suffering the same devastating loss. We are currently working with his family to see if a civil clinical negligence claim is applicable.”
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