Ms McKay had a history of asthma and bronchitis and had been a smoker for many years. She attended A&E suffering from weakness in her right leg and arm. A chest X-ray performed six months earlier had been reported as normal and she was reassured and discharged.
Over the next couple of years, she continued to feel unwell and was weak and unsteady. She had two subsequent chest x-rays taken, both of which stated soft tissue density requiring further investigation. She was seen in the neurology clinic and was reassured. No other action was taken in response to either reports and she was not told the result of the x-rays and the reports were not communicated to her GP.
Ms McKay continued to suffer from frequent chest infections and developed a persistent cough. She saw her GP who referred her for an urgent chest x-ray, which was done the same day. This concluded that she had wide spread malignant disease.
Following receipt of the x-ray, the GP referred Ms McKay urgently to Hospital S and she was admitted the following day. She underwent a number of investigations and was diagnosed as suffering from metastatic cancer. She died a month later.