Paul Johnson: Tragedy as Sheffield dad dies of cancer weeks after wedding

An inquest into the death of the 54-year-old found there were multiple ‘missed opportunities’ that could have saved or prolonged his life and that neglect was a contributing factor.

Mr Johnson, a father-of-two, died at the Macmillan Palliative Care Unit at Sheffield’s Northern General Hospital on January 18 this year, just a few months after being diagnosed with advanced cancer, and six weeks after marrying his partner of 17 years, Lise, on the ward.

Returning a narrative conclusion at an inquest into his death, which took place on September 27 at Sheffield’s Medico-Legal Centre, assistant coroner Carl Fitch concluded 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.

In November 2020, plasterer Mr Johnson -  who had a medical history of alcoholic hepatitis, decompensated alcohol liver disease, chronic pancreatitis, and type 1 diabetes - attended the Northern General Hospital’s A&E department suffering from abdominal pain and jaundice.

A CT scan at the time identified a nodule at the bottom of his lung which could have represented cancer, but this was never followed up. An ‘orange alert’, which is used to highlight urgent or unexpected significant findings, was not attached to a report of the CT scan’s findings by radiologists.

Mr Johnson’s condition gradually improved and he was discharged in December 2020. Almost two years later in November 2022, Mr Johnson 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 lung nodule reported on the scan two years earlier had more than tripled in size.

A biopsy of the lump confirmed Mr Johnson had 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 Fitch accepted the cause of death as metastatic non-small cell lung cancer. He said: "There was a missed opportunity to refer Paul to hospital earlier for diagnosis and treatment, and it was contributed to by neglect.

"I do not wish to write a report with any view to preventing further deaths. I’m quite satisfied enough is being done."

In a statement, 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.

Mr Anderson 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.

"The court also heard that those with signs of early lung cancer have a 75 per cent 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."

Dr Jennifer Hill, Medical Director, Sheffield Teaching Hospitals NHS Foundation Trust, said: "I realise that an apology will never be enough to alleviate the loss that Mr Johnson’s family have experienced. However we acknowledge that whilst our staff work hard to provide good care and thorough investigations to all our patients, opportunities were missed in detecting Mr Johnson’s cancer earlier and for that we are extremely sorry.

"We have taken what happened very seriously and conducted a full review of how and why it happened. We have already made changes to our processes and staff training and are continuing to embed further changes to limit the chances of anything similar happening again. This includes the imminent launch of a new, more robust alert system. We have also shared the learning widely with all the teams involved."