After a scan result remained on a doctor’s desk for six days, a pensioner died.
Trevor Reynolds, 78, of Abergele, North Wales, had a life-threatening blood clot discovered during a CT scan.
His results were handed to Dr. Angel Garcia-Alonso, a consultant oncologist who was on a long weekend off with annual leave, on a Thursday.
According to the inquest, Dr Garcia-Alonso first saw the scan when he returned from vacation on Wednesday.
Three days later, Mr Reynolds, a former lorry driver, died suddenly.
Mr Reynolds would not have died on May 15, 2021, if his scan had been followed up on sooner, according to the coroner.
Mr Reynolds was being treated for esophageal cancer at Ysbyty Glan Clwyd hospital in Bodelwyddan, North Wales.
Trevor Reynolds’ cause of death is unknown.
On May 6, last year, Dr. Phillip Travis, a consultant radiologist, delivered his report to his secretary.
The secretary forwarded it to Dr. Garcia, Alonso’s secretary, who left it on his desk for days without opening it.
Mr Reynolds was immediately put on a treatment regimen after the discovery.
He died of a blood clot and pneumonia on May 15, however.
Coroner for North Wales East and Central John Gittins delivered a narrative conclusion during the inquest.
“The statistics showed that if the clot treatment had begun sooner, there would have been a better probability of success, and that his cancer treatment had been beneficial,” he stated.
“On the balance of probabilities, Mr Reynolds would not have died on May 15, 2021 if the results of his scan had been followed up on when the radiologist reported them on May 6th.”
According to hospital administration manager Ellen Ruth Davies, the method for transmitting urgent findings has become more “robust.”
These include making certain that if a consultant is absent, other senior doctors can be contacted and informed about urgent cases.
Mr Gittins was disappointed that these changes were not formally adopted until December, seven months after Mr Reynolds’ death.
He was “amazed” to learn that the new system was only now being audited to see if the changes were successful.
“Had I seen that, I would have notified the GP and the patient, and gotten the patient on anticoagulation [blood clot prevention medicine] as soon as possible,” Dr Garcia-Alonso said.
When the coroner inquired if the delay had hampered the expected success of therapy, he replied, “Yes, it had a factor in the consequence.”
Mr Reynolds’ widow Maureen stated, “I’m still distressed and I’ll never get over it.”
“All I ask now is that they take action so that others do not have to go through what my family and I have.” It’s a complete disaster.”