A CT scan report showing that a patient had a clot on the lungs lay unseen on a consultant's desk for six days because he was away from his office.

By the time consultant oncologist Dr Angel Garcia returned to work at Glan Clwyd Hospital 79-year-old Trevor Reynolds's GP had arranged for him to be admitted.

The former HGV driver died five days later and Dr Garcia admitted at an inquest in Ruthin on Wednesday that his chances of survival would have been enhanced had he himself seen and reacted to the report sooner.


Although the inquest heard that systems had since been changed to ensure that reports of unexpected findings were seen immediately by clinicians John Gittins, senior coroner for North Wales East and Central, said he was "dumbfounded and disappointed" that it had taken so long to implement the changes following Mr Reynolds's death in May last year.

Issuing a Prevention of Future Deaths report to the Betsi Cadwaladr University Health Board, he said it was unacceptable that it had taken from May to December to implement the new system and an assessment of its effectiveness had still not been completed.

"I cannot be satisfied that there is no risk of future deaths on the evidence before me at this point in time," he said.

Mr Reynolds, of Turnberry Drive, Abergele, received chemotherapy for cancer of the oesophagus in February, 2021, and was invited back to Glan Clwyd Hospital for a CT scan review on May 6.


The inquest heard that although the scan showed the treatment to have been successful it also revealed a fairly large pulmonary embolism, or clot.

Consultant radiologist Dr Phillip Travis gave his report to his secretary, who in turn passed it to Dr Garcia's secretary, who placed it on his desk.

However, Dr Garcia told the inquest that he was then working in Wrexham one day, the weekend intervened and he then had two days off, so didn't return to the office until May 13th.

On the 10th Mr Reynolds was visited at home by his GP because he had trouble eating and breathing, and he was taken by ambulance to hospital, where he received anti-coagulation medication.

His condition deteriorated and he died five days later.

The cause of death was given as pneumonia and pulmonary embolism due to deep-vein thrombosis, with emphysemia and the treated cancer as contributory factors.

Miss Ellen Davies, an administration manager with the Board, explained the new protocol which was formally adopted in December and which medical secretaries were now following.

But the coroner said he could not understand why it had taken seven months to make such changes and for the results to still not have been assessed 12 months after Mr Reynolds' death.

 "It is more than frustrating it takes so long for something to change," he said.

"I am not privy to the discussions but it does seem a long time," replied Miss Davies.

Recording a narrative conclusion, Mr Gittins said the evidence indicated that if the treatment for the clot had been started sooner the chasnces of survival would have been greater.

"On the balance of probabilities therefore it is likely thst Mr Reynolds would not have died on the 15th of May, 2021, if the results of the scan had been acted upon when reported by the radiologist on the 6th of May," he added.