Man died after scan showing he needed urgent treatment left on desk

Cancer patient died after a scan result showing he needed urgent treatment for a blood clot was left on a consultant’s desk for SIX days, inquest hears

  • Trevor Reynolds, 78, would have lived if the results of his CT scan had been seen 
  • The retired lorry driver developed a blood clot that required urgent treatment
  • His results were left on the desk of consultant oncologist Dr Angel Garcia Alonso
  • The doctor was on annual leave so didn’t see them until he returned six days later
  • Mr Reynolds died at a North Wales hospital three days after his treatment began

A cancer patient died after a scan result showing he needed urgent treatment on a blood clot was left on a consultant’s desk for six days, an inquest has heard. 

Trevor Reynolds would have lived for longer had the results of his CT scan been seen and his treatment for the fatal clot started sooner in May last year.

Instead, the paperwork was left on the desk of consultant oncologist Dr Angel Garcia Alonso on a Thursday, who only saw it six days later after coming back from annual leave.

It was only seen at Ysbyty Glan Clwyd hospital in Bodelwyddan, North Wales, when Dr Alonso returned the following Wednesday. 

Retired lorry driver Trevor Reynolds, pictured, died after his treatment for a blood clot was delayed when his scan results were left on a consultant’s desk for six days

An inquest has concluded the 78-year-old, who was being treated for oesophagus cancer at the hospital, would have lived had his treatment not been delayed. 

Giving evidence to John Gittins, the coroner for North Wales East and Central, Dr Alonso said he felt the delay had contributed to Mr Reynold’s death.

Dr Alonso said: ‘Had I seen it, I would have alerted the GP and the patient and got the patient in and on anticoagulation as soon as possible.

When asked by the coroner if the delay had been a disadvantage in the likely success of treatment, he said: ‘Yes, it has played a part in the outcome.’

Mr Reynolds was undergoing cancer treatment when he had the scan showing he need urgently treatment on the blood clot in May last year.

On May 6 the radiologist placed the results on Dr Alonso’s desk – but he was out of office for another six days.

Dr Alonso said he was off-site the next day, then on leave.

Upon his return and the notes being read, Mr Reynolds was immediately placed on a course of treatment but he died on 15 May from the pulmonary emboli and pneumonia.

Hospital administration manager Ellen Ruth Davies said that since Mr Reynolds’ death changes in the procedure for passing on urgent results were now more ‘robust’.

These include making sure other senior clinicians can be contacted if a consultant is not available to be made aware of urgent cases.

Coroner for North Wales East and Central John Gittins recorded a narrative conclusion at the Ruthin inquest. He will now raise a prevention of ‘future deaths report’ in the hope of preventing another tragedy.

He said: ‘The evidence indicated that had treatment for the clot began sooner there would have been a better prospect of it being successful and further that the treatment of his cancer had been effective.

Mr Reynolds had been receiving treatment for cancer of the oesophagus at Ysbyty Glan Clwyd hospital (pictured) in Bodelwyddan, North Wales, when the scan showed he had the clot

‘On the balance of probabilities therefore it is likely that Mr Reynolds would not have died on the 15th of May 2021 if the result of his scan had been acted upon when reported by the radiologist on the 6th of May.’

The inquest heard he had died as a result of both the clot known as a pulmonary emboli and a pneumonia.

Mr Gittins said he was ‘disappointed’ these changes had not been formally adopted until December – seven months after Mr Reynolds’ death – and was ‘dumbfounded’ to hear the new system was only now being audited too see whether the new changes were working.

He said he hoped Betsi Cadwaladr health board could explain in greater detail what it was doing and what it had learnt from ‘this awful event’.

Mr Gittins said the evidence indicated that, had treatment for the clot began sooner, there would have been a better prospect of it being successful.

On the balance of probabilities, he added it was likely that Mr Reynolds would not have died on 15 May 2021 had his scan had been acted upon when reported.

Outside the court, Mr Reynolds’ widow Maureen, of Abergele, North Wales said: ‘I am still distressed and I’ll never get over it.

‘I just hope now that they will get something done and other people won’t have to go through what me and my family has gone through. It’s horrible.’

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