A coroner has warned that future deaths could occur unless action is taken to address substantial delays in ophthalmology follow-up appointments across Wales. This warning follows an inquest into the death of Alexandar McDonald, 70, who died from metastatic choroidal melanoma on 30 November 2025.
The inquest found that Mr McDonald could have begun treatment for his eye cancer six months earlier, but a recommended follow-up appointment was not provided by health professionals. Concerns were initially raised in June 2022 after a routine eye test and scan, leading a consultant to recommend a review in six months.
However, Mr McDonald did not receive this follow-up. A routine check-up in June 2023 led to a further scan and an eye cancer diagnosis. The coroner, Rose Farmer, stated that the melanoma would have been diagnosed six months earlier if the recommended appointment had occurred, allowing treatment to begin almost immediately.
Ms Farmer's prevention of future deaths report, sent to the Welsh government, highlighted that ophthalmology capacity appears insufficient to meet demand. She noted the absence of a national mechanism means patients requiring surveillance for ophthalmic conditions may experience prolonged delays, placing others at risk of delayed diagnosis and death.
The Welsh government stated it is "vital that lessons are learned from this tragic case, caused by unacceptable failings in the management of referrals." They added that all health boards should have standard operating procedures to manage operational matters, including capacity and ensuring patients are reviewed within clinically intended timescales.