A man died after the results of his CT scan were left on a desk for six days, an inquest heard. Trevor Reynolds, a retired HGV driver from Abergele in Conwy, passed away on May 15, 2021 at Glan Clwyd Hospital.
The 79-year-old underwent a scan at the hospital on a bank holiday Monday, May 3, as he was receiving treatment for cancer of the oesophagus. The scan revealed that he had a blood clot which required urgent care.
Three days later, the results were placed on a consultant's desk, though the consultant was out of the office until May 12. Mr Reynolds had been experiencing difficulty with his breathing and eating at the time, and on May 10 he was visited at his home by a doctor and was taken to hospital immediately, reports North Wales Live. You can read all our stories about Conwy here.
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Treatment was then given for the blood clot, but sadly Mr Reynolds' condition deteriorated and he died five days later. The consultant oncologist Dr Angel Garcia, on whose desk the results had been left, had worked in Wrexham for a day before the weekend and was on annual leave the following Monday and Tuesday.
By the time Dr Garcia returned to work at Glan Clwyd, Mr Reynolds had already been admitted. In the meantime the results of the CT scan had been sat on his desk. Dr Garcia appeared as a witness at Ruthin County Hall on Wednesday, May 4, and said that the 79-year-old's chances of survival would have been higher had he seen the report sooner.
John Gittins, senior coroner for North Wales east and central, issued a prevention of future deaths report after he was left "dumbfounded" that it had taken until December of 2021 for changes to be made in relation to how unexpected findings are seen immediately by clinicians.
An audit of the effectiveness of the changes made has yet to be completed, the inquest heard. A post-mortem examination was undertaken by Dr Mark Atkinson who provided a cause of death of pneumonia and pulmonary embolism due to deep-vein thrombosis on the background of emphysema and cancer of the oesophagus.
The coroner recorded a narrative conclusion. Mr Gittins said: "On the 3rd of May 2021, Mr Trevor Reynolds had a CT scan at Glan Clwyd Hospital, the purpose of which was to establish the effectiveness of treatment which he had been having for cancer of the oesophagus.
"On the 6th of May this was reported by a radiologist as incidentally revealing a clot on the lungs, a result which needed to be brought to the immediate attention of the referring clinician so that remedial work could be started. For reasons associated with working practices at that time the result of this scan was not acted upon until it was identified by Mr Reynolds' GP on the 10th of May and he was immediately admitted to hospital where treatment was commenced.
"Despite appropriate treatment being undertaken over the course of the next few days, Mr Reynolds passed away at Glan Clwyd Hospital on the 15th of May 2021 with a subsequent examination establishing that he had died as a result of both the pulmonary emboli and a pneumonia.
"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. 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." To get more stories like this sent straight to your inbox every single day, click here.
