Coroner Warns of Risk to Patients After Man's Eye Cancer Death

A 70-year-old man died of metastatic choroidal melanoma after a recommended medical appointment was not followed up, an inquest has found. Alexandar McDonald died on November 30, 2025, from the effects of the cancer.

A coroner determined that McDonald could have begun treatment six months earlier if the recommended follow-up appointment after a scan in June 2022 had occurred. The inquest heard that a routine eye check in June 2023 led to a diagnosis, but by then the cancer had metastasised to his liver.

Gwent area coroner Rose Farmer warned that other patients in Wales are at "significant risk" due to delays in ophthalmology follow-up appointments. The inquest was told that 140,000 ophthalmology follow-up appointments were awaiting review, with only 65 consultant ophthalmologists available.

"This case demonstrates the impact of not having timely follow up appointments," the coroner stated. "Similar delays may place other patients at risk of delayed diagnosis of malignancy and death."

The Welsh government acknowledged "unacceptable failings in the management of referrals" and stated that lessons must be learned. The government committed to holding health boards accountable for performance, emphasizing the need for standard operating procedures to manage referrals, surveillance capacity, and timely patient reviews.

Mohamed Elalfy, president of the Royal College of Ophthalmologists, cited long-standing challenges in Welsh services, including infrastructure issues, workforce shortages, and poor IT, as key reasons for delays. He called for urgent implementation of reforms.