A 70-year-old man died of eye cancer after a recommended appointment was not followed up by health professionals, an inquest found.
Alexandar McDonald died at the Grange University Hospital in Cwmbran, Torfaen, on 30 November 2025, from the effects of metastatic choroidal melanoma, external.
But a coroner found he could have begun treatment six months earlier, and warned more patients in Wales were at “significant risk”, as figures showed 140,000 ophthalmology follow-up appointments awaiting review, but just 65 consultant ophthalmologists available.
The Welsh government said it was “vital that lessons are learned from this tragic case, caused by unacceptable failings in the management of referrals”.
The inquest into McDonald’s death heard he had attended an urgent ophthalmology appointment in June 2022 following a routine eye test, where concerns were raised following a scan.
Although a consultant determined he needed to be reviewed again in six months, he received no follow-up appointment.
At a routine check-up in June 2023, however, concerns were raised and a further scan led to an eye cancer diagnosis.
Gwent area coroner Rose Farmer heard that, had McDonald been given a previous follow-up appointment as recommended, the melanoma would have been diagnosed six months earlier, with treatment beginning almost immediately.
Following the “delayed diagnosis”, the inquest heard McDonald underwent several treatments, but the cancer had later metastasised to his liver, leading to his death.


