Understand
Coroner warns over eye care failures after man dies of eye cancer following missed follow-up
Overview
A 70-year-old man, Alexandar McDonald, died of metastatic choroidal melanoma after a recommended six-month ophthalmology follow-up appointment was missed, leading to a delayed cancer diagnosis. A coroner warned that substantial delays and insufficient capacity in ophthalmology services across Wales put other patients at significant risk of delayed diagnoses and death.
Key points
- Alexandar McDonald died on 30 November 2025 from metastatic choroidal melanoma after a recommended follow-up scan in December 2022 was not arranged.
- A coroner found that the cancer could have been diagnosed six months earlier if the follow-up had taken place as recommended.
- Figures show there are approximately 140,000 ophthalmology follow-up appointments awaiting review in Wales, supported by only 65 consultant ophthalmologists.
- The coroner issued a prevention of future deaths report highlighting insufficient capacity and a lack of a national mechanism for surveillance of ophthalmic conditions.
- The Welsh government acknowledged unacceptable failings in referral management, while the Royal College of Ophthalmologists cited workforce shortages, poor IT infrastructure, and dilapidated estates.