An inquest into the death of a 70-year-old patient revealed critical failures in the management of ophthalmology follow-up care within Wales’s health system. The patient attended an urgent eye appointment in June 2022 after a routine eye test raised concerns identified through imaging. A consultant recommended he be reviewed again within six months, but no follow-up appointment was arranged. The patient did not receive another assessment until June 2023, when concerns were once again raised and a scan led to a diagnosis of eye cancer.
According to the inquest findings, had the initial recommended appointment been provided, the melanoma would have been diagnosed approximately six months earlier, allowing treatment to begin sooner. The patient subsequently underwent multiple treatments following the delayed diagnosis, but the cancer eventually spread to his liver, ultimately leading to his death on 30 November 2025.
The coroner’s investigation highlighted systemic capacity problems across Wales’s ophthalmology services. At the time of the report, approximately 140,000 ophthalmology follow-up appointments were awaiting review, while only 65 consultant ophthalmologists were available to provide care. The coroner noted the absence of a national mechanism to track patients requiring surveillance for eye conditions, creating a risk that others may experience similarly prolonged delays.
In response, the Welsh government acknowledged the failings and stated that health boards should implement standard operating procedures to ensure patients requiring ongoing monitoring receive timely reviews. Officials pledged to hold health boards accountable for performance. The Royal College of Ophthalmologists identified underlying structural challenges, including aging facilities, workforce shortages, and inadequate information technology infrastructure, as contributing factors to service delays.
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