An inquest has heard how a pensioner died of a blood clot after CT scans were left on a doctor 's desk for six days.
Trevor Reynolds, 79, from Abergele, had undergone a scan at Glan Clwyd hospital, Wales on May 3 - a bank holiday weekend - while undergoing treatment for cancer of the oesophagus.
The scan's results showed a blood clot which would require rapid attention.
But an inquest has heard how Mr Reynold's results were left on the desk of consultant Dr Angel Garcia on May 6 - with the doctor out of office until May 12.
In that time period, Trevor would be visited by a doctor at home and, after having difficulties eating and breathing, was taken to hospital immediately.
After receiving treatment in the hospital for the blood clot, the 79-year-old's condition worsened 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.
However, when Dr Garcia had returned to work, Trevor was still in hospital and his CT scans had been waiting on the doctor's desk.
Dr Garcia said at the inquest he believed Mr Reynold's chances of survival would have been much greater had he seen the scan sooner.
The hospital has since made changes as to how scans are seen by consultants, with the inquest hearing that an audit of the effectiveness of the changes made has yet to be completed.
Coroner John Gittins, said he was "dumbfounded" that it had taken until December 2021 for changes to be made.
Summarising, Mr Gittins said: "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 May 5, 2021, if the result of his scan had been acted upon when reported by the radiologist on May 6."
