A pensioner died of a blood clot after the results of his CT scan were left on a consultant's desk for six days, an inquest has heard.
Retired HGV driver Trevor Reynolds, from Abergele, died at Ysbyty Glan Clwyd, in Bodelwyddan, on 15 May last year.
The 79-year-old had undergone a scan at the hospital 3 May - Bank Holiday Monday - while receiving treatment for cancer of the oesophagus.
The scan showed a blood clot that required urgent attention.
The inquest heard how three days later on 6 May the results were left on the desk of consultant Dr Angel Garcia, who was out of office until 12 May.
During that period, Mr Reynolds was visited at home by a doctor due to having difficulty with his breathing and eating. He was taken to hospital immediately.
Despite then receiving treatment for the blood clot, Mr Reynolds' condition deteriorated and he died five days later.
Dr Garcia had worked in Wrexham for one day before the weekend and was on annual leave the following Monday and Tuesday.
When he returned to work at Ysbyty Glan Clwyd, Mr Reynolds was already in hospital. During that time, the his CT scan results had been waiting on the desk.
Appearing at the inquest at Ruthin County Hall on Tuesday, Dr Garcia said Mr Reynolds' chances of survival would have been higher had he seen the report sooner.
The hospital has since made changes to how unexpected findings are seen by clinicians.
The coroner, John Gittins, said he was "dumbfounded" that it had taken until December 2021 for changes to be made.
The inquest heard that an audit of the effectiveness of the changes made has yet to be completed.
A post-mortem examination identified the cause of death as pneumonia and pulmonary embolism due to deep-vein thrombosis on the background of emphysema and cancer of the oesophagus.
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 15 May 2021 if the result of his scan had been acted upon when reported by the radiologist on 6 May."