Betsi Cadwaladr: Woman's paracetamol death sees health board warned

Rhian Roberts was admitted to Glan Clwyd hospital in November 2020

Wales' largest health board has been warned over "continual delays" dealing with coroner's concerns, after a woman died from taking painkillers.

Rhian Roberts, 50, was admitted to Glan Clwyd Hospital in Denbighshire in November, where tests showed high levels of paracetamol.

But doctors were not made aware until the early hours of the following morning, two days before she died.

Betsi Cadwaladr University Health Board said it would consider the comments.

The coroner for north-east Wales John Gittins issued the health board with a report on preventing future deaths, after recording a conclusion of misadventure on Mrs Roberts.

He added: "I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety."

In the report, the coroner said tests on Mrs Roberts revealed "extremely high levels" of the over-the-counter pain relief drug.

But clinicians "did not become aware of this until the early hours of the following morning", which was when overdose treatment began.

Mrs Roberts' condition declined and she died on 25 November, 2020.

Mr Gittins added an investigation by the health board had found it needed to update the system for communicating life-threatening blood results and this should have been in place by 30 June, but had not yet been approved by 13 July.

Responding to the coroner, the health board's executive director of nursing, Gill Harris said: "We wish to offer our sincere condolences to the family of Mrs Roberts during this very difficult time.

"We will carefully consider the inquest findings and we will be responding directly to the coroner setting out our improvement plan to ensure appropriate actions are taken and lessons are learnt as a result."