Coeliac patient death: Expert to review inquest evidence

Wrexham Maelor is an 800-bed district hospital run by Betsi Cadwaladr University Health Board

An independent expert is to be appointed to review evidence given at the inquest of a coeliac patient who died after being fed Weetabix. 

Hazel Pearson, 80, died from aspiration pneumonia four days after being given the meal at Wrexham Maelor Hospital.

Her inquest was adjourned in June when assistant coroner Kate Sutherland said a hospital action plan to prevent it from happening again lacked detail.

On Wednesday, she said an expert would now review evidence in the case.

The inquest was previously adjourned so Betsi Cadwaladr University Health Board could provide more information before the coroner decided on a prevention of future deaths report.

But at the latest pre-inquest hearing, Ms Sutherland said that, soon after the inquest in June, she was contacted by a large number of members of the public who had read of the case in the press.

Healthcare assistants fed the patient Weetabix as they unaware she had coeliac disease

She said there was "significant concern" about the evidence heard, particularly relating to coeliac patients and vomiting.

Ms Sutherland said that the further pre-inquest hearing on Wednesday was "unusual", but "absolutely necessary".

"I intend to instruct an independent gastroenterologist expert to review all the evidence," she added.

Coeliac disease is a condition where the immune system attacks tissue in the body after the ingestion of gluten - a type of protein found in wheat, rye and barley.

When eaten, it can cause symptoms, such as bloating and constipation.

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However, the inquest in June was told coeliac disease did not usually cause vomiting.

It heard that although Ms Pearson's coeliac disease was noted on her admission documents, there was no sign over her bed indicating the condition which meant healthcare assistants were unaware of her dietary needs.

Ms Pearson, from Connah's Quay, Flintshire, had been admitted for pleural effusion, or water on the lungs but became ill within hours of eating her breakfast and vomited.

It was later found that material from the stomach had been inhaled into her lungs, causing an infection.

On Wednesday, Patricia Gaskell, representing the health board, said action had been taken since Ms Pearson's death and that a task and finish group was working on further improvements.

But the coroner told Ms Gaskell: "You may go back and repeat my dissatisfaction at their failure to get their house in order."

"There has to be learning out of this," Ms Sutherland added.

The inquest at Ruthin, Denbighshire, was adjourned at a date to be fixed.