Betsi Cadwaladr health board criticised over Weetabix death

Coeliac Hazel Pearson died four days after having Weetabix for breakfast

A health board has been criticised for reacting too slowly when a coeliac patient died after eating Weetabix.

Hazel Pearson, 79, from Connah's Quay, Flintshire, died of aspiration pneumonia four days after being given the cereal for breakfast at Wrexham Maelor Hospital.

She fell ill hours after eating them on 26 November, 2021, and was sick.

Material from her stomach was breathed into her lungs, which caused an infection. She died on 30 November. 

Coroner Kate Robertson told Ruthin coroner's court Mrs Pearson was known to be a coeliac, since it was in her records and her family repeatedly reminded staff about her condition.

Mrs Pearson would have accepted the meal believing it to be gluten free, said Ms Robertson.

• Coeliac patient died days after being fed Weetabix, inquest hears

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Staff, she said, should have known of the dietary restriction, adding that there were, "inadequate systems in place", amounting to a "gross failure".

A prevention of future deaths report will be issued to Betsi Cadwaladr health board as Ms Robertson considered there was still a risk deaths could occur.

For patients with food intolerances or allergies this was, she said, "insulting and dangerous"

Ms Robertson said: "Steps have been taken but progress has been far too slow. There are currently insufficient measures in place… training hasn't been delivered."

Betsi Cadwaladr health board has been criticised for reacting too slowly

Earlier, the health board's Steve Grayson told the hearing an online training programme on looking after coeliac patients had been uploaded on Wednesday.

Questioning the timing, Ms Robertson said it was "abhorrent" if that had happened because of the inquest rather than for patient safety.

She also criticised the lack of training given to staff on completing an NHS system used to record incidents about patient safety concerns.

The inquest heard Mrs Pearson, who had a weak heart and kidney disease, was initially admitted to Maelor hospital in August 2021 with shortness of breath.

She was later moved to Deeside community hospital for rehabilitation.

At Deeside, she was given meals containing gluten four times.

It was likely, said Ms Robertson, that she vomited each time though they were not all recorded on the system. 

She was readmitted to Wrexham Maelor with hospital acquired pneumonia.

The inquest previously heard that, while Mrs Pearson's coeliac disease was noted on her admission documents, there was no sign over her bed indicating the condition.

That meant healthcare assistants were unaware of her dietary needs.

Ms Robertson reached a conclusion of misadventure, contributed to by neglect.

Betsi Cadwaladr health board said it accepted the coroner's findings.

Chief executive Carol Shillabeer said: "We are implementing enhanced safety measures as a result in order to reduce the likelihood of these failures being repeated.

"We will review the coroner's concerns that have been raised and will respond detailing the actions we have taken and plan to take."

Coeliac UK's Tristan Humphreys said Mrs Pearson's death reflected "a clear failure of care and it is patently unacceptable that this was allowed to happen".