Weetabix inquest didn't prompt training - Betsi Cadwaladr

Coeliac patient Hazel Pearson was given Weetabix in hospital despite warnings about her gluten intolerance

Hospital bosses have denied that food intolerance training was prompted by an imminent inquest into the death of a coeliac patient who was given Weetabix.

Hazel Pearson, 79, from Connah's Quay, Flintshire, died at Wrexham Maelor Hospital in November 2021, seven days after being fed the wheat-based cereal.

An inquest heard she had been given food containing gluten two or three times at Deeside Community Hospital.

Her family said they had reminded staff several times about her condition.

The cause of Ms Pearson's death was given as aspiration pneumonia caused by ingestion of Weetabix, with her other medical problems including COPD and heart problems as contributory factors.

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Kate Robertson, assistant coroner for north Wales east and central, recorded a conclusion of misadventure, contributed to by neglect.

The inquest heard that improvements in staff training had begun the week before the hearing and wristbands would be given to patients with details of their food allergies or intolerances.

But in issuing a Prevention of Future Deaths (PFD) report, Ms Robertson said that progress over the past two years had been too slow and it appeared that the improvements had been triggered by the inquest being so imminent.

Responding to the PFD report, Dr Nick Lyons, acting deputy chief executive of Betsi Cadwaladr University Health Board, said: "I fully acknowledge that the delays in rolling out the improvements to managing patients with food intolerances and allergies were not acceptable.

"In hindsight, waiting for an all-Wales training package to be agreed was not the correct course of action and some local in-house training should have been developed."

But he told the coroner: "In relation to your concern that the training was launched only due to the impending inquest, I can advise that the health board had been pushing at an all-Wales level some eight months ahead of the inquest, but I appreciate how that may have looked just before the inquest date."

In her PFD report, the coroner also raised concern about the poor reporting and investigating of incidents, and Dr Lyons said new procedures would be introduced this April.