Coroner slams NHS board over ‘inadequate improvements’ two years after coeliac patient, 79, died when she was fed Weetabix at hospital and demands action be taken to avoid future tragedies

• Hazel Pearson died at Wrexham Maelor Hospital in November 2021 
• There was no sign above her bed and medics had no idea about dietary needs 
• Coroner said Betsi Cadwaladr Health Board made ‘inadequate improvements’ 

A coroner has slammed an NHS health board for failing people with food intolerances after a patient died when she was fed Weetabix at hospital.

Hazel Pearson, from Connah’s Quay, Flintshire, suffered a reaction and died four days after she was given the breakfast cereal during a stay at Wrexham Maelor Hospital, North Wales, in November 2021.

The 79-year-old’s medical records stated she suffered from gut condition coeliac disease, but there was no sign above her bed and medics had no idea about her dietary needs, an inquest heard.

Coroner Kate Robertson said the Betsi Cadwaladr Health Board, which is responsible for NHS services in the region, had not investigated Mrs Pearson’s death in the two years since she died and made ‘inadequate improvements’ to help patients since the tragic event.

Now, Ms Robertson has warned that more patients with intolerances or allergies will die unless action is taken.

Hazel Pearson, from Connah’s Quay, Flintshire, suffered a reaction and died four days after she was given the breakfast cereal during a stay at Wrexham Maelor Hospital, North Wales, in November 2021

In a Prevention of Future Deaths report, Ms Robertson said: ‘She [Ms Pearson] had known coeliac disease which was recorded on her medical records.

‘Her family had repeatedly informed staff about her coeliac disease.

‘On November 26, 2021, she was offered and consumed Weetabix probably believing it was a gluten free equivalent.

‘This caused her to vomit, aspirate, suffer significant oxygenation and subsequent respiratory deterioration which then led to her death from aspiration pneumonia.’

Mrs Pearson was not the first coeliac person to ingest gluten in the Welsh hospital, the coroner said. At least four other occasions were believed to have taken place, none of which included a completed incident report form. 

Ms Robertson, assistant coroner for North Wales, criticised Betsi Cadwaladr in the report for taking too long to create an e-learning module for staff and implement the use of red wrist bands for food intolerances / allergies.

Ms Pearson was not the first coelic person to ingest gluten in the hopsital, the cornor said.

She said: ‘Despite the deceased passing away just shy of two years ago, there have been inadequate improvements to manage patients with food intolerances and allergies.

‘The Health Board has been working with other organisations in Wales to create an e-learning module and implement the use of red wrist bands for food intolerances/ allergies, but this has taken far too long.

‘The e-learning training module was uploaded to [a computer] system the day prior to the Inquest. It is strongly suspected that this was due to the impending Inquest.

‘The Health Board has not investigated the incident at all.

‘A Medical Examiner Report was prepared following the death in November 2021 highlighting the ingestion of gluten in a coeliac patient. I have raised and continue to raise a number of concerns around the inadequacy of governance and poor investigation processes.

‘There were other incidences of gluten ingestion at Wrexham Maelor and Deeside Community Hospital.

‘On the at least four occasions at Deeside Community Hospital there were no [incident reports] completed at the time.

‘I was provided with no evidence that additional training, refresher training or induction training deals with when such reports should be made. I cannot be satisfied and reassured that all staff are aware of when to make a [incident report] and how to complete this.’

The coroner added ‘in my opinion action should be taken to prevent future deaths and I believe you have the power to take such action’.

At Mrs Pearson’s inquest, the coroner recorded a verdict of ‘misadventure contributed to by neglect’.

The famous breakfast cereal caused the 79-year-old her to vomit, aspirate, suffer significant oxygenation and subsequent respiratory deterioration which then led to her death from aspiration pneumonia

Charity Coeliac UK has also called for change.

Tristan Humphreys, Head of Advocacy for Coeliac UK said: ‘We are deeply saddened and concerned by this verdict and our thoughts go out to Mrs Pearson’s loved ones at this very difficult time.

‘Her death reflects a clear failure of care and it is patently unacceptable that*this was allowed to happen.

‘Coeliac disease is a serious autoimmune condition for which the only treatment is a medically prescribed gluten free diet.

‘It is critical that people with coeliac disease can access the gluten free food they need to be healthy.

‘This is all the more important when someone is unwell and, as in Mrs Pearson’s tragic case, unable to advocate for themselves.’

The Betsi Cadwaladr University Health Board apologised to Mrs Pearson’s family and said it was determined to make improvements to its procedures. 

Carol Shillabeer, Betsi Cadwaladr University Health Board’s CEO, said: ‘First of all, I would like to apologise to the family of Mrs Pearson and once again offer my sincere condolences for their loss.

‘We are determined to make improvements as a result of this case, in order to reduce the likelihood of these failures being repeated.

‘We will review the specific concerns raised by the Coroner and will respond in due course, detailing the actions we have taken already and further actions we plan to take.’

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