A coroner has told a health board to get its "house in order" after a coeliac patient died within days of being fed Weetabix in hospital.
Hazel Pearson of Belmont Avenue in Connah's Quay died at Wrexham Maelor Hospital on November 30, 2021 at 10.45pm. Four days before her death, t he 80-year-old was fed a breakfast cereal, which consists mostly of wheat. By 11.20am that day, the retired credit controller's condition had worsened with reports from nurses on the ward saying that she had begun to vomit heavily for large parts of the day. Coeliac disease is a condition where the immune system attacks tissues when gluten is eaten.
A pre-inquest review, held in Ruthin on Wednesday, was told that Betsi Cadwaladr University Health Board has not yet commenced an investigation into the circumstances surrounding the death of Mrs Pearson.
That information saw assistant coroner Kate Sutherland express her "dissatisfaction at the health board's failure to get its house in order" on the learnings to be made over the circumstances which led to Mrs Pearson's death.
At a previous hearing on June 16, Ms Sutherland, slammed the action plan put forward by the health board following Mrs Pearson's death as "amateurish with no strategic direction" with an "extremely narrow vision".
Mrs Pearson, who was first diagnosed with coeliac disease around 14 years earlier, had been in the Wrexham hospital because she had fluid around her lungs and needed treatment. She also suffered from heart problems and COPD.
A couple of months after being initially admitted to Wrexham Maelor, she spent around a month at Deeside Community Hospital where she was ill after being fed sausage and mash with gravy for lunch which was not gluten free, the court previously heard. This meal had caused her to vomit to the extent that she had difficulty swallowing as her throat had become sore, leading to the worsening of her condition and a return to the Maelor on November 23.
While an investigation has been carried out at Deeside Community Hospital where Mrs Pearson fell ill after being fed sausage and mash a couple of months before her admission to the Maelor, no investigation has taken place at the Maelor itself where she was fed the Weetabix four days before her death, a coroner was told.
Ahead of the full inquest, the coroner will instruct an independent expert to file a report based on the evidence already heard as well as what has come to light since the last hearing in June. Witnesses will also be recalled and asked to give evidence based on what is in the expert's report, the coroner said.
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