An 80-year-old woman with coeliac disease died within days of being fed Weetabix in hospital, an inquest has heard.
Hazel Pearson, from Connah’s Quay in Flintshire, was being treated at Wrexham Maelor hospital and died four days later on 30 November from aspiration pneumonia. Although her condition was recorded on her admission documents, there was no sign beside her bed to alert healthcare assistants to her dietary requirements.
Coeliac disease is a condition where the immune system attacks the body’s own tissues after consuming gluten, a type of protein found in wheat, rye and barley, causing damage to the small intestine.
The hospital’s action plan to avoid similar fatal incidents lacked detail and had “narrow vision”, the coroner said.
The hospital’s matron, Jackie Evans, told the inquest that changes, including placing signs above the beds of patients with special dietary requirements, had been implemented since Pearson’s death. But Sutherland raised concerns that the hospital had yet to carry out a formal investigation into what went wrong.
She said: “The action plan lacks detail. What has happened locally is commendable, but it lacks detail and it has narrow vision.” She added that the plan that had been put in place was “amateurish with no strategic vision”.
The assistant coroner said she would be unable to make a decision on a prevention of future deaths report until the Betsi Cadwaladr University Health Board (BCUHB) provided a witness to answer further questions about changes.
Source: The Guardian, 17 June 2022
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