AN investigation into the death of a hospital patient who was given cereal containing wheat for breakfast despite being a coeliac has been called “amateurish” by a coroner.

Kate Sutherland, assistant coroner for North Wales East and Central, said she was concerned at the limited scale of the inquiry and its findings,and said she needed to know whether there was still a risk to patients across the north.

The investigation was limited to the Maelor Hospital, Wrexham, where 79-year-old Hazel Pearson died on November 30, 2021.

But the inquest in Ruthin was told that while she was a patient at Deeside Community Hospital a couple of weeks previously she had been ill after being given sausage and mash.

Her son, David Pearson, said that he had repeatedly told doctors and staff at both hospitals that she had coeliac disease and had to have gluten-free food.

When he asked a Sister at Deeside Community Hospital if she was sure his mother had been given gluten-free food he was told “All our food is gluten-free” but the nurse later apologised for the error.

Mr Pearson said he and other family members took her favourite gluten-free food into hospital for her.

Mrs Pearson, a former credit controller, of Belmont Avenue, Connah’s Quay, was taken to the Maelor Hospital on November 23 suffering from breathing problems and failing kidneys and although frail her condition improved.

Health care worker Clare Player said she didn’t know that Mrs Pearson was coeliac and she herself chose to have the cereal. There was no note on the board behind her bed to state that she had to have gluten-free food.

She started vomiting later that morning and after heaving throughout much of the day vomited again during the evening, and passed away early the following morning.

The cause of death was given as aspiration pneumonia, with Chronic Pulmonary Obstructive Disorder and heart failure as contributory factors.

Ward manager Clare Jeavons said that following the incident posters were available to draw more attention to the fact when patients were coeliac, and all staff were made more aware of the potential issue.

Jacquie Evans, part of the panel which investigated the incident said a three-point action plan had been adopted.



But Ms Sutherland said she was concerned that there had been no formal investigation, that the Deeside incident had not been investigated and that no evidence had been heard about the lessons learned.

Adjourning the hearing for a witness to be called from the Betsi Cadwaladr University Health Board to explain whether any other similar incidents had been recorded across north Wales and what action had been taken, the coroner said: “I am significantly concerned about that and need somebody to give evidence about that strategic need.

“It is commendable that local action has been taken but I am concerned at what I have been told about the investigation. That is a very narrow vision – amateurish – and with no strategic vision as to learning.”

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