Wrexham Maelor Hospital still yet to launch probe after coeliac patient's death

Betsi Cadwaladr University Health Board has been slammed as failing to get its "house in order" after the patient's death. Credit: Media Wales

A health board has failed to get its "house in order" after a coeliac patient died within days of being fed Weetabix in hospital.

Hazel Pearson of Connah's Quay died at Wrexham Maelor Hospital on November 30, but so far no Betsi Cadwaladr University Health Board investigation has taken place into the circumstances surrounding the death of Mrs Pearson.

Coeliac disease is a condition where the immune system attacks tissues when gluten is eaten.

Four days before her death, the 80-year-old was fed the breakfast cereal, which consists mostly of wheat. By 11.20am that day, her condition had worsened with reports from nurses on the ward saying that she had begun to vomit heavily for large parts of the day.

A pre-inquest hearing was held today and the coroner expressed her "dissatisfaction at the health board's failure to get its house in order"

Mrs Pearson's condition deteriorated and she died of aspiration pneumonia.

At a part-heard inquest held on June 16, Kate Sutherland, assistant coroner for North Wales east and central, 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".

A short pre-inquest hearing was held at Ruthin County Hall today as part of the preparations for the future hearing which will likely be held in December or early next year.

At the hearing, the coroner expressed 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.

Mrs Pearson's coeliac disease was not mentioned on the board above her bed nor was it mentioned in the section of the handover to staff Credit: Media Wales

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 the 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.

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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.

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.