THE HEALTH Board has apologised to the family of a Flintshire woman who died in hospital in what a coroner ruled amounted to neglect. 

Hazel Pearson, from Connah's Quay, died after being given Weetabix at Wrexham Maelor Hospital, despite being a coeliac, in 2021.

A recent inquest into the 79-year-old's death heard that members of her family had repeatedly reminded staff that she was gluten-intolerant and it was in her medical notes.

Eating the Weetabix caused her to vomit, aspirate, suffer significant oxygenation and subsequent respiratory deterioration which then led to her death from aspiration pneumonia. 

Recording a conclusion of misadventure contributed to by neglect, Kate Robertson, assistant coroner for North Wales East and Central, said: “The staff knew or should have known.”

The coroner has since issued a prevention of future deaths notice to Betsi Cadwaladr University Health Board (BCUHB). 


The report states: "During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you."

The concerns raised by Ms Robertson are as follows:

1) "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 wristbands for food intolerances / allergies, but this has taken far too long. The e-learning training module was uploaded to BCUHB system the day prior to the inquest. It is strongly suspected that this was due to the impending inquest."

2) "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."

3) "There were other incidences of gluten ingestion at Ysbyty Maelor and Deeside Community Hospital. On at least 4 occasions at Deeside Community Hospital (where Mrs Pearson was initially being treated) there were no Datix 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 Datix report and how to complete this."

4) "In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

Carol Shillabeer, BCUHB'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.”