GIVING Weetabix to a hospital patient who was a coeliac amounted to neglect, a coroner has ruled.

Hazel Pearson, 79, vomited and her condition deteriorated rapidly after being given the wheat-based breakfast cereal at Wrexham Maelor Hospital, where she died seven days later.

An inquest in Ruthin heard that members of her family had repeatedly reminded staff that she was gluten-intolerant and it was in her medical notes.

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.”

At an earlier hearing it was revealed that while she was at Deeside Community Hospital in October and November 2021, Mrs Pearson, who was diagnosed as coeliac 14 years previously, had been given food containing gluten on three or four occasions and had vomited afterwards.

The retired credit controller, of Belmont Avenue, Connah’s Quay, who had several medical problems including COPD, heart and kidney problems, was transferred to the Maelor Hospital on November 23, 2021, with fluid around her lungs.

Dr Jeremy Woodward, a gastroenterologist at Addenbrooke Hospital in Cambridge, who was called as an expert witness by the coroner, told the inquest it was possible that the incidents at Deeside Hospital had had a cumulative effect and weakened Mrs Pearson’s resistance.

Ms Robertson recorded the cause of death as aspiration pneumonia caused by ingestion of Weetabix, with her other medical issues as contributory factors.

The inquest had been adjourned in June for Dr Woodward to be called and for evidence of what steps the Betsi Cadwaladr University Health Board had taken as a result of Mrs Pearson’s death.

Stephen Grayson, the Board’s Director of Allied Health Professionals, said that the need for staff training had been identified and wristbands would in future carry details of patients’ intolerancies and allergies.

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He said the improvements had been approved on Wednesday of this week, but the coroner said the timing appeared to have been because of the imminent inquest and not for the benefit of patients.

She is to issue a Prevention of Future Deaths report raising concerns about the Board’s response to Mrs Pearson’s death two years ago.

“There has been progress but it has been far too slow,” she said. “I am  not convinced there has been sufficient training.”

She said she hoped that the publicity given to the case would make groups and organisations consider how they handled issues such as intolerances.