A grandmother with coeliac disease died in hospital days after being fed Weetabix, an inquest heard.
Hazel Pearson, 80, was given the wheat-based cereal for breakfast on November 26 last year – but began to vomit hours later.
Her condition worsened and she died four days later at Wrexham Maelor Hospital in Wales.
The retired credit controller was diagnosed 14 years ago with coeliac disease, a condition where your immune system attacks your own tissues when you eat gluten.
Staff failed to mentioned Mrs Pearson’s dietary requirements on a board above her bed and in a specific section of a handover, the inquest heard.
Mrs Pearson’s son, David, had been regularly calling the hospital to check her dietary requirements were being followed.
Mr Pearson told how his ‘heart sank’ after learning his ‘very independent’ mum, described as a ‘loving mother, grandmother and wife’, was fed Weetabix on November 26.
Mrs Pearson was earlier taken to Wrexham Maelor hospital on August 20 due to developing fluid around her lungs.
During her stay she told her son she suspected she had been given non-gluten-free bread.
She later spent a month at Deeside Community Hospital where she was given sausage and mash for lunch – which a nurse admitted was not gluten free, the inquest heard.
A medical cause of death was ruled to be aspiration pneumonia at the opening of the inquest in December.
She also suffered from heart problems and COPD, and ‘wasn’t the same’ after a fall in 2017, the inquest heard.
Today, attempts to make changes in response to the tragedy were branded ‘amateurish’.
A three-point plan was drawn up by Betsi Cadwaladr University Health Board in a bid to ensure bed signage was accurate and staff were properly briefed on patients’ dietary needs.
Posters have also been placed in staff areas and attached to the notes trolley at Wrexham Maelor hospital, the inquest, in Ruthin, north-east Wales, heard.
But assistant coroner for North Wales east and central, Kate Sutherland said the plan has an ‘extremely narrow vision’ and ‘no strategic direction’.
The coroner said she was not satisfied with the health board’s learnings and adjourned the inquest to give time for the them to find someone with strategic influence to give evidence at a future hearing.
Gluten, a protein in wheat, barley and rye, is found in foods including cereal, pasta, cakes and bread, as well as some ready meals, sauces and most beers.
Visit the NHS website for more information about the condition.
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