An 80-year-old woman with celiac disease died within days of being fed Weetabix in hospital, an investigation has revealed.
Hazel Pearson, of Connah’s Quay in Flintshire, was treated at Wrexham Mailer Hospital and died four days later on November 30 from aspiration pneumonia. Although her condition was recorded in her admission documents, there was no sign next to her bed to warn health assistants about her nutritional requirements, BBC News reported.
Celiac disease is a condition in which the immune system attacks the body’s own tissues after consuming gluten, a type of protein found in wheat, rye and barley, causing damage to the small intestine.
The hospital’s action plan to avoid such fatalities lacked details and there was “close vision,” the coroner said.
Pearson was considered a pleural effusion, also known as water in the lungs, but fell ill only hours after eating her breakfast, causing her to vomit. It was later discovered that the infection was caused after material from her stomach was inhaled into her lungs.
Joel Abbott, a geriatric consultant, told the investigation that the vomiting may have been caused by an infection, but also by a kidney injury that the patient also had. He told assistant caregiver Kate Sutherland that celiac disease does not usually cause vomiting, although it can lead to bloating and diarrhea.
Hospital Secretary Jackie Evans told the investigation that the changes, including placing signs above the beds of patients with special dietary requirements, were implemented after Pearson’s death. But Sutherland expressed concern that the hospital has not yet conducted a formal investigation into what went wrong.
She said: “There are no details in the action plan. What happened at the local level is commendable, but it lacks detail and has a narrow vision. “She added that the plan was” amateurish without a strategic vision “.
The coroner’s court also heard that Pearson had fallen ill two weeks earlier when she was given gluten-containing food after being admitted to Deeside Community Hospital, also in Flintshire.
The assistant medical examiner said he would not be able to decide on preventing future deaths until Betsi Cadwaladr University’s Health Council (BCUHB) provided a witness to answer further questions about the changes.
The board has two weeks to provide an update on whether there have been other incidents and to provide more information about Deeside Hospital.
A new date for the hearing has not yet been set.
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