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Health board criticised over death of coeliac patient given Weetabix for breakfast

26 Nov 2023 3 minute read
Wrexham Maelor Hospital Emergency Department

Betsi Cadwaladr Health Board has been criticised following the death of a patient with coeliac disease who was given Weetabix for breakfast in one of its hospitals.

The health board’s training was also slammed as it was found to have reacted too slowly after Hazel Pearson, 79, from Connah’s Quay, Flintshire died after being given cereal she would have thought to be gluten free at Wrexham Maelor Hospital in November 2021.


Repeated reminders were made by Ms Pearson’s family members about her condition which was also included in her medical records.

Coroner Kate Robertson told the court that staff should have been aware of the patient’s condition following warnings from family members.

The coroner also said that that there were “inadequate systems in place” which amounted to a “gross failure.”

Ms Robertson described the risk of further patients dying due to insufficient measures currently in place and a gap in training delivery as “insulting and dangerous”.


Coeliac disease is caused by an abnormal immune system reaction to the protein gluten, which is found in foods such as bread, pasta, cereals and biscuits.

It’s an autoimmune condition, where the immune system mistakes healthy cells and substances for harmful ones and produces antibodies against them.

The charity Coeliac UK described the case of Mrs Pearson as tragic and deeply concerning.

Tristan Humphreys, Head of Advocacy for Coeliac UK said: It is critical that people with coeliac disease can access the gluten free food they need to be healthy. This is all the more important when someone is unwell and, as in Mrs Pearson’s tragic case, unable to advocate for themselves.

“Wales has mandatory food standards which make very clear the level of care that should be provided yet these have not been met.

“As a charity, we are empowering patients, family members, carers and working with hospital caterers by providing advice and guidance to support safe provision of gluten free food. However, it’s high time the health service consistently delivered the care people with coeliac disease deserve.”

Rhun ap Iorwerth, Plaid Cymru MS for Ynys Môn and Chair of the Cross-party Group on Coeliac Disease in the Senedd, said: “These revelations highlight the importance of following correct procedure when treating patients with coeliac disease and the potentially heartbreaking repercussions of not doing so.

“Whilst I’m glad to hear of new measures being introduced by Betsi Cadwaladr University Health Board to prevent similar incidents in future, the truth is that this tragedy could have been avoided.

“My thoughts are with the victim and her loved ones.”

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Another Richard
Another Richard
7 months ago

Criminal proceedings ought to focus minds wonderfully.

7 months ago

Not exactly an uncommon thing. I know of someone in hospital and they was going to use the normal toaster for gluten free bread. Unaware there is a dedicated device.Food allergies training is crap in the place it is diagnosed. Cwm Taff in this case.

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