An 80-year-old coeliac patient was given the cereal in hospital and died four days later.
A patient with coeliac disease died days after being fed Weetabix in hospital, an inquest has heard.
Hazel Pearson of Connah’s Quay, Flintshire was being treated at Wrexham Maelor hospital.
The 80-year-old died on 30 November from aspiration pneumonia four days after the meal.
The coroner said the hospital’s action plan to prevent this happening again lacked detail and had “narrow vision”.
Coeliac disease is a condition where your immune system attacks tissues in the body when you eat gluten.
Gluten is a type of protein found in wheat, rye and barley and when it is eaten it cause a range of symptoms such as bloating and constipation.
The inquest at Ruthin heard that although her coeliac disease was noted on her admission, there was no sign over her bed indicating the condition, which meant health care assistants who helped her were unaware of her dietary needs.
Mrs Pearson had been admitted for pleural effusion, or water on the lungs. She became ill within hours of her breakfast and vomited.
She was later diagnosed as having aspirated, when material from the stomach is inhaled into the lungs, causing infection.
The inquest also heard she had become ill two weeks earlier when she was given a meal containing gluten during a stay at Deeside community hospital.
Consultant geriatrician, Joel Abbott told the inquest it was difficult to pin point one cause of her vomiting, which could also have been due to infection, or a kidney injury, which Mrs Pearson also had.
He said that though it causes bloating and diarrhoea, coeliac disease doesn’t usually cause vomiting.
‘Amateurish with no strategic vision’
Assistant coroner Kate Sutherland said despite hearing evidence from Jackie Evans, matron in emergency assessments at the Wrexham Maelor, that some action taken, such as signs being placed above the beds of patients with dietary requirements, she was concerned there hadn’t been a formal investigation.
“The action plan lacks detail. What has happened locally is commendable, but it lacks detail and it has narrow vision.”
She said what had been put in place was “amateurish with no strategic vision”.
Ms Sutherland said Betsi Cadwaladr University Health Board (BCUHB) needed to provide a witness who could answer questions about the learning across the health board before she could make a decision on a prevention of future deaths report.
The health board has been given 14 days to update the coroner as to whether there have been repetitious incidents and to provide other information from Deeside Hospital.
A new date for the hearing is yet to be fixed.