A WOMAN from Rhyl died after a misdiagnosis led to her being incorrectly prescribed ultimately catastrophic medication.

Kayleigh Lorraine Colegate, of Larkmount Road, died at Ysbyty Glan Clwyd aged 35 on May 17, 2022.

At County Hall, Ruthin today (November 15), an inquest into her death concluded that Mrs Colegate’s death was due to natural causes, contributed to by neglect.

Mrs Colegate’s cause of death was stated as pulmonary embolism, which was undiagnosed, due to deep vein thrombosis.

Kate Robertson, assistant coroner for North Wales (East and Central), found there were “gross failures to procure basic medical attention” in Mrs Colegate’s case, and that she “would likely have survived” had she been diagnosed correctly and treated accordingly.

The inquest heard that Mrs Colegate, a married mother-of-two who worked as a childcare leader, began developing breathlessness on May 12, before seeing her GP at Madryn House Surgery on May 16.

Her GP’s initial interpretation was that she was suffering from supraventricular tachycardia (SVT), a heart condition, and on his advice, she attended Glan Clwyd later that day.

But despite it later transpiring that Mrs Colegate should have been diagnosed with a pulmonary embolism (a blood clot), doctors incorrectly gave her three increasing doses of adenosine, which should have worked had she been suffering from SVT.

Mrs Colegate was later prescribed a betablocker, metoprolol, which the family’s barrister, Sara Sutherland, labelled a “shocking event”.

Having gone into cardiac arrest three times, Mrs Colegate was pronounced deceased at 1.10am on May 17.

Mark Anderton, Glan Clwyd’s lead consultant for its emergency department on May 16, said he was shown an electrocardiogram (ECG) acquired by Mrs Colegate’s GP which “apparently showed an SVT”, so requested she be moved to the hospital’s resuscitation unit.

Another ECG was taken at 6.01pm, which showed sinus tachycardia.

But he said that, when he went to the resuscitation unit at about 7.10pm to check on staff, he was not told that Mrs Colegate had been given a series of adenosine injections, with no effect.

Dr Venkat Sundaram, an intensive care consultant, said there was “no indication” on Mrs Colegate’s ECG that she could have been suffering from an SVT.

Asked if he was surprised by the working diagnosis of SVT, he said: “Yes and no. I personally don’t rely on what the ECG says. ECGs have a tendency to misinterpret, as machines can.”

He admitted that it is a concern that there are “a lot of factors that can interfere with how a machine can interpret an ECG”.

Dr Tom O’Driscoll, who was clinical director in emergency care at Glan Clwyd at the time, admitted that aspects of communication among staff in Mrs Colegate’s case “weren’t great”.

A betablocker was, in Mrs Colegate’s case, “a poor choice of drug”, he admitted, adding: “If you knew you were dealing with pulmonary embolism, you wouldn’t give a betablocker.”

Describing ECG algorithms as “reasonable but not perfect”, he added: “Good practice is to assess any ECG on your own terms, as a clinician.”

Dr O’Driscoll said: “I wouldn’t be critical at all of GPs in respect of interpreting an ECG. It’s a relatively uncommon thing to do in a GP surgery; it’s not something they’re looking at daily.

“(But) it’s clear that it was an incorrect diagnosis; without any shadow of a doubt.”

Concluding, Ms Robertson described Mrs Colegate’s death as an “incredibly sad case”.

She said she would not issue a Prevention of Future Deaths report, as she was satisfied that the failures in Mrs Colegate’s case have “not been taken lightly” by Betsi Cadwaladr University Health Board.

But she said she will write to Madryn House to “raise their awareness of what has been identified”, and to understand what changes have come about as a result.

Ms Robertson added: “Interpreting ECGs is a basic task for clinicians, which are undertaken in volume by clinicians at the emergency department.

“At the point where adenosine did not have any effect, there was no appropriate reconsideration prior to the administration of the betablocker.

“There was no full assessment reconsidering the inadequate effects of the medication.”