MEDICS throughout Europe have been alerted to the circumstances which led to the death of a patient at the Wrexham Maelor Hospital.

A senior consultant also told an inquest in Ruthin that he had used the example of Kate Jones to highlight the issues when addressing junior and senior doctors at Betsi Cadwaladr University Health Board.

It follows a safety alert issued to all members of staff following the death of the 34-year-old cook in March, 2017.

The mother-of-three, of Swan Mere Close, Swanhill, Ellesmere, died of cerebral edema – swelling of the brain – 10 days after being admitted to hospital. She had been vomiting and had diarrhoea for about a week and also complained of a headache.

She was quickly diagnosed as having gastro-enteritis and given appropriate medication, which cured the problem, but she continued to have high blood pressure, something from which she had suffered for many years.

Miss Jones received medication for the hypertension and was being considered for discharge but her family became concerned when her behaviour changed. She was found wandering around the hospital and was shouting, and later became unresponsive.

Her sisters asked for a brain scan and told doctors that she may have been suffering from alcohol withdrawal as she normally drank about 20 pints of beer a week.

Hospital staff told the inquest of ongoing concern about low sodium and potassium levels in her blood, for which she was medicated.

Miss Jones became increasingly unresponsive and when a scan was eventually carried out the brain swelling was revealed.

Dr Stuart Robertson, consultant nephrologist, who headed the internal investigation after her death, said the alcohol withdrawal, which could have caused confusion and behavioural changes, was a “red herring” and the treatment for the blood pressure and low sodium and potassium had been appropriate.

It was “unfortunate”, however, that the link between the change in behaviour and the brain swelling was not made sooner.

“Early intervention may have changed the outcome but it was a very complex situation,” he said.

The swelling would have been caused by the sudden and marked decrease in sodium level, exacerbated by the dehydration through diarrhoea and vomiting.

Dr Robertson said that in his 25 years’ experience he had never come across such consequences of a rapid drop, but added that menopausal women were more susceptible.

Correcting sodium levels too quickly, he added, could actually cause brain damage.

He told the inquest that local guidelines were about to be issued following Miss Jones’ death when European guidelines were received.

Another step taken as part of an action plan is that when critically low sodium levels are found staff on the particular wards are notified that it could be life-threatening.

Recording a narrative conclusion, David Pojur, assistant coroner for North Wales East and Central, said that after learning what steps had already been taken he did not see the need to issue a Regulation 28 report to prevent future deaths.

After the hearing Miss Jones’ partner Shaun Walker and members of her family, who had raised concerns about her treatment, declined to comment.