'Beautiful' mum dies just one day after being given wrong hospital treatment

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An inquest has determined that neglect contributed to the death of a “beautiful” mother-of-two who was given an incorrect diagnosis by health professionals.

Kayleigh Colegate, 35, from Rhyl, experienced such extreme breathlessness she struggled to walk between rooms at her Larkmount Road home.

In May 2022, after visiting her GP surgery, a nurse observed that her hands were cold and clammy, and she could only speak in short sentences due to suspected pulmonary embolism. With her heart rate elevated, Mrs. Colegate was urgently referred to Ysbyty Glan Clwyd in Bodelwyddan, but significant ambulance delays led her father to drive her to the hospital.

At Ysbyty Glan Clwyd, doctors first thought she was experiencing supraventricular tachycardia (SVT), which is often not life-threatening, but in reality, she had sinus tachycardia, related to pulmonary embolism – a critical condition that requires immediate care.

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The inquest at Ruthin uncovered the tragic error that led to Mrs Colegate receiving the wrong treatment after a misdiagnosis, resulting in her death from an undiagnosed pulmonary embolism. An electrocardiogram (ECG) taken at her GP surgery had been incorrectly read as showing signs of Supraventricular Tachycardia (SVT), an issue highlighted by a senior doctor who pointed to "cognitive bias" impacting the accurate interpretation of the ECG results, North Wales Live has reported, reports Wales Online.

Dr Mark Anderton, an emergency lead consultant at Ysbyty Glan Clwyd, detailed during the inquest how he was notified about a patient with SVT on May 16, 2022, around 5.30pm. The patient, Mrs Colegate, who had been experiencing palpitations for four days, momentarily lost consciousness while at the hospital but then regained consciousness.

Evidence indicated that she was given adenosine between 5pm and 6pm to decrease her heart rate, which unfortunately didn't have the desired effect. A betablocker was administered at 6.40pm in a further effort to stabilize her condition.

Regrettably, Mrs Colegate passed away the next day.

Dr Tom O'Driscoll, a former clinical director in the emergency department, conducted further investigations which revealed that an ECG performed at the GP surgery had suggested SVT, leading to a misdiagnosis that influenced her treatment at the hospital. He clarified during the inquest: "It's clear it is a sinus tachycardia...It's clear it was incorrect - a misdiagnosis."

Dr O'Driscoll acknowledged that this error resulted in inappropriate treatment pathways being followed.

He commented on the issue of cognitive bias, stating: "What's crept in is a cognitive bias - the context has been allowed to cloud to some degree the correct interpretation of the ECG. It's easy for assumptions to start to creep in and they can be dangerous and in this case it was dangerous and it had a very significant outcome."

He conceded that prescribing a betablocker to Mrs Colegate, who suffered from a large pulmonary embolism, was a "poor choice". When barrister Sarah Sutherland, representing the Colegate family, asked if the betablocker was indeed the "wrong" drug, Dr O'Driscoll confirmed with a "yes", adding that neither adenosine nor the betablocker were necessary in this case.

Dr O'Driscoll reflected on the incident as a pivotal educational moment, calling it "one of the most important learning cases of my career", and shared the insights with approximately 300 medical professionals. Ms Sutherland found the events "shocking" and advocated for a narrative verdict indicating neglect.

However, Jack Scott, representing Betsi Cadwaladr University Health Board, argued that neglect had not been proven. Assistant coroner Kate Robertson determined that Mrs Colegate passed away from a pulmonary embolism due to deep vein thrombosis and ruled that her death was by natural causes, but was contributed to by neglect.

She decided that issuing a Prevention of Future Deaths report was unnecessary. Nonetheless, she expressed plans to contact Mrs Colegate's GP practice to highlight the issues uncovered and to understand the improvements made following this tragic case.

After the inquest, widower Ian Colegate shared his aspiration: "I just really hope that Glan Clwyd Hospital have learned from their mistakes. I hope they don't put another family through the pain we are going through and leave another family without their loved one or young kids without their mum or dad."

Earlier, Mr Colegate had honoured his late wife with heartfelt words, calling her "beautiful" and remarking: "She was loved by so many and will leave a hole in all our lives that we will never fill. Her kindness, humour and fun for life will live on in our memories."

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