Neglect contributed to death of 'beautiful' Rhyl mum misdiagnosed by medics

Neglect contributed to the death of a "beautiful" mum-of-two who was misdiagnosed by medics, an inquest concluded. Kayleigh Colegate, 35, from Rhyl, went to her GP surgery after suffering with shortness of breath which was so severe she could barely walk between rooms at her Larkmount Road home.

After visiting her GP surgery in May 2022, a nurse found her hands were cold and clammy and she was unable to speak except for in short sentences. She suspected she had a pulmonary embolism.

Mrs Colegate was found to have a raised heart rate, and was sent straight to Ysbyty Glan Clwyd in Bodelwyddan. Due to long ambulance delays, she was taken to hospital by her father.

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Doctors thought she was suffering with supraventricular tachycardia (SVT), a condition which in most cases is not serious. Mrs Colegate, a child care leader, was actually suffering with sinus tachycardia, an arrhythmia associated with pulmonary embolism.

An inquest, held in Ruthin on Friday, heard doctors misdiagnosed Mrs Colegate and gave her the wrong medication before she later died from the pulmonary embolism. The inquest heard an electrocardiogram (ECG) from her GP surgery suggested she had SVT, with a senior doctor saying "cognitive bias" crept in which "clouded" the correct interpretation of the ECG results.

In a statement Dr Mark Anderton, an emergency lead consultant at Ysbyty Glan Clwyd, said that at 5.30pm on May 16, 2022, staff made him aware a patient had SVT. He said Mrs Colegate had had palpitations for four days.

She had become unresponsive in a hospital bed before regaining consciousness. The inquest heard Mrs Colegate was given a drug called adenosine, which slows down the heart. It was given between 5pm and 6pm but was unsuccessful, the inquest heard.

Mrs Colegate was then given a betablocker, which also slows the heartrate, at 6.40pm. She sadly died on May 17. Dr Tom O-Driscoll, who was clinical director in the emergency department at the time and investigated the case, told the inquest the GP surgery's ECG suggested Mrs Colegate had SVT.

That interpretation was incorrect but he didn't blame the surgery, he said, because the electronic interpretation can be misleading. But hospital staff initially treated her case as SVT not a sinus tachycardia.

Dr O'Driscoll told the inquest: "It's clear it is a sinus tachycardia...It's clear it was incorrect - a misdiagnosis." Even then, the wrong treatment was followed, the inquest heard.

Dr O'Driscoll said: "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 said the betablocker had been a "poor choice" of drug for someone like Mrs Colegate with a large, pulmonary embolism.

Barrister Sarah Sutherland, for the Colegate family, asked him if the betablocker was in fact the "wrong" drug. He replied "yes", and said neither adenosine nor the betablocker drug were necessary.

Dr O'Driscoll said this had been "one of the most important learning cases of my career". His review of the case has offered "incredibly rich areas of learning". Some 300 doctors had been made aware of the case.

Ms Sutherland called the events "shocking" and asked for a narrative conclusion with a contribution of "neglect". Jack Scott, for Betsi Cadwaladr University Health Board, argued neglect was not proven.

Kate Robertson, assistant coroner for north east and central North Wales, found Mrs Colegate died from a pulmonary embolism due to deep vein thrombosis. She concluded Mrs Colegate's death was due to natural causes contributed to by neglect.

She said there is no need for a Prevention of Future Deaths report. But she added she would be writing to Mrs Colegate's GP surgery "to raise their awareness of what has been identified and to understand what learning and change has come about as a result of this incredibly sad case".

After the hearing widower Ian Colegate said: "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."

Mr Colegate previously described his wife as "beautiful" and said: "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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