Wrexham Maelor Hospital discharged patient's death concern
A report to prevent future deaths was issued after a woman died following discharge from Wrexham Maelor Hospital.
Carol Harvey died, aged 74, in April last year due to the effects of paracetamol overdose and a pre-existing heart condition, an inquest heard.
Coroner John Gittins recorded a narrative conclusion, saying she was probably left in "considerable pain".
He outlined concerns to Betsi Cadwaladr University Health Board, which apologised to Mrs Harvey's family.
Mrs Harvey was treated at the hospital but was discharged on 7 April and was later found drowsy and vomiting having suffered a large loss of blood.
The north Wales coroner said a message about her care left for a health team was not checked which meant carers did not visit.
This meant "it is probable that in the course of that evening and overnight she was in considerable pain as a result of a calf haematoma and consequently took an accidental overdose of painkillers", the report said.
After being re-admitted to hospital, she died on 9 April.
Mr Gittins has asked the health board for a detailed response and a timetable for action within 56 days.
The health board's medical director, Dr Evan Moore, said: "We apologise to Mrs Harvey's family for the missed opportunities to provide further care, and fully accept the coroner's findings.
"We have since put in place new measures to enhance communication between staff in different wards and departments, as well as a review of the way we discharge patients from acute hospitals on anticoagulant therapy."