Ysbyty Gwynedd patient died after chemotherapy complication
A woman admitted to hospital for chemotherapy died two days later after doctors misinterpreted a complication of her treatment as anxiety, an inquest has heard.
Siaron Lowis Bonds, 26, was admitted to Ysbyty Gwynedd in Bangor for treatment for blood cancer in 1994.
Her parents said they raised the alarm as her condition deteriorated, but action was not taken in time.
New evidence and law changes prompted a new inquest in Caernarfon.
The court heard 26-year-old Ms Bonds, from Llanrug, Gwynedd, had been diagnosed with non-Hodgkin's adult lymphoblastic lymphoma and was admitted to hospital on the morning of 7 September.
She started chemotherapy the next day, but by the morning of 9 September she was very unwell, her mother Nerys Bonds told the coroner.
"You could see she was in an awful lot of pain. She was drawing her legs up to get comfortable.
"By 10am, she'd deteriorated even further," Mrs Bonds said.
'Errors and omissions'
Ms Bond's parents raised their concerns with medical staff twice, but on the first occasion, the consultant replied that she was suffering from anxiety, the inquest heard.
Mrs Bonds told the hearing that when they raised concerns a second time, it was too late.
She said: "A young doctor came and told us that Siaron had passed away.
"Siaron's sisters arrived - it was just unbelievable she had passed so quickly. It was 3.30pm and she'd only come in on the 7th."
Ms Bonds died from acute tumour lysis syndrome (ATLS), which can happen when the rapid breakdown of cancer cells causes substances to be released into the bloodstream more quickly than the kidneys can remove them.
The court heard from a report into Ms Bond's death by Healthcare Inspectorate Wales in 2008, which concluded a "series of errors and omissions by staff contributed directly to her death".
It said an opportunity to diagnose ATLS was missed and by the time the seriousness of her condition was recognised, "it was too late" and she suffered a cardiac arrest.
Dr Rachel Williams, a staff doctor on duty the day before Ms Bonds died, told the inquest she appeared well initially after treatment but her tumour "must have melted with the chemotherapy", which would have flooded her bloodstream with high levels of potassium and phosphate.
She said she gave Ms Bonds a dose of potassium chloride in her drip, a routine thing to do in some cases but not recommended for patients with her diagnosis.
She said: "I regret giving the potassium chloride. I don't think it impacted on what happened to Siaron, but wasn't the right thing to do and I'm sorry."
The inquest continues.