Hospital staff 'missed opportunities' in chemotherapy death
Opportunities were missed to treat a cancer patient who died following chemotherapy complications, an inquest heard.
Siaron Lowis Bonds, 26, was treated at Ysbyty Gwynedd in Bangor for blood cancer in 1994 but died two days after her chemotherapy treatment began.
New evidence and law changes prompted a new inquest in Caernarfon.
But a coroner said "it was not possible to say" if Ms Bonds would have survived had staff spotted complications sooner.
Ms Bonds had high grade non-Hodgkins adult lymphoblastic lymphoma, and developed a complication called Acute Tumour Lysis Syndrome (ATLS).
A consultant who treated her said that had blood tests been carried out earlier, complications could have been diagnosed sooner.
Ms Bonds, from Llanrug, Gwynedd, died from ATLS, which can occur when the rapid breakdown of cancer cells causes substances to be released into the bloodstream more quickly than the kidneys can remove them.
The inquest heard from one doctor who said "the tumour must have just melted with the chemotherapy", releasing high levels of potassium into her bloodstream.
Coroner Joanne Lees said "opportunities were missed to identify ATLS, to administer treatment and to optimise her chances of survival".
"It is not possible to say that Siaron would have survived, had ATLS been identified earlier," she said.
"After chemotherapy she was not monitored regularly. No blood tests were taken until after a rapid deterioration which then identified ATLS.
"Her condition was initially misdiagnosed as chemotherapy induced sickness and associated anxiety. That blood test, sadly, was way too late."
The coroner said Ms Bonds should have been given fluid via a drip in more time before the chemotherapy, and staff on duty during the night did not call a specialist when her condition deteriorated.
"I find that Siaron Bonds died from a known side effect of life-saving chemotherapy treatment," Ms Lees concluded.
Ms Bonds' sister Glenda Murray thanked those who had supported the family during the inquest, adding: "Finally, some partial answers to concerns which have troubled us for nearly 25 years.
"We also trust that the findings will be acted upon and therefore ensure that no such tragedy will ever happen again.
"No facts that were disclosed will ever make up for the premature loss of Siaron, a beautiful young woman and a cherished daughter and sister."
Betsi Cadwaladr University Health Board said: "Our condolences are and always have been with the family."