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Investigation and inquest
On 28/2/2024 an investigation was opened touching upon the death of Marina Lorraine Waldron
The investigation concluded at the end of the inquest on 9/5/2025
The conclusion of the inquest was recorded as
A Narrative Conclusion in the following terms:
“Marina Lorraine Waldron died from the effects of aortic valve disease contributed to by the side effects of treatment for ischaemic heart disease on 15/2/2024 at the Grange University hospital in Llanfrechfa. Her death was also contributed to by malnutrition.
The medical cause of death was:
1a) Lower Gastro-intestinal bleeding from angiodysplasia
1b) Aortic Stenosis
2. Ischaemic heart disease with recent stent placement. Malnutrition.
Circumstances of the death
Marina Waldron was admitted to hospital on 17/12/2023 with evidence of gastrointestinal bleeding. I will not describe in detail the investigations performed or the treatment she received thereafter. I found that this difficult situation was investigated and managed appropriately. Despite receiving all appropriate treatment the gastrointestinal bleeding, caused by angiodysplasia, an uncommon complication of aortic stenosis, proved overwhelming and MW died on 15/2/2024.
Coroner’s concerns
During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed.
Examples of this include:
1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately
2. A failure to formally monitor MW’s dietary intake
3. A failure to respond to a low Albumin level which is a sign of malnutrition
4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission)
The medical staff who gave evidence agreed that malnutrition contributed to MW’s death.
Information checked against the published report and official responses