Source · Prevention of Future Deaths
Leonard Harmsworth
Ref: 2023-0202
Date: 20 Jun 2023
Coroner: Kate Sutherland
Area: North Wales East and Central
Responses identified: 0 / 3
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Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.
Date
20 Jun 2023
56-day deadline
15 Aug 2023 est.
Responses identified
0 of 3
Coroner's concerns
Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.
View full coroner's concerns
Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Report sections
Investigation and inquest
On 29 June 2022 an investigation was commenced into the death of Leonard Charles Harmsworth (DOB 29/3/33) who died on 18 June 2022. The investigation concluded at the end of the inquest on 19 June 2023. The conclusion of the inquest was a narrative conclusion.
Circumstances of the death
The circumstances of the death are as follows :- Leonard Charles Harmsworth died on 18 June 2022 at Ysbyty Glan Clwyd from cardiac related issues contributed to by a fractured ankle and immobility due to a fall. He had been admitted on 7 June following a fall at home. He remained under conservative management before undergoing manipulation. He suffered a sudden deterioration following a manipulation of his ankle and died on 18 June 2022.
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Report details
- Reference
- 2023-0202
- Date of report
- 20 June 2023
- Coroner
- Kate Sutherland
- Coroner area
- North Wales East and Central
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Aug 2023 (estimated).
Sent to
- Betsi Cadwaladr University Health Board
- North Wales Local Authorities
- Welsh Ambulance Service NHS Trust