Source · Prevention of Future Deaths
Ben Harrison
Ref: 2023-0099Deceased
Date: 22 Mar 2023
Coroner: Kate Sutherland
Area: North Wales East and Central
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted concerns that the Health Board's action plan following the death was not quickly addressed, with outstanding actions two years later. This delay indicates a lack of strategic direction for investigations and learning.
Date
22 Mar 2023
56-day deadline
17 May 2023 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted concerns that the Health Board's action plan following the death was not quickly addressed, with outstanding actions two years later. This delay indicates a lack of strategic direction for investigations and learning.
View full coroner's concerns
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
The Health Board undertook an investigation following Ben’s death. The investigation contains an Action Plan arising as a result of the learning. It has taken the Health Board a considerable amount of time to update and provide the Action Plan, the most recent version still containing outstanding actions and yet Ben died over 2 years ago.
It is particularly concerning that learning and actions arising therefrom are not more quickly addressed. If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim.
Overall, there is an evident lack of overall strategic direction to investigations and learning.
The Health Board undertook an investigation following Ben’s death. The investigation contains an Action Plan arising as a result of the learning. It has taken the Health Board a considerable amount of time to update and provide the Action Plan, the most recent version still containing outstanding actions and yet Ben died over 2 years ago.
It is particularly concerning that learning and actions arising therefrom are not more quickly addressed. If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim.
Overall, there is an evident lack of overall strategic direction to investigations and learning.
Report sections
Investigation and inquest
On 21 December 2020 an investigation was commenced into the death of Ben Christopher Harrison following his death on 18 December 2020.
A second pre-Inquest hearing took place on 21 March 2023 following an initial Pre-Inquest hearing last year.
The investigation remains ongoing at this time.
A second pre-Inquest hearing took place on 21 March 2023 following an initial Pre-Inquest hearing last year.
The investigation remains ongoing at this time.
Circumstances of the death
The circumstances of the death are as follows :
Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital he was found in cardiac arrest with a ligature around his neck,
. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves, both of which have to be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air. Ben was transferred to Intensive Care Unit and died 3 days later.
Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital he was found in cardiac arrest with a ligature around his neck,
. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves, both of which have to be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air. Ben was transferred to Intensive Care Unit and died 3 days later.
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Report details
- Reference
- 2023-0099Deceased
- Date of report
- 22 March 2023
- Coroner
- Kate Sutherland
- Coroner area
- North Wales East and Central
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 May 2023 (estimated from the report date).
Sent to
- Betsi Cadwaladr University Health Board
Part of a series
2024-0256
All responses identified