Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0202, written 20 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2023 |
|---|---|
| Reference | 2023-0202 |
| Deceased | Leonard Harmsworth |
| Coroner | Kate Sutherland |
| Coroner area | North Wales (East and Central) |
| Category | Wales prevention of future deaths reports (2019 onwards) · Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Sutherland
Assistant Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust
(WAST), North Wales Local Authorities
1
CORONER
I am Kate Sutherland, Assistant Coroner for North Wales (East and Central)
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
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.
4
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.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving rise to concern.
In my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
The MATTERS OF CONCERN are as follows. –
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.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have
the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely 15 August 2023. I, Kate Sutherland, the Coroner, may extend the period.
I would be prepared to accept a joint response from all organisations.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise, you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner.
I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her
information.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the coroner, at the time of
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
your response, about the release or the publication of your response by the Chief
Coroner.
9
Dated 20 June 2023
Signature
Assistant Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Tel 01824 708047 |
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