William John Charles Harnell · Prevention of Future Deaths report

On 15/12/2014 I commenced an investigation into the death of William John Charles Harnell then aged 67. The investigation concluded at the end of the inquest on 15 September 2015. The conclusion of the inquest was that Mr Harnell died as the result of an accident. He had suffered a fractured left neck of femur while attempting to mobilise from his wheelchair in the early hours of 22 October 2014. The cause of death was given as:
1 (a) Hospital Acquired Pneumonia;
1 (b) Left Hip Fracture;
II Cerebral Vascular Event and left sided weakness.

Mr Harnell was admitted to Hospital on 22 October. The fracture of his hip was not diagnosed until 3 November. I have already written to Plymouth Hospitals NHS Trust to raise concerns in this regard.

At Inquest I was told that Mr Harnell was fit to be considered for discharge from approximately 4 November 2014. Subsequently, he had chest pain which required investigation and may have delayed matters by approximately a week. By the middle of November, however, Mr Harnell was ready for discharge. Regrettably, Mr Harnell was not discharged and remained in Hospital until he developed Pneumonia and died on 15 December 2014 approximately one month later.

I heard evidence at Inquest that part of the reason why Mr Harnell continued to remain in Hospital was that he presented as an extremely challenging patient. He was, on occasions verbally and physically abusive to staff. It was not immediately clear whether this was due to a mental health condition or a personality defect.

I heard evidence that, but for this behaviour, Mr Harnell would have been discharged to a Community Hospital. That option was not available, however, and neither was a return to his home address given the decision to treat the hip fracture conservatively.

It seems clear from the evidence that by the middle of November it was plain Mr Harnell could only be discharged to a nursing Home of some sort. It was not, however, until 28 November when I understand ████████ the Social Worker involved rang five homes that may be able to offer this sort of facility

(1) There was delay in recognising that Mr Harnell was a most challenging patient for whom the usual means of discharge would not all be available.
(2) There appears to have been delay in determining Mr Harnell’s state of mental health
(3) There appears to have been delay in approaching the Nursing Homes that may have been able to accommodate him.
(4) There appears to be a lack of resources available for dealing with challenging (and vulnerable) patients like Mr Harnell.
(5) There appears to be no guideline or protocol to assist staff on how best to deal with the discharge of patients like Mr Harnell.