Leonard Charles Harmsworth · Prevention of Future Deaths report

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.

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.

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 was handed 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.