Ronald Hartley · Prevention of Future Deaths report

On 25th November 2021 I commenced an investigation into the death of Ronald Hartley. The investigation concluded on the 13th June 2022 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Frailty; 1b) Fractured Neck of Femur (Operated on); 1c) Fall

Ronald Hartley had an accidental fall in the garden at his home address. He was taken to Stepping Hill Hospital by his son after they were told the wait for an ambulance would be about 6 hours. At Stepping Hill Hospital, he was found to have a fractured neck of femur. He was subsequently operated on. Post operatively he initially recovered well, but then deteriorated which led to him becoming increasingly frail. On 22nd November 2021, he died at Stepping Hill Hospital.

The evidence to the Inquest from the family was that when they found Mr Hartley and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr Hartley to hospital. He had fallen in his garden in November. The family were faced with a choice of waiting with him for 6 hours when he clearly needed to be in hospital or transporting him to hospital themselves. Given his distress and their concerns about the impact of the prolonged wait on him they decided to transport him to hospital in their own vehicle. The Inquest was told that this was extremely difficult and caused significant pain and discomfort to Mr Hartley.