Leonard Harmsworth
PFD Report
Historic (No Identified Response)
Ref: 2023-0202
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 3
56-Day Deadline
15 Aug 2023
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
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.
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.
Report Sections
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.
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.
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Improve LAS procedures for timing and recording ambulance whereabouts
Fennell Inquiry
Ambulance Handover Delays
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.