Ben Harrison
PFD Report
Historic (No Identified Response)
Ref: 2023-0099Deceased
Coroner's Concerns (AI summary)
The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in implementing action plans following a death, risking recurrence of similar incidents.
View full coroner's concerns
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
The Health Board undertook an investigation following Ben’s death. The investigation contains an Action Plan arising as a result of the learning. It has taken the Health Board a considerable amount of time to update and provide the Action Plan, the most recent version still containing outstanding actions and yet Ben died over 2 years ago.
It is particularly concerning that learning and actions arising therefrom are not more quickly addressed. If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim.
Overall, there is an evident lack of overall strategic direction to investigations and learning.
The Health Board undertook an investigation following Ben’s death. The investigation contains an Action Plan arising as a result of the learning. It has taken the Health Board a considerable amount of time to update and provide the Action Plan, the most recent version still containing outstanding actions and yet Ben died over 2 years ago.
It is particularly concerning that learning and actions arising therefrom are not more quickly addressed. If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim.
Overall, there is an evident lack of overall strategic direction to investigations and learning.
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2024-0256
Sent to: BOC LimitedAll responded
This report (2023-0099Deceased) is shown above.
Sent To
- Betsi Cadwaladr University Health Board
Response Status
Linked responses
0 of 1
56-Day Deadline
17 May 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 21 December 2020 an investigation was commenced into the death of Ben Christopher Harrison following his death on 18 December 2020.
A second pre-Inquest hearing took place on 21 March 2023 following an initial Pre-Inquest hearing last year.
The investigation remains ongoing at this time.
A second pre-Inquest hearing took place on 21 March 2023 following an initial Pre-Inquest hearing last year.
The investigation remains ongoing at this time.
Circumstances of the Death
The circumstances of the death are as follows :
Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital he was found in cardiac arrest with a ligature around his neck,
. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves, both of which have to be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air. Ben was transferred to Intensive Care Unit and died 3 days later.
Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital he was found in cardiac arrest with a ligature around his neck,
. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves, both of which have to be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air. Ben was transferred to Intensive Care Unit and died 3 days later.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.