“There was a delay of 5 days in the formal reporting of the original X-ray; (2) There was…”
Dated 22 Sep 2015, from the coroner for Plymouth, Torbay and South Devon. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 17 Nov 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated22 Sep 2015
- Deadline17 Nov 2015
- Published on judiciary.uk22 Sep 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Plymouth NHS TrustNamed in the report as “Plymouth Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in September 2015. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Response publishedPublished on judiciary.uk in September 2015. |
| Social Services Truro Cornwall | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) There was a delay of 5 days in the formal reporting of the original X-ray; (2) There was a further delay of 2 to 3 days in the obtaining of a second X-ray; (3) The Consultant responsible for Mr Harnell’s care did not know of Hospital guidance that an MRI should be obtained where a first X-ray is inconclusive and/or the patient complains of pain or fails to mobilise. It was felt that this may be due to the fact that Mr Harnell ended up on a Respiratory Ward (even though he had a fracture of his hip) and what may have been known to Orthopaedic Clinicians was not known to Respiratory Physicians.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2015-0384
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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