Health board 'failings' contributed to death of man killed by his own son

Health board failings contributed to the death of a man who was killed by his own son after he absconded from hospital, a coroner has said. Retired doctor Kim Harrison - a renowned chest consultant - was beaten to death by his son Daniel after the 38-year-old absconded from Neath Port Talbot Hospital and went to the family home in the Swansea Valley in March, 2022.

Dr Harrison suffered catastrophic head and neck injuries in the attack and subsequently died in hospital. Previous stages of an inquest into his death heard details of a review carried out by Swansea Bay University Health Board following complaints by the Harrison family.

Among the findings highlighted by the review was official confirmation that, despite being detained under the Mental Health Act, the killer simply walked out of Ward F at the hospital through an open door. The review also highlighted a series of problems with Daniel Harrison's treatment during his time at the unit. For the latest Welsh news delivered to your inbox sign up to our newsletter.

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The inquest had previously heard how Daniel Harrison had a history of mental health difficulties and psychosis dating back to 2007. While there were times when he was stable and medicated and thrived in his chosen career of bespoke furniture-making, his mental health began to deteriorate from around 2018 and he stopped taking his medication. Over the following years he began to suffer from bouts of paranoia – including about technology – delusions, auditory hallucinations, and "thought broadcasting" where he believed other people could hear his thoughts.

He subsequently abandoned the business he had set up and began living in a property without electricity or running water before "going on the road" with his dog and leading an itinerant life. Due to their concerns the family made repeated efforts to get a mental health assessment for him, and they eventually made a formal complaint to the Swansea Bay University Health Board about how the case had been handled. A year before he killed his dad, Daniel Harrison was seen by a mental health expert who concluded he was not showing signs of psychosis but was leading an "alternative lifestyle".

On March 2, 2022, police were called to the family home in Clydach due to Harrison's threatening and aggressive behaviour, and he later agreed to go to Ward F in Neath Port Talbot Hospital. He was subsequently detained at the hospital under the Mental Health Act.

It was from this unit that he absconded on March 12 and ran to Port Talbot bus station where he caught a taxi to Clydach. He then walked to his parents' house on the outskirts of the village and killed his father in the kitchen of the property. Daniel Harrison subsequently pleaded guilty to manslaughter on the grounds of diminished responsibility and was made the subject of a hospital order.

At the conclusion of the inquest into Dr Harrison's death, assistant coroner, Kirsten Heaven returned a narrative conclusion, with the cause of the 68-year-old's death given as traumatic hypoxic ischemic brain injury as a result of unlawful killing. Ms Heaven stated in her summing up how in 2009, Daniel was “wrongly removed” from the care of what was described as area three of the community mental health team, which led to a lack of continuity in his care in 2018 when his treating consultant left.

She stated at this point, Swansea Bay University Health Board failed to put in place follow up arrangements from a replacement consultant psychiatrist which caused him to become disengaged from services, and him weaning himself of Olanzapine in an unmanaged and unmonitored way, leading to a return of his psychotic symptoms and a deterioration in his mental health.

She said: “Daniel probably would have engaged with a suitable replacement consultant psychiatrist had one been offered by the health board in a timely manner in 2018. There was a failure by Swansea Bay University Health Board to put in place appropriate and timely follow up arrangements from a consultant psychiatrist for Daniel in 2018 and this contributed to Kim’s death.”

Ms Heaven added that concerns were raised by Daniel’s parents with Swansea Bay University Health Board and Swansea Council from June 2020 to March 2022 about his deteriorating mental health in their attempts to get help for him. She said both parties “did not pay sufficient attention to the information being provided about Daniel”, adding that health board clinicians, including the community mental health team “should have ensured that Daniel was regularly and assertively visited in the community” to re-engage him with mental health services.

She also raised a matter of a Mental Health Act assessment which Daniel underwent on April 27, 2021 which did not result in him being admitted to hospital. The coroner described the assessment as “flawed”, adding that there was a failure by the health board to gather all available collateral information to inform the assessment and “inadequate consideration of the risks Daniel posed to himself and others”, which she said “possibly contributed to Kim’s death".

The coroner stated that on March 12, 2022, Daniel absconded through the front door of Ward F, which was being held open by a member of staff. She said the security systems in place at the time were “not fit for purpose” due to infrastructure and door design, and a lack of adequate training for health board staff at a time when the ward was under “significant pressure”.

She said: “This defective system was not picked up or identified by Swansea Bay University Health Board because they had not conducted a review of the security of Ward F despite a significant increase in the rate of absconding. This system failure contributed to Kim’s death.”

Ms Heaven stated how she intends to file a prevention of future deaths report, highlighting several key areas, including how, in her opinion, there was “a risk that future deaths will occur unless action is taken”. She said the first matter of concern related to the lack of access for doctors not employed by the health board to access the medical records of a patient subject to assessment under the Mental Health Act, and the lack of a system within the health board to require doctors to make entries in medical notes, a risk she said would result in “inadequate mental health act assessment or the loss of vital medical information in regards to a patient’s medical records.”

The second matter, she said, was the continued use of Ward F as a “single point access” and the intention that only 75% of staff would be trained on risk assessments by the end of 2024, which she said left a “significant number of staff untrained”.

The coroner also highlighted the health board’s decision to limit its patient safety investigation arising from Mr Harrison’s death and Daniel’s care and treatment to the point of him being admitted to Ward F and not to investigate any of his care and treatment in the community prior to this point. She said: “This raises a concern that Swansea Bay University Health Board are not properly investigating issues connected to a serious incident which in this case has resulted in a death, and hence therefore may not be learning lessons in respect of future risks.”

A statement from Swansea Bay University Health Board, issued after the inquest, said: "This is an extremely harrowing and tragic case and we fully acknowledge the distress and anguish felt by Dr Harrison’s family and friends. We offer our unequivocal apologies for our failings in this case, and are determined to learn and do everything possible to avoid anything like this happening again.

"We recognise that insights and information provided by family members about patients play a crucial role in planning and delivering care. We have strengthened our processes around ensuring this vital information is robustly recorded and shared with clinical teams. A number of key actions are in process, including additional security measures being built into the Ward F at Neath Port Talbot Hospital which provide extra locked areas around exit doors. We will now consider in depth the findings of the coroner, and take any necessary additional actions necessary." Join our WhatsApp news community here for the latest breaking news.