Failings found in mental health care of man who killed his father after escaping from hospital
Video report from Dean Thomas-Welch
A retired doctor was beaten to death by his own son who absconded from a hospital's mental health facility following a number of health board failures, a coroner has ruled.
Dr Kim Harrison, a renowned chest consultant, was beaten to death by his son Daniel Harrison at their family home in Clydach, Swansea, in March 2022.
Dr Harrison, 68, was a respected doctor at Swansea Bay University Health Board, who the coroner found failed in a number of ways in the care of Daniel Harrison before the fatal attack.
They include failing to properly assess and diagnose Daniel Harrison, possibly contributing to the fatal attack on his father, while the concerns of Daniel Harrison's family about his mental health in the weeks and days leading up to the attack were largely ignored.
An inquest into the death of Dr Harrison, which concluded on Tuesday, 16 April, was told how Daniel Harrison escaped from Neath Port Talbot Hospital by pushing past a nurse at a security door, ordering a taxi and then returning to the family home, where he killed his father.
He had been diagnosed with paranoid schizophrenia and had been detained under the Mental Health Act at the hospital in the days leading up to the attack.
Recording a narrative conclusion, assistant coroner Kirsten Heaven raised a number of concerns.
Previously, Daniel Harrison pleaded guilty to manslaughter on the grounds of diminished responsibility and was made the subject of a hospital order.
Dr Kim Harrison's wife Jane Harrison said after the hearing: "This inquest had focused on the events which led to the tragic death of my husband Kim in April 2022. It has exposed more failings in the care of our son, Dan, by Swansea Bay Health Board and the City and County of Swansea.
"As the coroner has made clear, Dan suffered a relapse of his chronic schizophrenic illness which was well managed until he was lost to follow-up by the health board in 2018.
"Our family could not have done more to seek help for Dan's deteriorating mental health from senior psychologists, social workers and managers.
"Together with close friends, we repeatedly raised concerns and yet to this day we have had no explanation as to why our calls were ignored, minimised or explained away.
"The coroner has recognised the defensive attitude of staff at the time and we were dismayed to see this continue throughout the inquest.
"We remain at a loss to understand how so many professionals could get it so wrong, how they could fail to deliver basic medical care and how major system failings could remain unaddressed.
"Throughout the inquest, staff have sought to give the impression that it was Dan's fault for not engaging with mental health services, leading to a recurrence of his psychosis and the tragic events that unfolded.
"The professionals giving evidence appear blind to their failure to reach out and engage with him. It was their duty to care for him.
"What is also apparent is the lack of accountability at every level in these organisations and this is apparently ingrained in the culture of the teams who should have been managing Dan's care.
"Culture affects people's behaviour and the behaviour in this case fell well below acceptable standards.
"We miss Kim every day. We continue to give Dan our love and support as he steadily recovers, though this is a long and difficult journey.
"Our family remain astounded by the lack of compassion, insight or reflection of the health board and the City and County of Swansea given the failings set out by the coroner, some of which contributed to Kim's death.
"They care for the most vulnerable in society and yet it took Kim's death to finally get [Dan] the care he so desperately needed and deserved."
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."
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