Care failings before son killed father - inquest

Dr Kim Harrison was killed in a sustained attack at his home in Clydach, Swansea

A man who fled a mental health unit and killed his father was failed by the health board in charge of his care, an inquest has heard.

A senior manager with Swansea Bay University Health Board admitted background information about Daniel Harrison, 37, was not shared with the clinician treating him.

The coroner's court at Swansea Guildhall also heard serious concerns about the security of the hospital unit were known before he absconded.

Dr Kim Harrison, 68, was punched, kicked and stamped on by his son at the family's home in Clydach, Swansea, in March 2022.

He admitted manslaughter by reason of diminished responsibility and was detained indefinitely under the Mental Health Act.

Harrison had a long history of mental health problems, the inquest heard, but managed the condition with medication for more than a decade while living with his parents, where he started a furniture making business.

But the inquest heard that his mental health started to decline in 2021 with paranoia and aggressive behaviour towards his parents, who were both doctors, culminating in an alleged assault involving his landlord.

In March 2022 he was detained at a secure ward in Neath Port Talbot Hospital.

Daniel Harrison had been detained at Neath Port Talbot Hospital

Stephen Jones, the nurse director for mental health and learning disabilities for Swansea Bay University health board told the court how background information about Harrison's mental decline was not given to the doctors treating him.

The assistant coroner for south west Wales, Kirsten Heaven, asked why it took 10 weeks for action on an independent review, which identified the failure to share information.

"I was asked to review the report for further information and accuracy so it remained as a draft," Mr Jones told the inquest.

The information still had not been shared, the inquest heard, when on 12 March 2022, Harrison barged past a nurse who had opened a secure door using a swipe card and made his way to his parents' house where he attacked his father.

Mr Jones also admitted the risk assessment done before Harrison's admission to the unit was inadequate due to staff not being fully trained, and that on 48 other occasions between 2019 and 2022 patients had fled through the same door Harrison used to escape.

He said the health board had since spent £640,000 on increased staffing and better security, and that risk assessment training was being done with staff.

Asked by Bridget Dolan, representing Dr Jane Harrison, why the psychiatrist was not given proper background to the case, Mr Jones said: "I absolutely agree it would have been useful [for the psychiatrist] to have this collateral information".

Failings recognised by health board

He could not say why this was not done, but added that an email had gone out in December 2023 to clinicians "reinforcing" the professional expectation to record and seek out relevant background information on patients in a mental health crisis.

Ms Dolan also asked why a video recorded by police showing Harrison's violent behaviour towards his parents was not shared with his doctors or considered in the risk assessment.

Mr Jones told the inquest that for data protection reasons that type of video could not be shared by email.

He was also questioned about a "robust plan" of care for Harrison, after the alleged attack on his landlord and a mental health assessment in 21 April 2021.

"Does Swansea Bay health board accept this plan was not robust?" Ms Dolan asked.

"Yes," Mr Jones replied.

Ms Dolan accused the health board of ignoring repeated warnings from Harrison's family his condition was worsening into psychosis.

"Do you accept there was an opportunity to engage with Dan in December 2021 when he was seeking help that wasn't taken," she asked.

"Yes, we should have," Mr Jones said, adding the health board had since recognised those failings and acted.

The inquest continues.