Failures led to ill son killing dad, coroner says
Serious failures by authorities "contributed" to the killing of a retired doctor by his schizophrenic son who had fled a secure mental health unit, a coroner has concluded.
Daniel Harrison, 37, was detained indefinitely under the Mental Health Act for manslaughter by reason of diminished responsibility.
It followed a sustained attack on Dr Kim Harrison, 68, at the family's home in Clydach, Swansea, in March 2022.
The coroner recorded a narrative conclusion with multiple failings in Daniel Harrison’s care contributing to the death.
The assistant coroner for south west Wales, Kirsten Heaven, said Swansea Bay University Heath Board (SBUHB) and Swansea council officials adopted a "fixed mindset" and a "defensive" attitude when the Harrison family asked for help with their son’s deteriorating mental health condition.
The inquest at Swansea Guildhall heard on Tuesday about "missed opportunities" to get Daniel Harrison help after he stopped taking anti-psychotic medication around 2019 and started refusing to engage with health services.
The coroner found a mental health assessment at Swansea police station in April 2021, which found he was not detainable under the Mental Health Act, was "seriously flawed" because collateral information about Daniel Harrison’s paranoid and increasingly aggressive thoughts about his parents were not explored.
Ms Heaven found the psychiatrist involved, Prof Peter Donnelly, was "too willing to accept Daniel Harrison was giving reasonable answers as opposed to paranoid delusion".
She also found Prof Donnelly acted with "extremely reckless conduct" in allowing Daniel Harrison back into the community after telling the inquest that he was worried about his own safety when considering the risk of making a home visit.
"Alarm bells should have been ringing for Prof Donnelly," she told the inquest.
She also found "significant failures by senior managers of the health board who were on notice about Daniel’s deteriorating condition," explaining how there was no "robust plan" in place to try to get Daniel Harrison back on the medication that had helped to manage his then-undiagnosed schizophrenia between 2007 and 2019.
The coroner concluded a failure by SBUHB to "assertively engage" with Daniel Harrison in the community allowed him relapse into psychotic behaviour "possibly contributed" to his father’s death.
Another contributing factor, she added, was a "system failure" by the health board to correct "defects" in the security system at Neath Port Talbot hospital.
Daniel Harrison was able to barge past a nurse who was holding open a normally locked door on the ward.
Ms Heaven found the health board had not responded adequately to previous incidents of absconding through the same door and staff were not given proper security training.
Daniel Harrison’s parents "consistently raised concerns with the health board and the local authority", Ms Heaven said, but "clinicians did not pay significant attention to collateral information from the parents".
In a statement, Dr Jane Harrison said the inquest "exposed multiple failings" in the care of her son.
"Our family could not have done more to seek help for Dan’s deteriorating mental health from senior psychiatrists, social workers and managers."
She said their grave concerns were raised repeatedly but said the family had "no explanation" as to why their calls were "ignored, minimised or explained away".
She accused the authorities of being "blind to their failure to reach out and engage" with her son, claiming an ingrained culture remained in mental health services .
"Our family remain astounded by the lack of compassion, insight and reflection by the health board and city and county of Swansea," she added.
"It took Kim’s death to finally get the care and treatment [Daniel] so desperately needed."
Ms Harrison welcomed the coroner's stated intention to file a prevention of future deaths report.
SBUHB "unequivocally" apologised for its failings and said it "fully acknowledged the distress and anguish felt by Dr Harrison’s family and friends".
"We 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."
It added it had strengthened its processes and put "key actions" in place for improvement, including additional security measures on the ward from which Daniel Harrison escaped.
