Wife's call for review after husband killed by son
A woman whose husband was killed by their schizophrenic son has called for an independent review into what happened.
Daniel Harrison, 37, fled from a secure mental health unit before fatally attacking his father, Dr Kim Harrison, at the family's home in Clydach, Swansea, in March 2022.
An inquest found failures in the care of Daniel had "contributed" to Dr Harrison's death.
Swansea Bay University Health Board apologised for its failings and said it had put "key actions" in place for improvement.
Daniel was detained indefinitely under the Mental Health Act for manslaughter by reason of diminished responsibility.
His mother, Dr Jane Harrison, said her son was let down at all stages of his mental health care.
"Our family has suffered immeasurable harm at the hands of managers and senior clinicians," she said.
"We are calling for an independent review of mental health services across Swansea Bay.
"Only through external scrutiny will the deep cultural issues that are clearly present be addressed and those responsible for the many professional and systemic failings be held to account."
A prevention of future deaths report, written by the assistant coroner for south west Wales, detailed how a Swansea council mental health worker failed to access Daniel's full history before a formal assessment under the Mental Health Act in February 2021.
Daniel's parents and brothers had repeatedly raised concerns with both the council and the health board about his behaviour, the report said, after Daniel stopped taking his medication and refused to engage with counselling services.
The assessment was also non-compliant, the report continued, because only one doctor was present.
Daniel then became increasingly paranoid and aggressive towards his parents who, on two more occasions, tried and failed to get a mental health assessment before he was eventually detained in 2022.
The coroner's report said the history provided by the Harrison family "was not afforded sufficient weight", with "reliance being placed solely on the records on the system which were out of date".
The report also raised concerns about the health board's use of locum doctors, some of whom did not record notes of their interactions with Daniel.
"There is no system within Swansea Bay University Health Board (SBUHB) to ensure doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital," the report added.
It said the lack of a single medical records system created "a risk that assessments may be flawed or may not detect that a person requires admission to hospital".
The inquest found staff in the ward where Daniel was being held prior to his escape had no risk assessment training.
The report said that only 75% of staff were now trained, "which raises a concern that risk to self and others and the risk of absconding will not be properly identified... thus creating a risk that other deaths will occur".
The report also raised concerns about Daniel's refusal to engage with mental health services when he was unwell.
The assistant coroner said authorities should refer such cases to "assertive outreach".
"I am concerned that if consent is required before a mentally unwell person in the community is able to receive assertive outreach then there may be a gap in the mental health services within SBUHB that creates a risk," the report stated.
Swansea Bay health board "unequivocally" apologised for its failings and said it had put "key actions" in place for improvement, including additional security measures on the ward where Daniel Harrison was treated.
"We recognise that insights and information provided by family members about patients play a crucial role in planning and delivering care," a spokesperson said.
"We have strengthened our processes around ensuring this vital information is robustly recorded and shared with clinical teams."
It said it would be responding formally to the coroner's report in June.
Swansea council said it again sent its "sincere condolences" to Dr Harrison's family and it would respond formally later to the coroner's report.
"We are in the process of reviewing our internal processes to determine what action is necessary in light of the concerns arising from the coroner's inquest and the subsequent report issued relating to the prevention of future deaths."
