Swansea: Nursing failure in the death of a doctor killed by his son

The report detailed how a member of Swansea City Council’s mental health team failed to gain access to Daniel Harrison’s full medical history ahead of a formal assessment under the Mental Health Act in February 2021.

Daniel’s parents and brothers repeatedly raised concerns about his behavior with both the council and Swansea Bay Health Board, the report said, after he stopped taking his medication and refused to seek counseling services.

The assessment was also not compliant, it said, as only one doctor was present.

Daniel then became increasingly paranoid and aggressive towards his parents, attempting and failing to obtain a mental health assessment on two or more occasions before he was finally incarcerated in 2022.

The coroner’s report said the story presented by the Harrison family was “not given sufficient weight” and “reliance was solely on records in the system, which were out of date.”

The report also raised concerns about the health authority’s use of substitute doctors, some of whom did not record notes about their interactions with Daniel Harrison.

“The Swansea Bay University Health Board (SBUHB) has no system in place to ensure that doctors are required to record the outcome of their assessment when deciding not to admit a patient to hospital,” the report continued.

It said the lack of a unified medical records system created “a risk that the assessment may be inaccurate or fail to recognize that a person needs to be hospitalized.”

The investigation found that staff at the station where Daniel Harrison was held before his escape had no risk assessment training.

The report said only 75% of staff were currently trained, “raising concerns that risks to self and others, as well as the risk of absconding, are not being properly identified”. This poses a risk of further deaths.”

The report also raised concerns about Daniel Harrison’s refusal to seek mental health services when he was unwell.

The deputy coroner said authorities should refer such cases to “assertive public relations.”

“I am concerned that if consent is required before a mentally ill person in the community can receive assertive contact, there may be a gap in mental health services within the SBUHB that poses a risk,” the report said.

Swansea Bay Health Authority “unequivocally” apologized for its failings and said it had taken “important steps” to improve, including additional security measures on the ward where Daniel Harrison was treated.

“We recognize that insights and information from family members about patients play a critical role in planning and delivering care,” a spokesperson said.

“We have strengthened our processes to ensure this important information is reliably recorded and shared with clinical teams.”

It said it would formally respond to the coroner’s report in June.

Swansea City Council has been contacted for comment.