Serious failings in care played a role in the murder of his father, the Welsh coroner
A series of serious failings in the care of a man with schizophrenia who killed his father an hour after absconding from a psychiatric ward contributed to the death, a coroner has ruled.
Coroner Kirsten Heaven also said security systems at the hospital where Daniel Harrison was held were inadequate and played a role in the events leading to the murder of retired breast consultant Kim Harrison.
The inquest in Swansea found that Daniel Harrison, a carpenter, was delusional because he believed his family was evil and that he was being targeted by drug cartels, motorcycle gangs and phone hackers.
His condition worsened after he weaned himself off antipsychotics when Swansea Bay University Health Board failed to get him the right services and at one point police warned it was only a matter of time before he would hurt a family member.
His family tried desperately to get help for him, but one of the key mental health professionals involved in his case concluded that his chaotic state stemmed from a desire to live an “alternative lifestyle” and not because he was very ill.
Harrison punched, kicked and stamped on his 68-year-old father at his home in Clydach, Swansea, after sneaking out of a ward at Neath Port Talbot Hospital in March 2022.
He admitted manslaughter by reason of diminished responsibility and a judge imposed hospital orders under the Mental Health Act, meaning he would be held indefinitely.
In a highly unusual move at the start of the inquest, Daniel Harrison, now 38, appeared via video link from the unit where he is being treated and read poems in honor of his father. He said he knew his father “would be so relieved.” ‘ to see the progress he was making.
The coroner said in a narrative conclusion that Daniel was suffering from untreated schizophrenia at the time of the attack, which caused him to have paranoid delusions about his father.
She said Harrison was “wrongfully” removed from the care of the community mental health team in 2009. When a consultant who had treated him left his position in 2018, Swansea Bay University (UHB) health board “failed to make appropriate and timely follow-up arrangements”. Heaven said: “This contributed to Kim’s death.”
Harrison self-medicated “in an unattended and uncontrolled manner” and the risk to himself and others began to increase.
The coroner said: “Daniel’s parents have consistently raised concerns with Swansea Bay UHB and the City and County of Swansea AMHP (licensed mental health professional) about Daniel’s deteriorating mental health. Swansea Bay UHB doctors and the AMHP service have not paid sufficient attention.”
Daniel was admitted to hospital on March 2, 2022, after behaving psychotically in the family home and being confrontational with his parents. While there his risk assessments were not fully completed and his family’s concerns were not fully registered. There was no clear plan for him.
On March 12, he disappeared through a door held open by an employee. Heaven said: “The security systems in place were not fit for purpose” and highlighted a “lack of adequate training”. The coroner said: “This system error contributed to Kim’s death.”
Swansea Bay UHB said: “We unequivocally apologize for our shortcomings in this matter, and are committed to learning and doing everything possible to prevent something like this from happening again.”
A spokesperson for Swansea Council said: “We will consider the coroner’s conclusion and findings in detail.”