Neglect led to man’s death at mental health unit, coroner finds

Coroner Kate Robertson outlined a series of “missed opportunities” that led to Mr Harrison being able to harm himself, including a failure to ensure the ward was safe for mental health patients at risk of self-harm.

When Ben, from Denbigh, voluntarily attended the ward on 11th December 2020, there was no recorded rationale of how staff should engage with him, no admissions pathway was completed, daily mental state examinations were not always done and daily room searches were not undertaken.

There was no one to one session between Ben and medical staff on the day he harmed himself.

Therapeutic observations were not undertaken at any time, visual observations were not accurately recorded and some staff on Cynnydd ward had not been properly trained to work in acute settings.

“But for these collective gross failures Ben would not have died when he did,” Ms Robertson said.

“Ben’s death was contributed to by neglect.”

During the four-day hearing, Peter Williams, a ward manager at the hospital, said there was “nothing to suggest Mr Harrison was a risk, because he was “future oriented”.

He was found hanged in a lounge in the ward on 15 December, four days after arriving.

Health board investigating officer Sarah McGarrity told the inquest Mr Harrison’s care and treatment was “not to the standard expected”.

A statement from Mr Harrison’s family said the coroner’s findings “speak for themselves”.

“To lose a son and brother in circumstances such as this was, and still is, tragic.”

They said the wait for the outcome of the inquest had been “distressing, frustrating and on many occasions, annoying”.

Nathalie Smilovici, a friend of Mr Harrison’s, described him as “charming, funny, thoughtful and kind”, adding friends had raised £2,000 for a mental health charity in his memory and that Ben’s donated organs had saved four lives.

In response to the coroner’s conclusions, Carol Shillabeer, Betsi Cadwaladr’s chief executive, said: ” offer my sincere condolences to Ben’s family and friends for their tragic and sad loss. I apologise for the failings in his care and the subsequent investigation.”

“We are striving to improve mental health and other services within north Wales and we fully accept the findings of the coroner. We will examine those findings in detail.”

She offered to meet with Mr Harrison’s family, saying she wanted to “hear about Ben and their experiences with the health board and assure them his story has been and will be a catalyst for improvement”.