Swansea: Failures led to mentally ill son killing dad, coroner says

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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.


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