Mental health patient killed father after health board ignored warnings.

An international lung expert was beaten to death by his son who escaped from a psychiatric hospital after the health board ignored repeated warnings from the victim and his wife, believing they were abusing their position as doctors to get preferential treatment.

A coroner ruled that Kim Harrison, 68, an expert in pulmonary fibrosis, who had recently retired, was brutally attacked by Daniel Harrison, 38, following a series of medical and security failures.

An inquest heard that Harrison and his wife Jane, who is also a doctor, had repeatedly complained to health staff that their son’s paranoid delusions were getting worse but were dismissed as “overbearing” by staff who had “fixed views” that they were abusing their position as doctors to get preferential treatment for Daniel.

Swansea coroner’s court heard that police had noted Daniel may “seriously hurt” one of his family members weeks before the fatal attack in April 2022.

Assistant coroner for Swansea, Kirsten Heaven, said that the Harrison family were failed by health chiefs and council workers as well as “inadequate” security measures at the hospital where Daniel was being treated.

She said that medical teams failed to properly assess and diagnose Daniel, possibly contributing to the fatal attack on his father, while the concerns of his family about his mental health before the attack were largely ignored.

The inquest was told Daniel escaped from Neath Port Talbot Hospital, Wales by pushing past a nurse at a security door, ordering a taxi and then returning to the family home 12 miles from the hospital, where he killed his father.

He had been diagnosed with paranoid schizophrenia and had been detained under the Mental Health Act at the hospital in the days leading up to the attack.

Kirsten Heaven said that no proper risk assessment was carried out into the dangers Daniel posed if he were to abscond and there was no treatment plan to control his psychosis.

The assistant coroner said that Daniel, who at one stage was living in a house without electricity or running water and washing in a stream, was able to “mask” his psychosis from assessors who wrongly claimed his behaviour was a “lifestyle choice” rather than mental illness.

Despite an independent review being carried out criticising Daniel’s care, it was not shared with doctors at Neath Port Talbot Hospital before he fled.

Kim Harrison, who helped set up the respiratory unit in Swansea’s Morriston hospital and became an international expert in pulmonary fibrosis, and his wife were warned of Daniel’s escape and told that he may be heading in their direction.

Despite the warning, Daniel attacked his father at the family home in Swansea, punching, kicking and stamping on him and beating him with a broom handle. His died from his injuries 20 days later.

After the attack Daniel Harrison caught a train to London and was arrested in the Rathbone Hotel near Paddington station the following day.

He admitted manslaughter by reason of diminished responsibility and a judge imposed hospital orders under the Mental Health Act, meaning he would be detained indefinitely in a secure unit.

Delivering a narrative conclusion at the inquest, Kirsten Heaven said that Daniel Harrison had been having treatment since 2007 but when his long-term consultant retired in 2018, Swansea Bay University Health Board “failed to put in place appropriate and timely follow-up arrangements.”

The assistant coroner said that Daniel then weaned himself off his medication, leading to a return of his psychotic symptoms. She said the health board failure “contributed to Kim’s death.”

She also said that clinicians and council-run mental health services “did not pay sufficient attention to the collateral information being provided about Daniel by his family.”

She said one mental health act assessment in April 2021 was “flawed” and gave “inadequate assessment” to the risk he posed, which “possibly contributed” to his father’s death.

The coroner also ruled the security at Ward F of Neath Port Talbot Hospital, where Daniel was supposed to be treated, was “defective” and “contributed to Kim’s death.”

After the inquest, Jane Harrison said: “We remain at a loss to understand how so many professionals could get it so wrong, how they could fail to deliver basic medical care and how major system failings could remain unaddressed.”

She said staff had sought to give the impression it was her son’s fault for not engaging with mental health services and they “appear blind to their failure to reach out and engage with him.

“We miss Kim every day. We continue to give Dan our love and support as he steadily recovers, though this is a long and difficult journey.

“Our family remain astounded by the lack of compassion, insight or reflection of the health board and the City and County of Swansea given the failings set out by the coroner, some of which contributed to Kim’s death.

“They care for the most vulnerable in society and yet it took Kim’s death to finally get Dan the care he so desperately needed and deserved.”

A statement from Swansea Bay University Health Board, after the inquest, said: “We offer our unequivocal apologies for our failings in this case, and 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. We have strengthened our processes around ensuring this vital information is robustly recorded and shared with clinical teams.

“Several key actions are in process, including additional security measures being built into the Ward F at Neath Port Talbot Hospital which provide extra locked areas around exit doors.

“We will now consider in depth the findings of the coroner and take any necessary additional actions necessary.”