A bereaved family represented by Bridget Dolan KC have called for an independent review into mental health services following the tragic death of Dr Kim Harrison (Kim) in 2022. Kim was assaulted by his son, Dan, who had been formally detained under the Mental Health Act; but less than an hour before the assault he had absconded from the ward in Neath Port Talbot Hospital whilst a staff member was conducting a conversation at an open door. Dan had been detained as he was considered to be a risk to others. At the time of the assault Dan was suffering from untreated schizophrenia which caused him to have paranoid delusions about his father.

The inquest revealed numerous failures by Swansea Bay University Health Board (SBUHB) in the care of Dan which had contributed to Kim’s death. The coroner found that before the killing, over a number of months, the Harrisons had raised their concerns with SBUHB staff on multiple occasions regarding the perceived failures in SBUHB’s management of Dan’s mental health; including writing to the SBUHB Interim Chief Executive, the Medical Director, the Nurse Director for the Mental Health & Learning Disabilities Service Group and other members of SBUHB’s senior management team.

The Coroner has now issued a ‘prevention of future deaths’ report (here) highlighting the shortcomings of the Health Board and the City and County of Swansea Local Authority including:

• The failure to put in place appropriate and timely follow up arrangements when Dan’s consultant left the service.
• The failure to ensure that Dan was regularly and assertively visited in the community so that he could be re-engaged with mental health services.
• A flawed Mental Health Act (MHA) assessment of Dan in early 2021.
• Failure of an AMHP  to comply with their s.13(4) MHA duty and to collect sufficient collateral information before visiting and assessing Dan under MHA.
• The defective security system and lack of adequate training of staff regarding door access on the ward, which was being operated in an unsafe manner.
• Failure to properly address Kim and Jane Harrison’s complaints about Dan’s care which they raised before the killing – when an independent report was commissioned by the Health Board but then was, inexplicably, not shared with the consultant psychiatrist whom it criticised at any point prior to Kim’s death.

Following an investigation by the Sunday Times which highlighted the scale of mental-health related killings in Britain, Dr Jane Harrison, Kim’s wife, said that she believes “the NHS has become used to poor mental health care and is tolerating the deaths that happen as a result.” Earlier she had told the BBC that she believed her son was let down at all stages of his mental health care, and that her “family has suffered immeasurable harm at the hands of managers and senior clinicians.”  Dan is as much a victim of this tragedy as his father.

Bridget Dolan KC is instructed by Joanna Bennett of Bindmans. You can read more about this case, as well as Bridget’s involvement, here.

Read the PFD report here.