Posted by Stephen Jones, the nurse director for mental health and learning disabilities for Swansea Bay University health board told the court how background information about Harrison’s mental decline was not given to the doctors treating him.
The assistant coroner for south west Wales, Kirsten Heaven, asked why it took 10 weeks for immediate action on an independent review, which identified the failure to share information.
“I was asked to review the report for further information and accuracy so it remained as a draft,” Mr Jones told the inquest.
The information still had not been shared, the inquest heard, when on 12 March 2022, Harrison barged past a nurse who had opened a secure door using a swipe card and made his way to his parents’ house where he attacked his father.
Mr Jones also admitted the risk assessment done before Harrison’s admission to the unit was inadequate due to staff not being fully trained, and that on 48 other occasions between 2019 and 2022 patients had fled through the same door Harrison used to escape.
He said the health board had since spent £640,000 on increased staffing and better security, and that risk assessment training was being done with staff.
Asked by Bridget Dolan, representing Dr Jane Harrison, why the psychiatrist was not given proper background to the case, Mr Jones said: “I absolutely agreed it would have been useful [for the psychiatrist] to have this collateral information”.