Concerns raised 7 Failure to conduct timely and sufficiently wide patient safety investigations View source Failure to conduct robust, transparent and timely formal complaint investigations View source Insufficient staff training in risk assessment on Ward F View source Requirement for consent before assertive outreach to mentally unwell people in the community View source Failure to gather sufficient collateral information for MHA 83 assessments View source Failure to record s.12 doctors’ assessment outcomes when patients are not admitted View source Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Complete a senior-management review and formulate recommendations and an improvement action plan for AMHP practice.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Continue working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024. View source
Action
Deliver specific refresher training to AMHPs on gathering, weighting and recording collateral information through external training agencies.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Discuss with Swansea University's AMHP training committee whether collateral-information competencies require greater emphasis in course delivery.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Conduct quarterly audits of AMHP referrals and assessments for 12 months, followed by twice-yearly audits subject to initial findings.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Direct AMHPs to document referral, contact, Nearest Relative, collateral-information, decision-making, medical-discussion and assessment-stage details on assessment forms.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Discuss with the Health Board the requirement for doctors to record their views and conclusions on the AMHP assessment form.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024. View source See 5 more actions
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AI-generated summary
Nicholas Kim Harrison · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely and sufficiently wide patient safety investigations
Wider context from the report “I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member , then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct robust, transparent and timely formal complaint investigations
Wider context from the report “I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member, then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in risk assessment on Ward F
Wider context from the report “I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single Point of Admission (‘SPOA’) for all adults requiring hospital admission in the locality for assessment of their mental illness. I heard that Ward F is a 21 bedded unit and that the move to using just Ward F as the SPOA (as opposed to three units which had been the practice) was brought in during the Covid-19 pandemic to manage the spread of the Covid-19 virus but that this change had been under consideration in SBUHB prior to the Covid-19 pandemic. I heard that this has resulted in a significantly increased level of acuity on Ward F with a significant increase in pressure on staff, a higher turnover of mentally unwell patients, and an increased pressure on staff from, for example, the need to prepare paperwork for the Mental Health Review Tribunal for Wales in a short period of time after admission. During the inquest I heard evidence (and SBUHB accepted) that the risk assessment conducted on ████████ during his time in Ward F was not adequate and that there was no assessment of ████████ risk of absconding. I found that the pressure on staff in Ward F due to its use as the SPOA impacted on ████████ care whilst he was on Ward F. I heard evidence from SBUHB that at the time there was insufficient training on risk assessments in Ward F . I heard from SBUHB that the current target is to ensure that 75% of staff on Ward F are trained in risk assessment by the end of 2024. I am concerned that only having 75% of staff trained in assessing risk means that risks may not be adequately assessed in respect of all patients on Ward F which raises a concern that risk to self and / or others and / or the risk of absconding will not be properly identified thus creating a risk that other deaths will occur. This is particularly so given the increased rates of acuity in the patients on Ward F due to it being used as the SPOA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Requirement for consent before assertive outreach to mentally unwell people in the community
Wider context from the report “I am concerned that if consent is required before a mentally unwell person in the community is able to receive assertive outreach then there may be a gap in the mental health services within SBUHB that creates a risk that mentally unwell people will remain in the community without access to mental health services in circumstances where they may pose a risk to their own life or the lives of others. This is because whilst they may need access to mental health services, they may be too unwell to consent to that access. I am concerned that if there is such a systemic deficiency within SBUHB in relation to how to engage mentally unwell people in the community then this creates a risk that deaths will continue to occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Failure to gather sufficient collateral information for MHA 83 assessments
Wider context from the report “I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record s.12 doctors’ assessment outcomes when patients are not admitted
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital . I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83 . I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a senior-management review and formulate recommendations and an improvement action plan for AMHP practice.
Verbatim wording from the response “Nevertheless, and in light of His Majesty's Coroner's concerns, senior management have carried out a review with the aim of gaining a fuller understanding of this matter of individual AMHP practice and formulating recommendations and an action plan for improvement. Specific actions, to be taken within the next month, include:” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.
Verbatim wording from the response “vi. The AMHP assessment form is to be updated to include an additional section for the recording of the views of relevant others or reasons for not consulting with them, and AMHPs are to be directed/instructed to complete this section in as much detail as possible.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.
Verbatim wording from the response “The Council will continue to work with SBUHB via the various forums referred to above in order to ensure, as far as is reasonably possible, that the appropriate mental health professionals, deemed by SBUHB as requiring WCCIS access, is granted such access. Discussions have already taken place between SBUHB and the Council with the view to arranging for all patient clinical notes to be available across the relevant systems accessed by both organisations.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver specific refresher training to AMHPs on gathering, weighting and recording collateral information through external training agencies.
Verbatim wording from the response “iii. The Council will seek to deliver, via its external training agencies, specific refresher training to its AMHP team relating to the gathering, weighting and recording of collateral information.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with Swansea University's AMHP training committee whether collateral-information competencies require greater emphasis in course delivery.
Verbatim wording from the response “ii. The Principal Officer for Mental Health Services, in his capacity of Chair of Swansea University's AMHP training course committee, will discuss with the committee the key competence area relating to the obtaining of collateral information, and any requirement for the delivery of the course to include greater emphasis on the gathering, weighting and recording of collateral information.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of AMHP referrals and assessments for 12 months, followed by twice-yearly audits subject to initial findings.
Verbatim wording from the response “xii. Audits of AMHP referrals and assessments are to be conducted quarterly for the first 12 months, then bi-annually from then on, depending on the findings of the initial quarterly audits. The audits will be undertaken by the Principal Officer for Mental Health Services with support from managers.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct AMHPs to document referral, contact, Nearest Relative, collateral-information, decision-making, medical-discussion and assessment-stage details on assessment forms.
Verbatim wording from the response “iv. AMHPs are to be directed/instructed to record all relevant assessment referral and contact information on the AMHP assessment form.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with the Health Board the requirement for doctors to record their views and conclusions on the AMHP assessment form.
Verbatim wording from the response “xi. The AMHP assessment form is to be amended so that the section referencing the doctors involved in the assessment process prompts the detailed recording of the doctors' individual views as to the individual's case and criteria for detention. The Council's Head of Adult Services has opened dialogue with Swansea Bay University Health Board's (hereafter "SBUHB") Service Group Director of Mental Health and Learning Disabilities with regard to the requirement for doctors to record their views/conclusions on the AMHP assessment form.” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.
Verbatim wording from the response “It is not within the Council's remit to respond to all of the matters of concern set out by His Majesty's Coroner in the Report, and it is appropriate that the Council responds to the first and second matters of concern. I shall address each in turn:” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.
Verbatim wording from the response “This is a matter of concern for SBUHB and NHS Wales to primarily address, but the Council wishes to comment specifically in relation to access to its systems by Section 12 doctors.” Source location Response from City and County of Swansea
Open published response
Concerns raised 1 Serious road design safety hazard at the Kingsway/Metro system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Hannen Foss · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Hannen Foss, aged 37, died following a collision at a pedestrian crossing on the Kingsway, Swansea, on 24 September 2013. The report raised concerns about numerous pedestrian-coach collisions and incidents on the Kingsway/Metro system, including two fatalities, and identified a serious road-design issue requiring attention.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Council; that does not assign responsibility.
PFD Monitor interpretation Serious road design safety hazard at the Kingsway/Metro system
Wider context from the report “Since 1st January 2008 there have been in excess of 100 reported road traffic collisions and incidents on the Kingsway/Metro system which in a large number of cases included incidents of injuries or near misses between pedestrians and coaches. There have been 2 fatalities including Mr Foss and most recently the death of Sgt Louise Lucas. There would appear to be a serious design issue which must be addressed by the Local Authority to make the road safer for the public.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install temporary pedestrian barriers directing pedestrians to existing signal-controlled crossings.
Verbatim wording from the response “• Temporary pedestrian barriers were installed on 12 April 2015 to assist in directing pedestrians to existing signal controlled pedestrian crossings. This is however presently being monitored as to whether this contributes to any reduction in accidents or poses any potential risk. I will keep you advised as to whether the barriers will remain in situ following the monitoring period.” Source location 2015-0062-Response-by-Swansea-City-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Kingsway road layout, including removing eastbound bus movements and implementing the associated infrastructure changes.
Verbatim wording from the response “• The Authority is revising the road layout and in particular removing the eastbound bus movements along the Kingsway. This rerouting responds to the concerns raised in your Regulation 28 Report and it also brings forward the infrastructure changes required in the City Centre as part of the City Centre Regeneration Framework. I anticipate that once the formalities have been addressed this revised layout will be in place during October 2015.” Source location 2015-0062-Response-by-Swansea-City-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor temporary pedestrian barriers for accident reduction and potential safety risks.
Verbatim wording from the response “• Temporary pedestrian barriers were installed on 12 April 2015 to assist in directing pedestrians to existing signal controlled pedestrian crossings. This is however presently being monitored as to whether this contributes to any reduction in accidents or poses any potential risk. I will keep you advised as to whether the barriers will remain in situ following the monitoring period.” Source location 2015-0062-Response-by-Swansea-City-Council
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations