The inquest found staff in the ward where Daniel Harrison was being held prior to his escape had no risk assessment training.
The report said that only 75% of staff were now trained, “which raises a concern that risk to self and others and the risk of absconding will not be properly identified”. thus creating a risk that other deaths will occur”.
The report also raised concerns about Daniel Harrison’s refusal to engage with mental health services when he was unwell.
The assistant coroner said authorities should refer such cases to “assertive outreach”.
“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,” the report stated.
Swansea Bay health board “unequivocally” apologised for its failings and said it had put “key actions” in place for improvement, including additional security measures on the ward where Daniel Harrison was treated.
“We recognise that insights and information provided by family members about patients play a crucial role in planning and delivering care,” a spokesperson said.
“We have strengthened our processes around ensuring this vital information is robustly recorded and shared with clinical teams.”
It said it would be responding formally to the coroner’s report in June.
Swansea council has been asked to comment.
