HOSPITAL staff fighting to revive a patient who had tried to harm himself did not realise that the oxygen cylinder they were using had not been fully turned on.

An inquest heard that only one of two valves had been opened, making it ineffective.

Staff carried out CPR on Ben Harrison, who had been a patient at the Ablett psychiatric unit for two days.

He was taken to the adjacent emergency department at Glan Clwyd Hospital, but he died two days later.

At an inquest in Ruthin, Peter Williams, the ward manager, said the 37-year-old, who had suffered with mental health problems for many years, was under a 15-minute observation regime, the highest possible level.

But he said Mr Harrison was not considered to be a high risk because he was engaging with the service and was “future orientated”.

“There was nothing to indicate a risk at that time,” he said.

Mr Williams told the inquest that he understood that the cylinder was “on” but the same issue with the valves had occurred on other occasions.

On December 15, 2020, he was found suspended in the unit’s lounge.

Mr Williams said that because of the Covid restrictions the unit was going through a challenging period.

“We were firefighting from one day to the next,” he said.

Earlier this year Kate Robertson, assistant coroner for North Wales East and Central, issued a Prevention of Future Deaths report to the Betsi Cadwaladr University Health Board, expressing concern at the delay in implementing an action plan adopted after Mr Harrison’s death.

The inquest heard that Mr Harrison, who was originally from Denbigh, had severed all contact with his family several years ago but in November, 2020, they learned from North Wales Police that he had been admitted to hospital in London after apparently stepping in front of a car.

After returning to North Wales he was paranoid and didn’t want to go to Ysbyty Glan Clwyd because he believed that armed police would arrest him and that he would be tortured in prison.

His sister Kate took him to the Countess of Chester Hospital, but as he had a Denbigh address, she said, they told him he had to go to Glan Clwyd.

In a statement read at the hearing his father Paul Harrison said he had learned about the issue with the oxygen cylinder only when told by a member of staff involved in the Health Board’s serious incident review.

“I am concerned that he was let down by the staff,” he said.

The hearing is due to conclude on Friday.