LACK of appropriate treatment of a mental health patient at Ysbyty Glan Clwyd amounted to neglect, a coroner has ruled. 

Ben Harrison had been a patient at the Ablett psychiatric unit for two days when his body was found in a lounge room.

A four-day inquest concluded at County Hall in Ruthin concluded today (Friday, May 10) into the 37-year-old's death that occurred on December 17, 2020. 

The inquest was told of a number of "gross failures" in the care Mr Harrison, from Denbigh, received.

Assistant coroner for North Wales East and Central, Kate Robertson, said there had been "missed opportunities" that led to Mr Harrison's death.

These included a failure to ensure the ward was safe for patients at risk of self-harm, and a lack of one-to-one sessions involving Mr Harrison and staff, as well as a lack of proper room searches.

The inquest heard that some staff members on the unit were not properly trained.

The coroner, who recorded a narrative conclusion, said: "But for these collective gross failures Ben would not have died when he did.

Ben’s death was contributed to by neglect."

The inquest heard that staff working on the unit said there was "nothing to suggest Mr Harrison was a risk, because he was "future oriented".

The inquest was told that a month before Mr Harrison's death, he had been treated for serious injuries after deliberately walking in front of a vehicle in London.

He was found hanged in a lounge in the ward on December 15, four days after arriving.

Betsi Cadwaladr University Health Board’s CEO, Carol Shillabeer, said: “I offer my sincere condolences to Ben’s family and friends for their tragic and sad loss. I apologise for the failings in his care and the subsequent investigation.

“We are striving to improve mental health and other services within North Wales and we fully accept the findings of the Coroner. We will examine those findings in detail.

“Finally, I extend an offer to Ben’s family to come and meet with me. I want to hear about Ben and their experiences with the Health Board and assure them his story has been and will be a catalyst for improvement.”

The coroner said she would be issuing a prevention of future deaths report to BOC which designed an oxygen valve that staff failed to use correctly when Mr Harrison was being treated after being found with the ligature around his neck. 

The inquest heard that only one of two valves on the oxygen cylinder had been opened, making it ineffective. This meant Mr Harrison was relying on oxygen from the open air for 5-10 minutes. 

Staff carried out CPR on Mr Harrison and he was taken to the adjacent emergency department at Glan Clwyd Hospital, but he died two days later.

The coroner said that in "high pressure circumstances", the need to open the second valve would "not be overtly noticeable". BOC will have 56 days to respond to the report. 

The inquest was told that Mr Harrison was a "charming, funny, thoughtful and kind" man, who saved four lives by donating his organs.