'No facilities available to prevent death' - coroner

Declan Morrison, who had been sectioned, was observed banging his head over three separate days before he died of related injuries

A coroner has said "facilities were simply not available in the community" to prevent the death of a man with severe mental health conditions who had been "in crisis for several months".

Declan Morrison, 26, from Cambridge, died from "catastrophic" injuries caused by banging his head repeatedly against a wall while in a hospital unit, an inquest concluded earlier this month.

Now the area's coroner, Simon Milburn, has asked the Department of Health and Social Care (DHSC), NHS England and the Cambridgeshire and Peterborough Integrated Care Board (ICB) to set out how they will stop a similar tragedy happening again.

A spokesperson for the DHSC extended "deepest sympathies" to Mr Morrison's family and said the coroner's comments were being carefully considered.

In a Prevention of Future Deaths Report, Mr Milburn stated: "The Integrated Care Board for Cambridgeshire & Peterborough funded a bespoke residential ‘Crisis Service’ in November 2023.

"It remained open for 38 weeks (during which it operated at 98% capacity) before funding was withdrawn.

"Had such a placement been available to Declan it would potentially have avoided the need for him to be detained under the Mental Health Act."

Mr Morrison, from Cambridge, was autistic, had attention deficit hyperactivity disorder (ADHD), severe learning disabilities, was bipolar and non-verbal, and required 24-hour care.

The coroner's report said between 2014 and March 2022 Mr Morrison lived in private placements sourced by Cambridgeshire County Council’s Learning Disability Partnership (CCCLDP).

Mr Morrison moved into his final placement in May 2021, but by the end of that year it was unable to meet his complex needs.

The coroner said continued attempts by CCCLDP to find Mr Morrison a suitable residence found "nothing available either locally or nationally".

On 8 March 2022, after his behaviour declined further, he was detained under Section 136 of the Mental Health Act, before being taken to Addenbrooke's Hospital in Cambridge.

From there, Mr Morrison was then placed temporarily at the 136 suite at Fulbourn Hospital, also in Cambridge.

Mr Milburn, the coroner for Cambridgeshire and Peterborough, said of the unit: "It is/was not a suitable facility for longer term detention and or for someone with Declan’s complex needs.

"Staff there were not appropriately trained to care for him.

"His behaviour became more agitated and disturbed. As a result, he engaged in self-harming behaviours, including blows to the head," said Mr Milburn.

Mr Morrison was found unresponsive on 18 March 2022, having suffered catastrophic brain injuries. He died at Addenbrooke's on 2 April 2022.

The coroner said it was his opinion "there is a risk that future deaths could occur unless action is taken".

He said he was concerned about a "widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS".

Mr Milburn has given the organisations 56 days to issue plans of action.

An NHS spokesperson said: “The NHS extends its deepest sympathies to the family and friends of Declan Morrison.

"We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course.”

A spokesperson for the Cambridgeshire & Peterborough ICB said: "Cambridgeshire & Peterborough ICB have accepted the recommendations of the independent author within the report.

“We will continue to work closely with our system partners to safeguard children and adults, and share information across all services and agencies in relation to safeguarding issues.”

A Department of Health and Social Care spokesperson said: "It is important that we learn the lessons from every prevention of future deaths report, and we will consider the report carefully before responding appropriately."