Coroner Cites Lack of Facilities in Death of Man with Severe Mental Health Conditions

A coroner has stated that “facilities were simply not available in the community” to avert the death of an individual suffering from severe mental health conditions who had experienced a “crisis for several months.” Declan Morrison, 26, a resident of Cambridge, succumbed to “catastrophic” injuries resulting from repeatedly striking his head against a wall within a hospital unit, as determined by an inquest that concluded earlier this month. Simon Milburn, the coroner for the region, has now requested that the Department of Health and Social Care (DHSC), NHS England, and the Cambridgeshire and Peterborough Integrated Care Board (ICB) detail the measures they will implement to prevent a recurrence of such a tragedy. A spokesperson for the DHSC conveyed “deepest sympathies” to Mr Morrison’s family and indicated that the coroner’s observations were undergoing careful consideration. Within a Prevention of Future Deaths Report, Mr Milburn declared: “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 “It remained open for 38 weeks (during which it operated at 98% capacity) before funding was withdrawn.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, a Cambridge resident, was diagnosed with autism, attention deficit hyperactivity disorder (ADHD), severe learning disabilities, and bipolar disorder, was non-verbal, and necessitated 24-hour care. According to the coroner’s report, from 2014 until March 2022, Mr Morrison resided in private accommodations arranged by Cambridgeshire County Council’s Learning Disability Partnership (CCCLDP). Mr Morrison relocated to his last placement in May 2021, but by the conclusion of that year, it proved inadequate for his intricate needs. The coroner noted that ongoing efforts by CCCLDP to locate an appropriate residence for Mr Morrison yielded “nothing available either locally or nationally.” On 8 March 2022, following a further deterioration in his behaviour, he was detained under Section 136 of the Mental Health Act, prior to being transported to Addenbrooke’s Hospital in Cambridge. Subsequently, Mr Morrison was temporarily housed at the 136 suite at Fulbourn Hospital, also situated in Cambridge. Mr Milburn, the coroner for Cambridgeshire and Peterborough, commented on 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,” Mr Milburn stated. Mr Morrison was discovered unresponsive on 18 March 2022, having sustained catastrophic brain injuries. His death occurred at Addenbrooke’s on 2 April 2022. The coroner expressed his view that “there is a risk that future deaths could occur unless action is taken.” He conveyed his apprehension regarding a “widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS.” Mr Milburn has granted the organizations 56 days to present their action plans. An NHS spokesperson remarked: “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 stated: “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 commented: “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.” For updates on Cambridgeshire news, follow BBC Sounds, Facebook, Instagram, and X. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the content of external websites. Information regarding our external linking policy is available.