Family Seeks Answers After Son’s Death in Mental Health Suite

The relatives of a man who passed away following repeated head-banging against a wall within a mental health facility stated that individuals with their son’s specific requirements lacked an adequate “safety net.” Declan Morrison, a 26-year-old from Cambridge, lived with autism, significant learning disabilities, and attention deficit hyperactivity disorder. Prior to his death, he remained unclothed in a room equipped with CCTV surveillance; however, his family reported that staff only initiated an alert once he was discovered unresponsive. His parents, Graeme and Sam Morrison, are currently seeking explanations regarding the deficiencies in their son’s care. Mrs Morrison commented: “He was left to his own devices in a surrounding that he couldn’t understand, with no stimuli, bright lights and bare walls.” During March 2022, Declan stayed for 10 days in the Section 136 mental health assessment suite due to a nationwide shortage of beds. He struggled to manage in the stark, clinical setting, which, according to the Mental Health Act, is intended for a maximum duration of 24 hours. Coroner Simon Milburn characterized the suite as “wholly inappropriate” for Declan’s specific requirements. Mr Morrison expressed his belief that the choice to depend on CCTV monitoring instead of direct interaction with Declan potentially “exacerbated the situation.” The coroner noted that personnel at the facility lacked adequate training for attending to patients with learning disabilities. Mrs Morrison stated that she became aware of Declan’s critical condition on 18 March 2022, while he was in the ambulance. She remarked, “To find out actually your son now needs a brain operation to live – it was horrifying.” Declan received emergency surgical intervention but did not recover. His death occurred on 2 April 2022. Between 2014 and 2021, Declan resided at Sunndach House near Peterborough, an establishment managed by Kisimul, a firm owned by a Luxembourg-based investment fund. A 2019 assessment of Declan’s requirements determined that the facility was no longer capable of delivering the necessary standard of care for his protection. Nevertheless, Declan remained at Sunndach House in 2021. Declan’s family indicated that his conduct deteriorated subsequent to several of his carers departing to work at a nearby Amazon warehouse for an additional 50p per hour. Mrs Morrison commented, “Something as simple as 50p is making a difference, and it’s affecting our children.” Concurrently, as Declan grappled with comprehending the absence of familiar carers, his family reported that his medication regimen was also altered. During his inquest in October, testimony from an independent psychiatrist informed the jury that adverse effects from the new medications might have exacerbated his behavior. Declan relocated in May 2021 to Yewdale Farm in Willingham, Cambridgeshire, a residential care facility operated by CareTech Community Services. A safeguarding report titled Something has to Change, produced by the Cambridgeshire and Peterborough Safeguarding Partnership following Declan’s death, highlighted the significant presence of agency personnel providing his care. However, his father stated that Declan had “spent most of his time on his own as they [staff] couldn’t interact with him.” CareTech indicated that when Declan demonstrated “responsive” engagement with staff, direct support was provided. If he chose not to interact, staff would remain in an adjacent room, observing him through a window. While at Yewdale Farm, Declan had scaled fences and physically attacked a staff member. By February 2022, CareTech declared its inability to continue meeting Declan’s needs, asserting that he required clinical care. According to the family’s legal representative, 67 facilities throughout the UK were contacted regarding Declan’s care, yet none could provide him with a placement. In correspondence addressed to the government and the NHS, the coroner noted: “Demand for such placements outstrips supply – providers are effectively able to ‘pick and choose’ who they offer placements to.” Mr Morrison commented, “It seems wrong that a care provider can, at a drop of a hat, remove care, because there’s certainly no safety net behind that, because it’s just not provided for by local government.” He added, “It can’t just be as simple as ‘we can’t keep your son or daughter safe’.” Caretech asserted that it did not “pick and choose” its residents. In March 2022, Declan experienced an episode of elevated anxiety, leading to his detention by police officers under the Mental Health Act. He was then transported to an emergency “place of safety,” identified as a Section 136 suite, located at Fulbourn Hospital in Cambridgeshire. This suite is intended for individuals awaiting a mental health assessment. Declan remained there for 10 days, exceeding the prescribed 24-hour limit. Declan’s parents were in Aberdeen during this period, but his father reported they had received assurances that he was “doing fine.” Saoirse Kerrigan, the family’s solicitor from law firm Leigh Day, stated that Declan had started “bouncing off the walls,” leading to a severe brain injury. Ms Kerrigan remarked: “These injuries were sustained while Declan was being monitored by eight CCTV cameras and under 24-hour observation by nursing staff located within the site.” She further noted that he had been “growing increasingly agitated and repeatedly hitting his head.” The coroner’s report for the prevention of future deaths concluded that the mental health suite exacerbated Declan’s crisis, and “ultimately this resulted in his death.” Both Cambridgeshire County Council and the NHS in Cambridgeshire and Peterborough acknowledged this finding. The two organizations announced that a learning disability and autism improvement program is scheduled for implementation starting in spring 2025. Cambridgeshire and Peterborough NHS Foundation Trust, responsible for mental health services, reported that it has strengthened procedures to enhance patient care for individuals remaining in the Section 136 suite beyond 24 hours. Kisimul recognized issues related to the “loss of key employees,” attributing this partly to Brexit and competition from other sectors. Nicky Cooper, Kisimul’s director of quality and practice, affirmed that the well-being of individuals supported by the service constituted the “highest priority.” The Department of Health and Social Care stated that the forthcoming Mental Health Bill aims to “improve the monitoring of people with learning disabilities and autism who may be at risk of going into crisis.” This legislation would legally obligate the NHS and local authorities to guarantee that the requirements of individuals such as Declan are addressed without hospital detention. NHS England indicated that it has developed guidelines and is “carefully considering” the coroner’s findings.