
Man with severe learning disabilities sustained fatal head injury while held in hospital ‘place of safety’ for ten days, jury hears
An inquest has heard that 26-year-old Declan Morrison died after spending over a week in a short-term unit designed to hold patients detained under the Mental Health Act for no more than 24 hours.
Posted on 07 October 2024
Declan died on 2 April 2022 after sustaining multiple injuries including fractures to the spine and a devastating bleed on the brain while detained in a designated ‘place of safety’ at Fulbourn Hospital, Cambridgeshire.
A two-week inquest was held at Peterborough Town Hall to examine the suitability of Declan’s accommodation, his treatment and care, and the circumstances that led to his death. It concluded on 3 October.
The jury found that the Section 136 suite was not an appropriate place for Declan, and that the staff there did not have the necessary experience or training to care for someone with Declan’s complex needs. They concluded that his behaviour was not effectively managed and as a result his condition declined.
The jury also found that there had been a deterioration in Declan’s behaviour and mental health at Yewdale farm in the months prior to his detention due to the environment being unsuitable to meet his needs and that this probably contributed to his death.
Area Coroner for Cambridgeshire and Peterborough Mr Simon Milburn expressed serious concerns around the lack of appropriate settings nationally for people with complex needs such as Declan’s and confirmed that he will be issuing Prevention of Future Death reports to the Department for Health and Social Care and NHS England.
Declan, who was diagnosed with autism, severe learning disability, bipolar affective disorder, and ADHD, spent days slamming himself into walls and hitting his head repeatedly under the supervision of staff with no training or experience in dealing with learning disability.
Declan, who was non-verbal, had been living at supported accommodation at Sundach House, Yaxley for several years before being transferred to Yewdale Farm, Cambridgeshire – a move that his family were not happy about.
On 8 March 2022 at Yewdale Farm Declan experienced a mental health crisis and he was detained under the Mental Health Act. He was taken to Addenbrooke’s Hospital and subsequently detained under section 2 of the Mental Health Act for assessment and treatment. The Multi-Disciplinary Team responsible for Declan’s care were unable to find an appropriate setting for Declan’s assessment and care under Section 2, so he was transferred to a Section 136 suite at Fulbourn Hospital as a temporary measure while a nationwide search for an appropriate placement commenced.
The inquest heard that despite extensive efforts, no suitable placement was found, and Declan remained in the suite for ten days, during which his condition deteriorated.
CCTV footage from the suite showed Declan engaging in repeated and prolonged periods of self-injurious behavior, including running into walls, falling on the floor, jumping off furniture and repeatedly flipping his body over the top of a door. The jury heard that on the night of 17 March 2022, Declan was observed “slamming into everything headfirst” and subsequently vomiting.
Medical experts agreed that vomiting after sustaining a blow to the head was a “red flag”. Consultant neuroradiologist Dr Curtis Offiah told the inquest that if a patient with a potential head injury starts to vomit, “they have a bleed on the brain until proven otherwise.” Despite this, the duty doctor was not called in response to Declan vomiting.
Declan was found unresponsive at 03:18 on 18 March 2022. Records confirm that an ambulance was not called until 03:31.
Declan underwent emergency surgery at Addenbrookes Hospital but sadly did not recover from his injuries. Declan died on 2 April 2022 at Addenbrooke's Hospital, surrounded by his loving family.
Independent expert in psychiatry Dr Mala Singh told the inquest that Declan’s deterioration in the section 136 suite was foreseeable and that that there was a clear risk of serious and possibly fatal injury.
Declan’s family are represented by Leigh Day Saoirse Kerrigan and Yvonne Kestler, and Sophy Miles of Doughty Street Chambers.
Graeme Morrison, Declan’s father said:
“We, Declan’s family, never supported the decision for him to move to Yewdale Farm and it became clear almost immediately that the staff there were unable to meet his needs. We also had concerns about his medication and twice I asked for a second opinion which was not sought. Within months Declan was in crisis and confined to a place that subsequently led to his death.
“I would urge all parents of children with complex needs like Declan’s to speak up if you are not satisfied that your child is getting what they need. Advocate for your child. Do not be afraid to ask for a second opinion. Do not be silenced. Do not give up until you are entirely satisfied that they are safe and their needs are being met. Do not let them reach the point of crisis that Declan did because if they do, there may be no place of safety for them.”
Phylanopia Morrison, Declan’s mother said:
“Our hearts are forever broken over an incident that should have never been allowed to happen to the most vulnerable of people. I believe that Declan’s most basic needs were not met because he was deemed too difficult due to his disability. Lessons have got to be learnt from this tragedy so that other families do not have to be put through the anguish we have.”
Kaitlyn Morrison, Declan’s sister said:
“As a nurse myself, I will never be able to understand how Declan's traumatic injuries could have gone unnoticed whilst under 24 hour CCTV and constant observation by nursing staff. I cannot comprehend the rationale for not escalating Declan’s episode of vomiting to the duty doctor.”
Saoirse Kerrigan, solicitor for the family said:
“This case has revealed a shocking scarcity of specialist placements for people with complex needs like Declan’s. The jury heard that while Declan was in Fulbourn Hospital the local authority contacted more than 67 providers in addition to specialist hospital units but were unable to find a suitable placement for Declan.
“All of those responsible for Declan’s care agreed that the s136 suite was completely unsuitable for him but there was simply no appropriate alternative. This highlights an urgent need to address this national issue. The family are therefore pleased that the coroner has indicated his intention to issue Prevention of Future Death reports to the Integrated Care Board, NHS England and the Department of Health and Social Care.”