Declan Morrison

Our Ref:  

Date:  16 December 2024  

Simon Milburn 
Area Coroner 
Coroner’s Office 
Cambridgeshire & Peterborough Coroner's Service 
Lawrence Court  
Princes Street  
Huntingdon 
PE29 3PA 

Response to be sent via email  

Dear Mr Milburn 

Re: Regulation 28 Report to Prevent Future Deaths – Declan Gordon Gerard Morrison 

Thank you for your Regulation 28 Report dated 23rd October 2024 concerning the death of Declan Gordon 
Gerard Morrison who died on 2nd April 2022.  

Firstly, we would like to express our sincere condolences to Mr Morrison’s family and friends. We have 
taken this matter extremely seriously.  

We have fully participated in the two Safeguarding Review processes that took place prior to the inquest 
and continue to embed the learning from these. We want to ensure that we do all we can to learn from 
Declan’s life and death and to improve care for future patients.  

The  Regulation  28  Report  concludes that  Declan’s  death  resulted  from traumatic  acute  on  chronic  sub 
dural haemorrhage (operated). Following the inquest, you raised four concerns which we consider in two 
groups below. 

Processes  to  identify  and  best  manage  a  breakdown  in  placement  for  someone  with  Learning 
Disability and Autism who is at risk of hospital admission 

Concern (2) Once it was clear that Declan’s community placement had broken down in late 2021 
no  suitable  alternative  could  be  found.  This  resulted  in  a  decline  in  Declan’s  mental  health  and 
behaviour which ultimately necessitated his detention under the Mental Health Act.  There was then 
nowhere suitable to detain him under Section 2 of the Mental Health Act. 

Page 1 of 3 

 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Since 2022 we have reviewed the functioning of the Dynamic Support Register (DSR) across 
Cambridgeshire and Peterborough and associated Care and Treatment Reviews. The Dynamic Support 
Register works across the whole Integrated Care System to prevent unnecessary hospital admissions for 
people with learning disabilities and autism of all ages. The process of the Dynamic Support Register 
uses a risk stratification approach to identity people at risk of admission to a mental health hospital, allow 
multidisciplinary teams to work together to review the needs if each person on the register, and mobilise 
the right multi-agency support to help prevent hospital admission. 

We have: 
• 

Identified clear and robust criteria for rating individual risk and ensured this is consistent across 
Cambridgeshire and Peterborough. 

•  Ensured that Standard Operating Procedures (SOPs) are in place for both children and adults. 
The outcome of which is to clarify actions and responsible commissioners for the care that care 
that the review decides is indicated. 

Care Treatment Reviews are a critical component to keep someone with a Learning Disability and Autism 
well cared for and out of hospital. They are triggered through the process of the Dynamic Support Register. 
We have: 

•  Trained more people to undertake these reviews. 
•  Established a register of people who can chair an emergency Care Treatment Review as required. 

The availability of other placement options so admission to hospital can be avoided 

Concern  (1)  The  evidence  revealed  that  there  is  currently  a  widespread  shortage  of  available 
placements for someone with Declan’s complex needs both in the community and within the NHS. 
Concern  (3)  The  Section  136  suite  was  completely  inappropriate.  Declan’s  mental  health  and 
behaviour declined further and ultimately resulted in his death 
Concern (4) Declan was in crisis for several months – the facilities were simply not available in the 
community and once detained, in order to prevent his death  

We agree that there is currently a widespread shortage of available placements for someone with Declan’s 
complex needs both in the community and within the NHS. 
Generally, we do not commission these beds on our own as an ICB as they tend to be for welfare and not 
for medical treatment. We do tend to commission these beds jointly with our Local Authority colleagues. 
As availability of these types of beds is a nation-wide issue, we have raised our concerns on the difficulty 
in finding them with NHS England. 

The Cambridgeshire and Peterborough Learning Disability and Autism Board reports into the ICB Quality 
Performance and Finance Committee and has a Quality Improvement Programme work underway. One of 
the five priority programmes of work across the system to find a solution and build contingency plans and 
processes for when there is no accommodation and or no staffing available to meet the needs of someone 
who has a learning disability and is in mental health crisis. Locally, a short pilot community crisis bedded 
model was implemented from November 2023 to April 2024 with service development funds from NHS 
England and the understanding from this pilot is informing the improvement work which will report to the 
ICB Quality Performance and Finance Committee in early 2025. 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 Historically  care  for  people  with  Learning  Disabilities  has  been  delivered  by  the  Learning  Disability 
Partnership which is a joint agreement between the CCG/ICB and Cambridgeshire County Council. In this 
agreement Cambridgeshire County Council had the lead responsibility for the management of care for the 
people with learning disabilities. Declan’s care was delivered via this arrangement. In November 2022, a 
joint review of the Learning Disability Partnership commenced. The results of this review and the outcomes 
of the system learning event being held on 12th December 2024, will support the formation of a new service 
model for patients like Declan.  

We recognise the importance of learning all that we can from tragic events like this one and of taking action 
to change services to improve the outcomes and experiences for local people. 

Please do not hesitate to contact us should you need any further information. 

Yours sincerely 

  MA FRCP MRCGP FFPH DTM&H     
  Chief Medical Officer 

Chief Executive 

Page 3 of 3

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

13 January 2024 

Our ref: 

HM Coroner Simon Milburn 
Area Coroner, Cambridgeshire & Peterborough 
Coroner’s Service, Lawrence Court 
Princes Street 
Huntingdon 
PE29 3PA 

By email: 

Dear Mr Milburn,  

Thank  you  for  the  Regulation  28  report  of  23rd  October  2024  sent  to  the  Department  of 
Health and Social Care about the death of  Declan Morrison. I am replying as the Minister 
with responsibility for adult social care.       

I would like to say how saddened I was to read of the circumstances of Declan’s death and 
I offer my sincere condolences to Declan’s family and loved ones. The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to 
my attention.  

In  preparing  this  response,  my  officials  have  made  enquiries  with  the  Care  Quality 
Commission  to  ensure  we  adequately  address  your  concerns.  NHS  England  will  be 
providing a separate response. 

Your report highlights a shortage of suitable placements in the community and in the NHS 
for people with complex needs, leading to the longer-term use of a Section 136 Suite. I am 
clear that we want people to be supported in the community with the care that is right for 
them.  

In order to achieve this, we are committed to building consensus on the long-term reform 
needed to create a National Care Service based on consistent national standards. We will 
set out next steps for a process that engages with adult social care stakeholders, including 
cross-party and people with lived experience of care. 

Under  current  NHS  England  statutory  guidance,  published  9  May  2023,  Integrated  Care 
Boards  (ICBs)  are  expected  to  assign  an  executive  lead  role  for  learning  disability  and 
autism to a suitable board member. The named lead is expected to support the board in 
planning to meet the needs of its local population of people with a learning disability and 

  
  
 
 
 
 
 
 
 
 
 
  
 
  
  
 
 
 
 autistic people and to have effective oversight of, and support improvements in, the quality 
of care for people in a mental health, learning disability and autism inpatient setting.  

I  was  concerned  to  read  that  Declan  spent  several  months  in  crisis.  To  support  those 
needing  mental  health  crisis  support,  there  are  now  around  600  new  or  expanded  crisis 
alternative services in England such as crisis cafes, safe havens, crisis houses. £150 million 
in  capital  funding  was  made  available  across  2023/24  and  2024/25  for  new  projects  to 
support mental health crisis response and urgent and emergency mental health services. 
And  an  additional  £26  million  investment  for  new  mental  health  crisis  centres  was 
announced  in  the  Autumn  Budget  to  reduce  reliance  on  accident  and  emergency 
departments. 

As highlighted in your report, when no suitable placement could be found Declan was then 
detained under Section 2 of the Mental Health Act .Through our proposed reforms to the 
Mental Health Act 1983 (MHA), as set out in the Mental Health Bill introduced to parliament 
on 6th November 2024, integrated care boards (ICBs) will have a legal duty to ensure hold 
Dynamic Support Registers of people with a learning disability and autistic people who have 
risk factors for detention under Part II of the MHA. The Dynamic Support Register is intended 
to improve monitoring of the needs of, and support for, people who may be at risk of going 
into crisis and being detained under Part II of the MHA.  

Further,  the  Mental  Health  Bill  would  place  a  duty  on  ICBs  and  local  authorities  to  have 
regard to information on the Dynamic Support Register when exercising their commissioning 
and market shaping functions under the NHS Act and Care Act respectively. Both ICBs and 
local authorities would have a duty to seek to ensure the needs of people with a learning 
disability and autistic people can be met without detaining them under Part II of the MHA.  

Individual trusts and local health systems  are expected to effectively assess and manage 
bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the 
availability  of  specialist  units.  NHS  England’s  2024/25  priorities  and  operational  planning 
guidance reinforces this focus on improving patient flow as a key priority – with local health 
systems directed to reduce the average length of stay in adult acute mental health wards to 
deliver more timely access to local beds. And in areas where there is a clear need for more 
beds, this has been addressed in part through investment in new units, as part of a whole 
system transformation approach. 

I  also  noted  your  report  highlighted  that  staff  were  not  appropriately  trained  to  care  for 
Declan.  This  is  clearly  vitally  important  in  ensuring  people  get  the  right  support.  

The  Health  and  Care  Act  2022  sets  out  that,  from  1  July  2022,  CQC  registered  service 
providers  are  required  to  ensure  their  staff  receive  learning  disability  and  autism  training 
appropriate to their role. This includes staff working in mental health inpatient settings. 

In October 2024, the Care Quality Commission (CQC) held a decision review meeting and 
have asked the Cambridgeshire and Peterborough NHS Foundation Trust to supply further 
information, including any investigation reports and what learning they have taken to mitigate 
future  risk  to  others.  The  CQC  continue  to  monitor  the  service  as  part  of  their  ongoing 

 
 
 
 
 
 
 
 
 
 
 
 engagement with the Trust and will consider any areas of concern and how these have been 
addressed.  

Thank  you  once  again  for  your  report  and  the  concerns  that  you  have  highlighted.  I  am 
determined that we improve the care and support  to address the concerns raised in your 
report in relation to the care of Declan. The right support in the community can help prevent 
needs escalating so that detention is only ever where absolutely appropriate, and it must be 
high quality should that admission take place.  

Yours sincerely,

Simon Milburn 
HM Area Coroner  
Cambridgeshire & Peterborough Coroner Service 
Lawrence Court  
Princes Street 
Huntingdon 
PE29 3PA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

18 December 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Declan Gordon Gerard 
Morrison who died on 2 April 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  23 
October  2024  concerning  the  death  of  Declan  Gordon  Gerard  Morrison  on  2  April 
2022. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Declan’s family and loved ones. NHS England 
are keen to assure the family and the Coroner that the concerns raised about Declan’s 
care have been listened to and reflected upon.   

Your Report raises concerns regarding the availability and provision of residential care 
and mental health placements for people with complex needs in the community and 
within the NHS. My response has been informed by the Learning Disability and Autism 
Programme team at NHS England. We very much recognise the importance of there 
being the right mental health support and care for people in their local area, including 
for people like Declan who may have multiple, complex and/or high levels of need.  

In  2024/25,  NHS  England  made  available  £124  million  for  local  areas  to  invest  in 
community services to help prevent the need for admission to mental health hospitals 
for people with a learning disability and autistic people. In line with the commitments 
set out in the NHS Long-Term Plan published in 2019, we would expect local areas to 
have community alternatives to hospital in place, including crisis and intensive support 
for people at greatest risk of admission.  

In  line  with  NHS  England’s  Care  (Education)  and  Treatment  Review  and  Dynamic 
Support  Register  policy  (NHS  England  »  Dynamic  support  register  and  Care 
(Education)  and  Treatment  Review  policy  and  guide),  we  would  expect  each  local 
system to have an awareness of people with a learning disability and autistic people 
in the local area who are at risk of a mental health hospital admission, so that agencies 
can plan and put in place support that may help to keep the person living well in the 
community.  

NHS England has worked with the Local Government Association and the Association 
of Directors of Adult Social Service to develop a set of guiding principles, published in 
2023 (NHS England » Joint guiding principles for integrated care systems – learning 
disability  and  autism)  for  integrated  care  systems,  setting  out  how  partners  in  local 

                                                                                                                       
 
 
 
 
 
 
 
  
 
  
 
 
 
  
 systems can work together to improve the lives and outcomes of people with a learning 
disability and autistic people, of all ages. It includes guidance on commissioning the 
right community services to meet the needs of people with a learning disability and 
autistic people.  

NHS England has also commissioned six new Neighbourhood Mental Health Centres, 
offering  24/7  community  support  for  individuals  with  serious  mental  illness.  These 
centres  integrate  crisis  intervention,  community  support,  and  open  access  beds  to 
facilitate extra support, tailored to local needs. This includes support for people who 
have a learning disability and who are autistic. These Mental Health Centres in local 
neighbourhoods  enable  individuals  to  visit  without  a  referral,  to  receive  help  from  a 
range  of  professionals  including  psychiatrists,  social  workers,  and  peer  support 
workers,  and  support  such  as  psychological  therapies,  medication  support,  and 
assistance with related issues such as housing or employment. Each centre, led by 
an NHS provider, will work in partnership with people with lived experience, as well as 
voluntary,  charity,  faith  and  social  enterprise  organisations. The  two-year  pilot 
programme  is  across six  neighbourhoods, all  of  which  have  their  own  marginalised 
populations  that  do  not  tend  to  have access  mental  health  services.  The  pilot  sites 
received their first funding allocation in July 2025, and this will continue into 2025/26.  

We  note  that  your  Report  is  also  addressed  to  Cambridgeshire  and  Peterborough 
Integrated Care Board (ICB), the responsible commissioner for Declan’s care, and we 
are aware they have responded to the Coroner separately to outline the learning they 
have  undertaken  in  response  to  this  case  and  the  next  steps  they  will  be  taking  to 
enhance service development for complex patients. We are aware that this includes 
work to better support patients under a Mental Health Act and an outline of the ICB’s 
work  to  transform  services  for  people  with  mental  health,  learning  disabilities  and 
autism, including ensuring that there is no inappropriate detention of individuals with 
learning disabilities and/or who are autistic.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Declan, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
  
 
  
  
 
 
 National Medical Director