‘My autistic son had no safety net in times of crisis’

The family of a man who died after repeatedly banging his head against a wall in a mental health unit have said there was no “safety net” for people who needed their son.

Declan Morrison, 26, from Cambridge, was autistic, had severe learning disabilities and attention deficit hyperactivity disorder.

Hours before his death, he was left naked in a room with CCTV cameras, but his family said the alarm was raised only when staff found him unresponsive.

His parents, Graeme and Sam Morrison, are now demanding answers about what went wrong with their son’s care.

Mrs Morrison said: “He was left to his own devices in an environment of no stimulation, bright lights and bare walls that he could not understand.”

In March 2022, Declan spent 10 days in a Section 136 mental health assessment suite, as there were no beds available in the whole of the UK.

But he could not cope with the harsh, clinical environment that required a maximum of 24 hours under the Mental Health Act.

The suite was described by coroner Simon Milburn as “Completely unfair” For Declan’s needs.

Mr Morrison believed the decision not to rely on CCTV and not interact with Declan “may have made the situation worse”.

The coroner said that staff at the facility were not properly trained to care for patients with learning disabilities.

Mrs Morrison said she discovered something was wrong with Declan on March 18, 2022 while he was in the ambulance.

“To actually find out that your son now needs a brain operation to live – it was horrific,” he said.

Declan underwent emergency surgery but never recovered. He died on 2 April 2022.

From 2014 to 2021, Declan lived in Sundach House near Peterborough, run by Kisimul, a company owned by Luxembourg-based investment funds.

In 2019, after a review of Declan’s needs, it was concluded that the facility could no longer provide an appropriate level of care for his safety.

Yet in 2021 Declan was still living in the Sundach house.

Declan’s family said his behavior worsened after some of his carers went to work for an extra 50p an hour at a nearby Amazon warehouse.

“Something as simple as 50p is making a difference and it is making an impact on our children,” Mrs Morrison said.

At the same time Declan was struggling to understand the loss of familiar caregivers, his family said his medication was also changed.

In evidence given to the inquest by an independent psychiatrist in October, the jury heard how the side effects of new drugs could have made his behavior worse.

In May 2021, Declan was moved to Yewdale Farm in Willingham, Cambridgeshire, a residential care home run by CareTech Community Services.

A safeguarding report titled Something Has to Change, which was compiled by the Cambridgeshire and Peterborough Safeguarding Partnership after Declan’s death, noted that the agency staff caring for him were of a high standard.

Yet his father said Declan “spent most of his time alone because they (the staff) couldn’t interact with him.”

Caretec said that when Declan is “responsive” to staff engagement, they will support him directly. If he did not want to talk, the staff would sit in an adjacent room and observe him through the window.

Declan had jumped over the fence at Yewdale Farm and attacked a staff member.

In February 2022, CareTech said it could no longer meet Declan’s needs and he needed clinical care.

According to the family’s lawyer, 67 facilities across the UK were contacted for Declan’s care, but none were able to give him an appointment.

In a letter to the government and the NHSThe coroner said: “Demand for such placements exceeds supply – providers are effectively able to ‘choose’ who they provide placement to.”

“It seems wrong that a care provider can remove care without hesitation, because there is certainly no safety net behind it, because it is not provided by local government,” Mr Morrison said.

“It can’t be as simple as ‘we can’t keep your son or daughter safe’,” he said.

CareTech said it did not “pick and choose” its residents.

In March 2022, Declan suffered severe anxiety and police officers took him into custody under the Mental Health Act.

He was taken to an emergency “place of safety”, known as the Section 136 suite, on the site of Fulbourn Hospital in Cambridgeshire.

This suite is designed for patients awaiting mental health evaluation. Declan stayed there for 10 days instead of the scheduled 24 hours.

Declan’s parents were in Aberdeen at the time but his father said he was told he was “doing fine”.

The family’s lawyer Saoirse Kerrigan said Declan had started “bouncing off the walls”, resulting in a catastrophic brain injury.

Ms Kerrigan, of law firm Leigh Day, said: “These injuries occurred while Declan was being monitored by eight CCTV cameras and 24-hour monitoring by nursing staff based within the site.”

He said he was becoming “increasingly agitated and hitting his head repeatedly”.

coroner’s Prevention of future deaths report Said Declan went into deep distress due to the mental health suite and “ultimately died as a result”.

Cambridgeshire County Council and the NHS in Cambridgeshire and Peterborough said they had accepted it.

The two organizations said the learning disability and autism improvement program will be rolled out from spring 2025.

Cambridgeshire and Peterborough NHS Foundation Trust, which runs mental health services, said it had tightened procedures to improve patient care when a person spends more than 24 hours in a section 136 suite.

Kisimul acknowledged problems with “the loss of key staff”, stating that this was partly caused by Brexit and competing industries.

Kisimul’s director of quality and practice, Nicky Cooper, said the welfare of people receiving help from the service is the “top priority”.

The Department of Health and Social Care said something new mental health bill This will “improve monitoring of people with learning disabilities and autism who may be at risk of going into crisis”.

The bill would legally require the NHS and local authorities to ensure that the needs of people like Declan are met without detaining them in hospital.

NHS England said it happened guidelines prepared and was “carefully considering” the coroner’s report.

• If you have been affected by this story or want support, you can find organizations that provide support and information BBC Action Line.