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

18 December 2024

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.

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.

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.

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.

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.