Coroner to seek action after man dies banging head

A coroner is to call for action after an inquest heard a man with severe mental health conditions died from head injuries after banging his head repeatedly over three days.

Declan Morrison, 26, had been placed at the 136 suite at Fulbourn Hospital, in Cambridge, after being sectioned under the Mental Health Act.

His inquest found he repeatedly hit his head and fell over before being discovered unresponsive in the early hours of 18 March 2022.

The coroner's office confirmed a prevention of future deaths report would be issued by coroner Simon Milburn. A hospital spokesperson said it would ensure any learnings identified were acted on.

The inquest into Mr Morrison's death, conducted over two weeks before a jury at Peterborough Town Hall, concluded he died on 2 April 2022 "from head injuries caused by him banging his head whilst he was detained" at the Fulbourn suite.

Mr Morrison, who was autistic, had attention deficit hyperactivity disorder (ADHD), severe learning disabilities, was bipolar and non-verbal, and required 24-hour care.

The firm representing his family, Leigh Day, said he had been living in supported accommodation for several years before being transferred to Yewdale Farm in Willingham, north of Cambridge, in May 2021.

The inquest heard on 8 March 2022 an incident occurred at the care home.

The family's solicitor said he was taken to Addenbrooke's Hospital, where he was detained under the Mental Health Act for assessment and treatment.

It said he was then transferred to 136 suite at Fulbourn Hospital as a temporary measure, while suitable alternative accommodation could be found for him.

The inquest heard he was observed repeatedly banging his head and falling over on the evening of 13 March, the morning of 14 March and the evening of 17 March.

He was observed as unresponsive at 03:18 GMT on 18 March and was taken to Addenbrooke's.

A CT scan revealed his head banging in the 24 hours prior had caused "bleeding into an area of existing fragility caused by an older injury".

A coroner's report said: "The 136 suite was an inappropriate setting to care for Declan's needs due to the environment, and that staff were not experienced in or trained to care for individuals with Declan's complex needs."

It also said Yewdale Farm was "not an appropriate placement for him, and as a result his behaviour and mental health deteriorated".

Commenting through the family's legal team, Declan's father, Graeme Morrison, urged parents "to speak up if you are not satisfied that your child is getting what they need".

"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."

Prevention of future deaths reports are sent when a coroner believes action is needed to protect lives.

Speaking on behalf of Fulbourn Hospital, the Cambridgeshire and Peterborough NHS Foundation Trust offered its condolences to Mr Morrison's family.

"This is a tragic case, and we are committed to working with our partners to ensure learnings that have been identified are embedded into our future practices," it said.

A spokeswoman for Yewdale Farm said Mr Morrison's death was "a terribly sad incident" and also offered condolences to his family.

She said he was moved to Fulbourn Hospital "which is where he tragically sustained the serious injuries that led to his death".

"We will nonetheless review the coroner's report and consider if there are lessons to learn," she said.

Follow Cambridgeshire news on BBC Sounds, Facebook, Instagram and X.