Declan Morrison
23 Oct 2024 · Coroner Simon Milburn · Cambridgeshire and Peterborough
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. shortage of suitable placements
“widespread shortage of available placements for someone with [the deceased]'s complex needs both in the community and within the NHS”
2. inappropriate Section 136 Suite
“Section 136 Suite was completely inappropriate”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“young adults with autism who were at risk of self-harm as well as harm to others have very limited options in terms of placements where their needs can be met.”
This report
“The evidence revealed that there is currently a widespread shortage of available placements for someone with [the deceased]'s complex needs both in the community and within the NHS.”
Closely relatedConfidence 0.85 · high
Earlier report
“That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.”
This report
“The Section 136 Suite was completely inappropriate. [the deceased]'s mental health and behaviour declined further and ultimately this resulted in his death.”