“The evidence revealed that there is currently a widespread shortage of available…”
Dated 23 Oct 2024, from the coroner for Cambridgeshire and Peterborough. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 18 Dec 2024.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated23 Oct 2024
- Deadline18 Dec 2024
- Published on judiciary.uk24 Oct 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in October 2024. |
| NHS England | Response publishedPublished on judiciary.uk in October 2024. |
| NHS Cambridgeshire and Peterborough Integrated Care BoardNamed in the report as “Cambridgeshire and Peterborough Integrated Care Board” | Response publishedPublished on judiciary.uk in October 2024. |
The coroner’s concerns
– (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. (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. (3) The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death. (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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2024-0570
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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