Independent Investigation into the care and treatment of M

An independent investigation report into the care and treatment of M was published on 22nd November 2022, highlighting factors that lead to his inappropriate admission to an inpatient unit.

An independent investigation report (commissioned in 2018 and published on 22nd November 2022) describes the experience of M in two different hospitals that failed to meet his needs. M is a young man with a learning disability and autism, who was first detained in hospital at the age of 15. Over the 444 days he spent in hospital his mental and physical health deteriorated. All the while, M’s parents were fighting to get him the care and treatment he needed. 

M was first admitted in May 2015 to a psychiatry bed in Cygnet Hospital Woking (CHW). The professionals in this setting were not suitably trained to work with people with learning disabilities or autism and as a result many of M’s basic needs, such as diet and health checks, were not met. M’s parents repeatedly raised concerns about his care and after gaining media attention they secured a case review which recommended that M should be moved to a specialist inpatient setting. 

M was moved to St Andrews Hospital (SAH) in Northampton, as they claimed to provide care suited to a young person with a learning disability and autism. However, the nursing staff at the hospital did not help M to maintain good hygiene or engage in activities, his self-injury and challenging behaviour escalated and M experienced inappropriate seclusion and chemical restraint. M received anti-psychotic medication before a behavioural approach had been attempted, against recommended practices and NICE guidelines for young people with learning disabilities and autism. 

Throughout M’s parents were left to advocate for their son alone. Despite his detention under the Mental Health Act, he did not receive his statutory entitlement to an Independent Mental Health Advocate, and his parents found staff became defensive when they asked questions. CBF have heard from many families who have had similar encounters with the health and care system, and the service failings identified in this report are not new, unknown or unique.  

Children and young people with learning disabilities and autism lack local specialist services to prevent them reaching crisis and their families continue to struggle to access the information and support they need. Despite over 10 years of “transforming care” and “building the right support” programmes their relatives still end up admitted into settings that cannot meet their needs, and they still struggle to secure discharge into community-based services. 

The “system” that should be there to support people with M’s needs, and their families, continues to fail people at great human and financial cost. Likewise successive Government Ministers have failed to deliver change without any consequence to themselves but with catastrophic and lasting consequences for individuals and families. 


Support from the CBF

Resources on our website

You may wish to read these frequently asked questions about safeguarding or visit the restraint and seclusion page on our website. 

Family Support Service

If you have been affected by any of the issues raised in this statement, you can call the Family Support Service on 0300 666 0126

Or email us at

We are open at the following times:

Monday – Thursday: 9am – 5pm Friday: 9am – 3pm

We offer information about challenging behaviour to anyone who provides support to a child, young person or adult with a severe learning disability. We can also signpost you to other specialist organisations and sources of information.

Please note we are a small support service so you may not be able to get support straight away. We will support families with urgent concerns as a priority.

Professionals are also welcome to contact the CBF.

Related News