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Training and resources for professionals

Learning briefing: Morgan – Substance abuse death

The Incident

Morgan was a young person who had recently moved to Devon. Following the death of a close family member, their family struggled to meet Morgan’s needs who subsequently experienced neglect. Following care proceedings, they moved to Devon to be cared for by another family member – something that Morgan was very happy about. During this period, Morgan also experienced the death of their father.

During the COVID lockdown, Morgan did not attend school to protect the health of a family member. Both the school and Children’s Social Care were in contact with Morgan through this time.

Sadly, Morgan was found deceased in their bedroom with an aerosol can near their face.

Good practice

  • There was a good relationship between the Devon family and Morgan’s GP, which enabled them to talk about Morgan’s behaviours. The GP responded well to the family’s concerns and sought information from professionals who knew Morgan.
  • Meanwhile, Morgan had a positive relationship with their social worker, school teacher and youth worker. There was evidence of child-focused interactions with Morgan e.g., social worker taking Morgan to the park.

Reflection on practice

  • Although a bereavement support referral was made, it appeared that Morgan didn’t receive any counselling.
  • Elsewhere, it was unclear whether Morgan was a carer for a family member. The impact of the family member’s health on their ability to care for Morgan was not assessed. The aforementioned was a missed opportunity to ensure that, not only family and community support was explored, but that Early Help support was offered to address any needs.
  • Morgan’s experiences prior to moving to Devon was not fully understood by professionals.  Limited information was received by the school and the school nursing service was not aware of Morgan. In their conversations with the social worker, youth worker and teachers, Morgan shared some of the challenges of living in rural Devon with their family. They moved just before a period of lockdown that limited their ability to make friends at school. That said, these relationships did form once they returned to school. They described struggling with the family’s rules and restrictions on phone use and travel. They missed seeing their mother and friends and missed the freedom that they were used to in the city – independent travel, shopping choices etc. These cultural differences were not explicitly recognised by professionals and therefore, Morgan and their family were not offered the support they might have needed to adjust; for Morgan, living in rural Devon and for the family, caring for a teenager.

Messages for practice

  • Designated Safeguarding Leads in schools to be proactive in seeking information from other schools when children transfer into their education setting, especially when those children have vulnerabilities
  • All staff working with children to be aware of the implications on young people moving from city areas to rural areas, whether into or within Devon. Limited transport reduces access to peers and leisure activities and impacts on independence and autonomy.
  • Social workers and GPs to ensure that they consider the impact of family and carer’s physical, emotional and mental health needs on their ability to care for a child and that, not only sources of family and community support are explored, but Early Help support is offered to address those needs.
  • GPs and other professionals working with young people need to possess an awareness of the hallmarks of aerosol misuse to subsequently educate and support young people.

If you are worried about the safety or wellbeing of a child or young person in Devon,
please complete the request for support online form.


If you think that the child is at risk of significant harm,
contact our Front Door directly by calling 0345 155 1071.


In an emergency call 999.