Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0278, written 5 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2025 |
|---|---|
| Reference | 2025-0278 |
| Deceased | Cain Donald |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
CAIN ALEX RIVER DONALD REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Oxford Health NHS Foundation Trust 1 CORONER I am Nicholas Graham, Area coroner, for the coroner area of Oxfordshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 11/08/2022 I commenced an investigation into the death of Cain Alex River Donald, aged 26. The investigation concluded at the end of the inquest on 7 May 2025. The conclusion of the inquest was Suicide. The medical Cause of Death was Hanging 4 CIRCUMSTANCES OF THE DEATH Cain Donald died on 29 July 2022 by hanging. Prior to his death, Mr Donald had been released from prison in December 2019 and remained on Probation. He experienced a decline in his mental health in June 2022, exhibiting paranoid behaviour and using substances. He was admitted to Ashurst Psychiatric Intensive Care Unit (PICU) on 28 June 2022 and was discharged directly into the community on 19 July 2022 following a decision by a Mental Health Review Tribunal. Following discharge, he was receiving support from the Crisis Home Treatment Team (CRHTT). The inquest specifically focused on the events preceding his death, particularly his discharge planning, the involvement of the Probation Services and his family, and the role of the CRHTT, including medication administration. I found deficiencies in the planning and execution of his discharge. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. 1 (1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. Post-discharge management of risk arising from medication compliance and multi-disciplinary team review. (3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his death. 6 DETAILS OF ACTION TAKEN BY RECIPIENT As well as the actions the Trust has already undertaken, the Trust should review the discharge planning arrangements to ensure their effectiveness, particularly in the light of any Tribunal decision requiring discharge from detention, and specifically in relation to discharge from the PICU. Furthermore, the Trust should review arrangements for the medication supervision by staff from the CRHTT and also how concerns about medication compliance are escalated and risks reviewed in the light of suspected or actual non-compliance. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31 July 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 2 and (acting on behalf of themselves and Cain's four siblings). Thames Valley Probation Services I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. The Chief Coroner may publish either or both in a complete or redacted or summary form. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 [DATE] 05/06/2025 [SIGNED BY CORONER] 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Private & Confidential Mr N Graham HM Area Coroner for Oxfordshire Sent via email only to: 28 July 2025 Dear Mr Graham, Inquest into the death of Cain Donald We received your letter dated 5 June 2025 and your report to prevent future deaths. You identified two areas of concern. Your first area of concern was the way in which Mr Donald’s discharge to the community was planned and executed, including liaison with family members and the Probation Service; your second concern was rooted in the arrangements in place to ensure that Mr Donald took his medications, including escalation of concerns by staff. The Trust’s Associate Director of Nursing for the Oxfordshire mental health directorate attended the inquest on both days and provided evidence on the second day. My colleague has contributed to this response given that they heard all evidence given to you first-hand. On the first area of concern, the Trust has a Discharge Policy that applies to transfers of care from all Trust wards to community care. You heard evidence that direct transfers from a psychiatric intensive care unit to community care are relatively rare, in that it is more usual for a patient to be stepped-down from an intensive care unit to a general ward. Similarly, it was not a common situation for the unit to face a position in which a patient is discharged by a Mental Health Tribunal against the advice of the Responsible Clinician. You recall that in Mr Donald’s case he applied to the Tribunal to be discharged from detention under the Mental Health Act and was represented by solicitors at the Tribunal. His Responsible Clinician did not judge that should take place; the Tribunal took its own view and discharged Mr Donald from detention under the Act. Given the function of an inquest, you did not hear evidence from anyone connected with the Tribunal, nor were the Tribunal’s papers in evidence at the inquest. The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording. The revised policy will be available on the Trust’s Intranet under Clinical Policies from the week commencing 31 July 2025. Ward teams will be briefed on the revised policy at their next available team meetings, which will take place in August at the latest. The Associate Director of Nursing emailed relevant colleagues on 25 July to direct that this and to provide them with a copy of the revised policy. More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work. On your second concern, I understand that you heard evidence from a consultant in the CRHTT. On reflection it may have been helpful for you to have heard evidence in person from one or more of the nurses working in the CRHTT who visited Mr Donald at home in the period before his death. You were taken to an entry in the medical records on 24 July 2022 and that entry formed the basis of the questions about medications supervision. The MDT is a place where CRHTT nurses can escalate any concerns about a patient and the Trust recognises that the contemporaneous records of MDT meetings in this case afforded you limited assistance with discussions that took place at subsequent MDT meetings. Following the inquest, our Associate Director of Nursing discussed the position with managers in the CRHTT and their reflection is that a more detailed note in the records of what exactly was expected in terms of medication management would have assisted the delivery of care to Mr Donald. The CRHTT has implemented an action to address this issue, which has been developed with the wider team. The 7-Day MDT process now includes a designated minute taker for MDT meetings and, upon completion, the minutes are recorded on RiO and subsequently reviewed and validated for accuracy by a Band 7 Clinician. Lastly, the CRHTT is reviewing their medications management process in light of the inquest and your findings. The CRHTT clinical nurse lead is leading this work and met our Associate Director of Nursing in May 2025 in order to discuss your findings. The CRHTT has reviewed 2 both its standard operating procedure and local staff orientation resources to ensure clarity regarding how and who is responsible for making decisions and undertaking actions in relation to all aspects of medications management. In summary, there are four broad scenarios for medications management: clinician administers medications, patient takes responsibility for self-administration of medications, a trusted person is involved, or prompting medications. The team has (since the inquest) developed two documents to assist with decision making and assessment of efficacy of medications. The first is a flow- chart directed at achieving the right route for each patient how medications are administered; the second is an assessment pro-forma to measure the efficacy of medications. The CRHTT clinical lead is meeting the Associate Director of Nursing again on 30 July 2025 in order to review the two new forms and, thereafter, the forms will be adopted by the team. The CRHTT clinical nurse lead was grateful to have the benefit of a meeting with members of Cain’s family on 9 July 2025 at which their experience of the dialogue with family around medications management was shared. Yours sincerely, PP Chief Medical Officer on behalf of , , Chief Executive Officer 3
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