Cain Donald

I am Nicholas Graham, Area coroner, for the coroner area of Oxfordshire.

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

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.

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) 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.

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.