Concerns 'not addressed' after patient's suicide

Concerns raised following a psychiatric patient's suicide have not been "adequately addressed" by an NHS trust, a coroner has said.

Cain Donald, 26, was admitted to the Littlemore Mental Health Centre in Oxford in 2022 before successfully appealing his detention and then taking his own life.

In a prevention of future deaths report, coroner Nicholas Graham said there had been "deficiencies in the way Mr Donald's discharge was planned and executed".

Oxford Health NHS Foundation Trust, which had been responsible for his care, said it was "reviewing" what further action it could take and extended its condolences to Mr Donald's family.

An inquest previously heard Mr Donald had been referred to the psychiatric intensive care unit with symptoms of paranoia and psychosis on 26 June 2022.

When he returned home he was monitored twice a day by the crisis resolution home treatment team.

However, in the report, the coroner said there had been "insufficient communication and liaison" with Mr Donald's family members, and they had not been "properly engaged in the discharge planning process".

"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," Mr Graham wrote.

On 24 July 2022, a decision was made that Mr Donald should be supervised when taking his medication at home visits, yet records of visits showed this had not been done.

Mr Donald was found dead days later. A toxicology report found no trace of the medication he was prescribed in his system.

There had been "no evidence of steps taken" by the NHS trust to the "address issues" around the failure to supervise Mr Donald taking his medication, Mr Graham wrote in his report.

He added: "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."

Rebekah Mackay, Mr Donald's girlfriend at the time of his death, has previously said he was "let down by the system".

Following the outcome of the inquest, she said her boyfriend had "reached out for help but didn't receive the care and support he so desperately needed".

"I hope that Cain's death will not be in vain and that real change can come out of this process," she added.

In a statement, an Oxford Health spokesperson said: " We are now reviewing action which may be available to the trust in addition to that already taken and will respond to the coroner within the time required."

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