Cain Donald
5 Jun 2025 · Coroner Nicholas Graham · Oxfordshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. discharge planning deficiencies
“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community”
2. medication supervision failure
“Evidence suggested that during the period immediately prior to Mr [name redacted] death, staff of the CRHTT did not implement specific instructions to supervise Mr [name redacted] taking his medication”
3. inadequate risk mitigation through family and probation involvement
“The evidence revealed deficiencies in the way Mr [name redacted] 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 [name redacted] posed to himself”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community.”
This report
“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.”