Mark Hughes
4 Mar 2026 · Coroner Benjamin Myers · Manchester South
The coroner's concerns
1. delayed referral to home based treatment team
“The purpose of the referral to South Trafford CMHT by the nurse mental health practitioner on behalf of the general practice, was for Mr [name redacted] to be referred to the HBTT. This was as a direct alternative to hospital admission.”
2. no weekend assessment
“Moreover, with regard to a referral in the circumstances of this matter, the CMHT do not operate over the weekend. This meant that from Friday 20th June 2025 at 17:00, there could be no assessment and no referral to the HBTT, until 09:00 on Monday 23rd June 2025, at the earliest.”
3. self-harm leading to death
“It was during this period of delay that Mr [name redacted] took his own life.”
4. lack of direct referral pathway
“The After Action Review Report produced by the CMHT after Mr [name redacted] death, identified the following as a 'Concern/Gap' : 'To explore whether PCN Nurses can refer directly to HBTT.'”
5. procedural restriction
“In evidence, it was accepted on behalf of the CMHT that there are occasions when a nurse associated with a general practice, or a general practitioner, may need to refer directly to the HBTT; but that the formal procedure does not allow for this.”
6. ongoing inability to refer directly
“Therefore, at the time of Mr [name redacted] death, such a referral could not be made. It still cannot be made, notwithstanding the availability of this course in other boroughs and the findings of the After Action Review.”