Mark Hughes
PFD Report
All Responded
Ref: 2026-0123
All 1 response received
· Deadline: 29 Apr 2026
Coroner's Concerns (AI summary)
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for high-risk patients, created dangerous gaps, particularly over weekends.
View full coroner's concerns
1. The purpose of the referral to South Trafford CMHT by the nurse mental health practitioner on behalf of the general practice, was for Mr Hughes to be referred to the HBTT. This was as a direct alternative to hospital admission.
2. Whilst the usual course is for the South Trafford CMHT to make contact with the service user on the day of referral, the evidence established that on an urgent referral, the South Trafford CMHT have a timeframe of up to 5 days to arrange an assessment.
3. 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.
4. It was during this period of delay that Mr Hughes took his own life.
5. South Trafford CMHT is part of Greater Manchester Mental Health NHS Foundation Trust. The evidence established that in other boroughs within the area of Greater Manchester Mental Health NHS Foundation Trust, general practice medical professionals are able to refer direct to the HBTT.
6. The After Action Review Report produced by the CMHT after Mr Hughes’s death, identified the following as a ‘Concern/Gap’ : ‘To explore whether PCN Nurses can refer directly to HBTT.’
7. 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.
8. Therefore, at the time of Mr Hughes’s 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.
9. Had it been possible for the nurse who assessed Mr Hughes on behalf of the general practice to refer him direct to the HBTT, the delay occasioned by the system of referral to the HBTT operated by South Trafford CMHT would have been avoided.
10. It was explained in evidence on behalf of the CMHT, that had the HBTT been able to assess Mr Hughes, it was unclear whether they would have accepted the referral. However, what the HBTT would or would not have decided is unknown: nor does this obviate the concern raised.
11. The concern is that in South Trafford, a service user cannot be referred directly to the HBTT from a general practice where: i. there is an urgent referral arising from a high risk of self-harm and / or suicide;
ii. where this referral is considered necessary by the general practice professionals; and,
iii. where such a referral could be made were it to take place in other boroughs within the area covered by Greater Manchester Mental Health NHS Foundation Trust.
2. Whilst the usual course is for the South Trafford CMHT to make contact with the service user on the day of referral, the evidence established that on an urgent referral, the South Trafford CMHT have a timeframe of up to 5 days to arrange an assessment.
3. 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.
4. It was during this period of delay that Mr Hughes took his own life.
5. South Trafford CMHT is part of Greater Manchester Mental Health NHS Foundation Trust. The evidence established that in other boroughs within the area of Greater Manchester Mental Health NHS Foundation Trust, general practice medical professionals are able to refer direct to the HBTT.
6. The After Action Review Report produced by the CMHT after Mr Hughes’s death, identified the following as a ‘Concern/Gap’ : ‘To explore whether PCN Nurses can refer directly to HBTT.’
7. 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.
8. Therefore, at the time of Mr Hughes’s 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.
9. Had it been possible for the nurse who assessed Mr Hughes on behalf of the general practice to refer him direct to the HBTT, the delay occasioned by the system of referral to the HBTT operated by South Trafford CMHT would have been avoided.
10. It was explained in evidence on behalf of the CMHT, that had the HBTT been able to assess Mr Hughes, it was unclear whether they would have accepted the referral. However, what the HBTT would or would not have decided is unknown: nor does this obviate the concern raised.
11. The concern is that in South Trafford, a service user cannot be referred directly to the HBTT from a general practice where: i. there is an urgent referral arising from a high risk of self-harm and / or suicide;
ii. where this referral is considered necessary by the general practice professionals; and,
iii. where such a referral could be made were it to take place in other boroughs within the area covered by Greater Manchester Mental Health NHS Foundation Trust.
Responses
Action Taken
• The Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT. • Mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust. (AI summary)
• The Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT. • Mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust. (AI summary)
View full response
Dear Mr Myers Re: Mark Hughes (deceased) Regulation 28 Preventing Future Deaths Response Thank you for highlighting your concerns following Mr Hughes inquest which concluded on 26th February 2026. On behalf of Greater Manchester Mental Health NHS Trust (GMMH), I would like to offer Mr Hughes’s family our sincere condolences for their loss. During the Inquest evidence was heard that the mental health Primary Care Nurse (PCN) was unable to make a direct referral to the Trafford Home-Based Treatment Team (HBTT), as an alternative to hospital admission. PCN’s were able to refer directly to HBTT in other boroughs of the Trust. In Mr Hughes case, the PCN was required to make the referral through the Community Mental Health Team (CMHT) who have up to 5 days to arrange an assessment. The CMHT do not operate at weekends, and this led to further delays in an assessment and referral to HBTT.
Following Mr Hughes death, the Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT.
Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust: In South Trafford, a service user cannot be referred directly to the HBTT from a general practice where:
i. there is an urgent referral arising from a high risk of self-harm and / or suicide;
ii. where this referral is considered necessary by the general practice professionals; and,
iii. where such a referral could be made were it to take place in other boroughs within the area covered by Greater Manchester Mental Health NHS Foundation Trust. Executive Offices The Curve Bury New Road M25 3BL
P a g e 2 | 2
I am sorry that you were not provided with clear information in the Inquest in relation to whether the PCN could refer directly into mental health services in Trafford. To confirm mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust, following an assessment of the persons mental health. This information has been shared with urgent care staff and our PCN colleagues via a Practice Note issued on 28th April 2026 and will be included in the May edition of the Trust Patient Safety Newsletter that is shared with all staff across the Trust electronically by 28th May 2026. In addition, a planned away day is scheduled to take place on 6th May 2026 lead by the clinical service managers for urgent care, during which senior operational leads will meet to review and confirm the HBTT Standard Operating Procedure (SOP). The SOP that went live in February 2026 has a list of services that can refer into HBTT and states that this is not an exhaustive list and that GMMH operate an inclusive referral process to support all GMMH internal teams. This session will be used to clearly outline referral pathways and operational expectations across all GMMH HBTT services. The away day will specifically reinforce that all GMMH services, including Living Well and PCNs, can refer directly to the HBTT, ensuring timely access to urgent care services when needed and this work is intended to reduce variation, improve shared understanding, and strengthen safe, equitable access to HBTT services across the system. Where a general practice does not have specific mental health staff the GP’s can currently refer for a mental health assessment by referring to the Neighbourhood Team or the Community Mental Health Team (CMHT). As part of the transformation of community mental health services GMMH are implementing a Referral and Assessment hub who will triage all external referrals and direct to the most appropriate service. These hubs are already in place in some areas of the Trust; the SOP will be finalised by the end of May 2026 and there will be a Referral and Assessment hub functioning in all areas of the Trust by the end of August 2026 enabling GP’s and other professionals to have a single point of referral. If a referral is assessed to be urgent the GP can initiate a mental health act assessment or refer the patient to A&E where they can be seen by the Mental Health Liaison Service (MHLS). I thank you again for bringing these matters of concern to the Trust’s attention. If you have any further questions in relation to the Trust’s response, please do let me know.
Following Mr Hughes death, the Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT.
Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust: In South Trafford, a service user cannot be referred directly to the HBTT from a general practice where:
i. there is an urgent referral arising from a high risk of self-harm and / or suicide;
ii. where this referral is considered necessary by the general practice professionals; and,
iii. where such a referral could be made were it to take place in other boroughs within the area covered by Greater Manchester Mental Health NHS Foundation Trust. Executive Offices The Curve Bury New Road M25 3BL
P a g e 2 | 2
I am sorry that you were not provided with clear information in the Inquest in relation to whether the PCN could refer directly into mental health services in Trafford. To confirm mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust, following an assessment of the persons mental health. This information has been shared with urgent care staff and our PCN colleagues via a Practice Note issued on 28th April 2026 and will be included in the May edition of the Trust Patient Safety Newsletter that is shared with all staff across the Trust electronically by 28th May 2026. In addition, a planned away day is scheduled to take place on 6th May 2026 lead by the clinical service managers for urgent care, during which senior operational leads will meet to review and confirm the HBTT Standard Operating Procedure (SOP). The SOP that went live in February 2026 has a list of services that can refer into HBTT and states that this is not an exhaustive list and that GMMH operate an inclusive referral process to support all GMMH internal teams. This session will be used to clearly outline referral pathways and operational expectations across all GMMH HBTT services. The away day will specifically reinforce that all GMMH services, including Living Well and PCNs, can refer directly to the HBTT, ensuring timely access to urgent care services when needed and this work is intended to reduce variation, improve shared understanding, and strengthen safe, equitable access to HBTT services across the system. Where a general practice does not have specific mental health staff the GP’s can currently refer for a mental health assessment by referring to the Neighbourhood Team or the Community Mental Health Team (CMHT). As part of the transformation of community mental health services GMMH are implementing a Referral and Assessment hub who will triage all external referrals and direct to the most appropriate service. These hubs are already in place in some areas of the Trust; the SOP will be finalised by the end of May 2026 and there will be a Referral and Assessment hub functioning in all areas of the Trust by the end of August 2026 enabling GP’s and other professionals to have a single point of referral. If a referral is assessed to be urgent the GP can initiate a mental health act assessment or refer the patient to A&E where they can be seen by the Mental Health Liaison Service (MHLS). I thank you again for bringing these matters of concern to the Trust’s attention. If you have any further questions in relation to the Trust’s response, please do let me know.
Sent To
- Greater Manchester Mental Health NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
29 Apr 2026
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 9th July 2025, an inquest was opened concerning the death of Mark Alan Hughes, aged 56 years at the time of death. The investigation concluded at the end of the inquest on the 26th February 2026.
The medical cause of death was: 1a) Stab wound to the heart
The conclusion of the inquest was: Suicide
The medical cause of death was: 1a) Stab wound to the heart
The conclusion of the inquest was: Suicide
Circumstances of the Death
Mark Hughes had been diagnosed with anxiety since 2019. During May and June of 2025, his mental state deteriorated significantly. His anxiety heightened, he was unable to sleep and he expressed thoughts of self-harm and suicide. There were occasions when he went missing from home, and on the 13th June 2025, he was found by the police after his wife had reported him missing. Mr Hughes had contact with general practice doctors at the medical centre to which he was registered during this period. On the 20th June 2025, he attended an assessment by the nurse mental health practitioner who worked with the general practice. She considered him to be a high risk of self-harm and suicide. She concluded that an urgent referral to the South Trafford Community Mental Health Team [‘CMHT’] was the appropriate course; her intention being that the CMHT would refer Mr Hughes to the Home Based Treatment Team [‘HBTT’] who would be able to support him at home, as an alternative to hospital admission. Whilst the purpose of the referral was to obtain support by the HBTT, the referral had to be via the CMHT, because in South Trafford, a general practice is unable to refer direct to the HBTT: it has to be via the CMHT. The nurse mental health practitioner discussed this with Mr Hughes’s general practitioner, who agreed with this referral. The general practitioner also prescribed a course of zopiclone to Mr Hughes, in light of the assessment and as advised by the mental health practitioner who conducted it.
The CMHT sought to make contact with Mr Hughes on the afternoon of Friday the 20th June 2025. By 17:00 hours that day there had been no contact. The CMHT do not operate during the weekend in the circumstances of a referral such as this. Therefore, the referral was deferred until 09:00 on Monday 23rd June 2025, to be followed-up then.
At some time between 21:00 on the 22nd June 2025 and 07:48 on the 23rd June 2025, Mr Hughes locked and barricaded himself inside his garage at his home. Having already taken a potentially fatal quantity of codeine and morphine, he stabbed himself in the chest . He died as a consequence of the stab wound.
The CMHT sought to make contact with Mr Hughes on the afternoon of Friday the 20th June 2025. By 17:00 hours that day there had been no contact. The CMHT do not operate during the weekend in the circumstances of a referral such as this. Therefore, the referral was deferred until 09:00 on Monday 23rd June 2025, to be followed-up then.
At some time between 21:00 on the 22nd June 2025 and 07:48 on the 23rd June 2025, Mr Hughes locked and barricaded himself inside his garage at his home. Having already taken a potentially fatal quantity of codeine and morphine, he stabbed himself in the chest . He died as a consequence of the stab wound.
Copies Sent To
2. Washway Road Medical Centre
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.