Dear Mr Graham, Inquest into the death of Cain Donald We received your letter dated 5 June 2025 and your report to prevent future deaths.

You identified two areas of concern. Your first area of concern was the way in which Mr Donald’s discharge to the community was planned and executed, including liaison with family members and the Probation Service; your second concern was rooted in the arrangements in place to ensure that Mr Donald took his medications, including escalation of concerns by staff.

The Trust’s Associate Director of Nursing for the Oxfordshire mental health directorate attended the inquest on both days and provided evidence on the second day. My colleague has contributed to this response given that they heard all evidence given to you first-hand.

On the first area of concern, the Trust has a Discharge Policy that applies to transfers of care from all Trust wards to community care. You heard evidence that direct transfers from a psychiatric intensive care unit to community care are relatively rare, in that it is more usual for a patient to be stepped-down from an intensive care unit to a general ward. Similarly, it was not a common situation for the unit to face a position in which a patient is discharged by a Mental Health Tribunal against the advice of the Responsible Clinician. You recall that in Mr Donald’s case he applied to the Tribunal to be discharged from detention under the Mental Health Act and was represented by solicitors at the Tribunal. His Responsible Clinician did not judge that should take place; the Tribunal took its own view and discharged Mr Donald from detention under the Act. Given the function of an inquest, you did not hear evidence from anyone connected with the Tribunal, nor were the Tribunal’s papers in evidence at the inquest.

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The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording. The revised policy will be available on the Trust’s Intranet under Clinical Policies from the week commencing 31 July 2025. Ward teams will be briefed on the revised policy at their next available team meetings, which will take place in August at the latest. The Associate Director of Nursing emailed relevant colleagues on 25 July to direct that this and to provide them with a copy of the revised policy.

More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work.

On your second concern, I understand that you heard evidence from a consultant in the CRHTT. On reflection it may have been helpful for you to have heard evidence in person from one or more of the nurses working in the CRHTT who visited Mr Donald at home in the period before his death. You were taken to an entry in the medical records on 24 July 2022 and that entry formed the basis of the questions about medications supervision. The MDT is a place where CRHTT nurses can escalate any concerns about a patient and the Trust recognises that the contemporaneous records of MDT meetings in this case afforded you limited assistance with discussions that took place at subsequent MDT meetings. Following the inquest, our Associate Director of Nursing discussed the position with managers in the CRHTT and their reflection is that a more detailed note in the records of what exactly was expected in terms of medication management would have assisted the delivery of care to Mr Donald. The CRHTT has implemented an action to address this issue, which has been developed with the wider team. The 7-Day MDT process now includes a designated minute taker for MDT meetings and, upon completion, the minutes are recorded on RiO and subsequently reviewed and validated for accuracy by a Band 7 Clinician.

Lastly, the CRHTT is reviewing their medications management process in light of the inquest and your findings. The CRHTT clinical nurse lead is leading this work and met our Associate Director of Nursing in May 2025 in order to discuss your findings. The CRHTT has reviewed

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both its standard operating procedure and local staff orientation resources to ensure clarity regarding how and who is responsible for making decisions and undertaking actions in relation to all aspects of medications management. In summary, there are four broad scenarios for medications management: clinician administers medications, patient takes responsibility for self-administration of medications, a trusted person is involved, or prompting medications. The team has (since the inquest) developed two documents to assist with decision making and assessment of efficacy of medications. The first is a flow- chart directed at achieving the right route for each patient how medications are administered; the second is an assessment pro-forma to measure the efficacy of medications. The CRHTT clinical lead is meeting the Associate Director of Nursing again on 30 July 2025 in order to review the two new forms and, thereafter, the forms will be adopted by the team.

The CRHTT clinical nurse lead was grateful to have the benefit of a meeting with members of Cain’s family on 9 July 2025 at which their experience of the dialogue with family around medications management was shared.