Missed opportunities could have prevented the deterioration of Cain Donald that ended in his death, inquest concludes

Recording a narrative conclusion, HM Area Coroner Nicholas Graham said that had supervision and escalation taken place, it is possible the deterioration in Cain’s condition – that ultimately ended in his death – could have been prevented.  

The inquest also found that Cain’s his family were not properly engaged in the process that led to Cain’s discharge from hospital after being sectioned under the Mental Health Act.  

The court heard that Cain attended A&E at the John Radcliffe Hospital with symptoms of paranoia and psychosis on 26 June 2022. This was his first and only known episode of psychosis. He was detained under the Mental Health Act and transferred to a Psychiatric Intensive Care Unit, Ashurst Ward in Littlemore Hospital.

Cain challenged his detention on 5 July 2022 at the Mental Health Tribunal, and his discharge was ordered by the Tribunal on 15 July 2022 against the recommendations of his responsible clinician who told the inquest that he believed Cain was still unwell and would not take his medication if given the choice.

He was discharged three days later. Cain’s Responsible Clinician told the court that he was not expecting the Tribunal to order Cain’s discharge and that the Trust’s discharge policy did not envisage discharge from a Psychiatric Intensive Care Unit directly into the community. Cain’s team had three days to plan for his release.

Cain was discharged into the care of the Crisis Resolution Home Treatment Team for the stated purpose of medication concordance which was to be monitored at twice daily home visits.  After being discharged, the court heard that nurses who attended Cain said that his medication was being administered, however on other occasions he was reluctant or had indicated he had already taken it.  

On 24 July 2022 a decision was made that Cain should be supervised taking his medication at home visits. However, the notes of visits in the following days show this was not done and nurses continued to accept Cain’s assurances that he was taking his medication.    

Cain took his own life and was found dead in a local park on 29 July 2022. A toxicology report found no traces of Cain’s medication in his system.  

In a narrative conclusion the Coroner found that Cain’s family and the Probation Service were not properly engaged in the discharge planning process and that arrangements for the supervision of medication were not adhered to or escalated. They found that if supervision and escalation had taken place, it is possible that this would have prevented the deterioration in Cain’s condition which led to his death.  

The Coroner has deferred his decision on whether to issue a Prevention of Future Deaths (PFD) report pending disclosure of Oxford Health’s updated discharge policy which, at the time of Cain’s discharge, did not envisage discharge from a psychiatric intensive care unit directly into the community.  

Cain’s family were represented by Saoirse Kerrigan, a solicitor at law firm Leigh Day and Paul Clark, a barrister from Garden Court Chambers.

Cain’s girlfriend, Rebekah Mackay said:  

“I truly believe that Cain was let down by the system. He reached out for help but didn’t receive the care and support he so desperately needed. That’s especially hard to accept when men's mental health is in such a critical state right now.

“What I wanted most from the inquest was for those who were responsible for Cain’s care to acknowledge that more should have been done to support Cain. No one else should have to go through what Cain went through — or what we, as his family, are still going through. I hope that Cain’s death will not be in vain, and that real change can come out of this process.

“I’ll never get over losing Cain. But I do hope that by speaking out, things can start to change, and that support systems will improve for other young men experiencing mental health difficulties before it’s too late.”

Saoirse Kerrigan said:  

“When questioned, Trust employees accepted that Cain’s discharge process should have been better managed and more should have been done to support Cain’s family who were caring for him after he was discharged. Significantly, the Coroner found a number of possible causative factors and concluded that had medication been supervised and had concerns escalated at an earlier stage, this could have prevented Cain’s deterioration.

“We hope that this tragic case results in improvements in Oxford Health’s discharge policies and that more is done to support families caring for people discharged from mental health detention so that another family does not have to endure the heartbreak and ordeal that Cain’s family has.”