PFD report

Cain Alex River Donald · Prevention of Future Deaths report

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Issued 5 Jun 2025•Oxfordshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
8

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised8

  1. Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community
    Part of recurring concern: Failure to ensure safe discharge planning for inpatient mental health admissionsPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to involve the Probation Service in discharge planning
    Part of recurring concern: Unreliable hospital discharge processes
  3. Lack of training or guidance for CRHTT staff on medication supervision and escalation
    Part of recurring concern: Unreliable medication supervision and escalation for mental health patients
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Review the Discharge Policy and recommend amendments, including a new section on unplanned discharge.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.
  2. Action

    Obtain approval and publish the revised Discharge Policy, then brief ward teams on its requirements.

    Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
  3. Action

    Produce and circulate additional discharge guidance for staff through the discharge checklist.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community

Wider context from the report

“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's 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 Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe discharge planning for inpatient mental health admissions; Unreliable hospital discharge processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to involve the Probation Service in discharge planning

Wider context from the report

“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's 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 Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of training or guidance for CRHTT staff on medication supervision and escalation

Wider context from the report

“Post-discharge management of risk arising from medication compliance and multi-disciplinary team review. (3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his death. ”

Is this part of a recurring concern?

Yes — Unreliable medication supervision and escalation for mental health patients.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to escalate non-compliance with medication supervision instructions

Wider context from the report

“Post-discharge management of risk arising from medication compliance and multi-disciplinary team review. (3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his death. ”

Is this part of a recurring concern?

Yes — Unreliable medication supervision and escalation for mental health patients.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to engage family members effectively in discharge planning

Wider context from the report

“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's 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 Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions; Failure to involve families and carers in mental health care planning and decisions; Unreliable hospital discharge processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to supervise medication taking as specifically instructed

Wider context from the report

“Post-discharge management of risk arising from medication compliance and multi-disciplinary team review. (3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his death. ”

Is this part of a recurring concern?

Yes — Unreliable support for patients taking prescribed medication; Unsafe medication administration.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient communication with family members about discharge risks and support needs

Wider context from the report

“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's 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 Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Failure to involve families and carers in mental health care planning and decisions; Failure to provide families with information needed to support people receiving mental health care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to rapidly coordinate complex discharge arrangements

Wider context from the report

“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's 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 Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe discharge planning for inpatient mental health admissions; Unreliable hospital discharge processes.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the Discharge Policy and recommend amendments, including a new section on unplanned discharge.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Obtain approval and publish the revised Discharge Policy, then brief ward teams on its requirements.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Produce and circulate additional discharge guidance for staff through the discharge checklist.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Adopt the new medications-management flowchart and assessment pro-forma for use by the CRHTT.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 3 · response
Published 17 June 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the CRHTT medications management process, standard operating procedure and staff orientation resources to clarify responsibilities and decision-making.

Verbatim wording from the response

“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”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a medications-management flowchart and assessment pro-forma to support administration-route decisions and efficacy assessment.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 3 · response
Published 17 June 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Record 7-Day MDT minutes on RiO using a designated minute taker and have a Band 7 clinician review and validate their accuracy.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Record 7-Day MDT minutes on RiO using a designated minute taker and have a Band 7 clinician review and validate their accuracy.

Verbatim wording from the response

“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.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026