Man who took his own life 'let down by system'

Cain Donald was 26-years-old when he died

The former girlfriend of a man who took his own life ten days after being discharged from a psychiatric intensive care unit has said he was "let down by the system".

Cain Donald died near Northbrook, Oxfordshire, in July 2022 having been discharged after successfully appealing his detention at a mental health tribunal.

Opportunities to prevent the decline of Mr Donald's mental health were missed, an inquest into his death recently concluded.

Recording a narrative conclusion, coroner Nicholas Graham said Mr Donald's family and the probation service had not been "properly engaged in the discharge planning process".

In his conclusion, Mr Graham said upon Mr Donald's discharge from a specialist unit, arrangements for the supervision of taking his medication "had not been adhered to nor escalated".

"Had engagement, supervision and escalation taken place it is possible this may have prevented a deterioration in Cain's mental health which led to this death," Mr Graham added.

'Real change'

The inquest previously heard Cain attended A&E at John Radcliffe Hospital with symptoms of paranoia and psychosis on 26 June 2022, and was transferred to Ashurst Psychiatric Intensive Care Unit in Littlemore.

Mr Donald challenged his detention at a mental health tribunal, and his discharge was ordered - against the recommendations of his responsible clinician.

Having been released three days after the verdict, the crisis resolution home treatment team took over his care and he was monitored at twice daily home visits.

On 24 July 2022 a decision was made that Mr Donald should be supervised when taking his medication at home visits, yet records of visits showed this had not been done.

Mr Donald was found dead days later. A toxicology report found no traces of his medication in his system.

The BBC has contacted Oxford Health NHS Foundation Trust, which manages the Ashurst Psychiatric Intensive Care Unit and Oxford's crisis resolution home treatment team, for comment.

Speaking via Leigh Day solicitors, Mr Donald's girlfriend at the time of his death, Rebekah Mackay, said she "truly believes" that the 26-year-old was "was let down by the system".

Following the outcome of the inquest, she said her former boyfriend had "reached out for help but didn't receive the care and support he so desperately needed".

"I'll never get over losing Cain," she continued.

"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.

"I hope that Cain's death will not be in vain, and that real change can come out of this process."