“The purpose of the referral to South Trafford CMHT by the nurse mental health…”

The 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. ii. iii. there is an urgent referral arising from a high risk of self-harm and / or suicide; where this referral is considered necessary by the general practice professionals; and, 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

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0123

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0