The intervention comes after an inquest held at South Manchester Coroners’ Court, where Assistant Coroner Benjamin Myers KC concluded that systemic barriers in access to urgent mental health support may have contributed to Mr Hughes’ death.

The full report by the coroner can be found here

A deteriorating crisis, a delayed response

Mark Hughes, who had been diagnosed with anxiety in 2019, experienced a marked decline in his mental health in the weeks leading up to his death in June 2025. The inquest heard that he suffered from severe insomnia, expressed suicidal thoughts, and had gone missing on several occasions.

On 20 June 2025, Mr Hughes was assessed at Washway Road Medical Centre, where a nurse practitioner identified him as being at high risk of self-harm and suicide. An urgent referral to the South Trafford Community Mental Health Team (CMHT) was made, with the expectation that he would then be escalated to the Home Based Treatment Team (HBTT) as an alternative to hospital admission.

However, the inquest exposed a critical structural constraint: in South Trafford, GPs and associated clinicians are not permitted to refer directly to the HBTT. Instead, all referrals must pass through CMHT—a step that introduced delay at a point of acute risk.

Despite attempts by CMHT to make contact on the same day, no contact was established before 5pm. With no weekend provision for progressing such referrals, Mr Hughes’ case was deferred until the following Monday.

He died during that intervening period.

A postcode lottery in crisis care

The coroner’s Prevention of Future Deaths report highlights a stark inconsistency across Greater Manchester. In other boroughs served by GMMH, direct referral from primary care to HBTT is permitted in high-risk cases. In South Trafford, it is not.

Evidence presented at the inquest confirmed that clinicians themselves recognise situations where direct referral is clinically necessary—but are prevented from acting due to procedural rules.

The coroner was explicit in his conclusion: had direct referral been possible, “the delay… would have been avoided.”

This raises wider concerns about what can only be described as a postcode lottery in crisis response, where access to urgent, potentially life-saving intervention depends not on clinical need, but on local administrative policy.

Preventable harm and organisational responsibility

In his letter to GMMH Chief Executive Karen Powell, the coroner stated:

“In my opinion action should be taken to prevent future deaths and I believe you [and your organisation] have the power to take such action.”

This is not simply a matter of individual oversight, but of system design. The barrier identified is procedural, predictable, and—crucially—already resolved elsewhere within the same trust footprint.

For families and campaigners, such findings reinforce longstanding concerns: that fragmentation, inconsistency, and inflexible pathways within mental health services continue to create avoidable risk.

Beyond procedure: a question of priorities

While the technical issue identified relates to referral routes, the implications are broader. Crisis systems are expected to respond rapidly, flexibly, and proportionately to risk. Where frontline clinicians identify imminent danger but are constrained by process, the system itself becomes a source of harm.

The case also raises questions about:

• Weekend and out-of-hours continuity, particularly for high-risk referrals
• Clinical autonomy, and whether practitioners are empowered to act on risk
• Standardisation across services, to eliminate inequities in access to care

At its core, this is a case about time—lost time in a moment of escalating crisis—and about whether systems are designed to prioritise urgency when it matters most.

A call for change

Prevention of Future Deaths reports are among the clearest mechanisms through which systemic failings are formally recognised. They are not issued lightly.

The expectation now is that GMMH will respond with concrete changes—not only addressing the specific referral restriction in South Trafford, but ensuring that no similar barriers persist elsewhere.

For CHARM readers, the case underscores a familiar and troubling pattern: risk is often well recognised at the frontline, but systems fail to move quickly enough around it.

The question is no longer whether change is needed, but whether it will be delivered at the pace that safety demands.

Source: PDF Report issues by Benjamin Myers KC, HM Assistant Coroner, Greater Manchester South