“In view of the importance of robust NHS inves ga ons in preven ng future deaths…”
Dated 20 Jan 2026, from the coroner for Manchester South. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 17 Mar 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated20 Jan 2026
- Deadline17 Mar 2026
- Published on judiciary.uk26 Jan 2026
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Pennine Care NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
– 1. In view of the importance of robust NHS inves ga ons in preven ng future deaths undertaken from the perspec ve of seeking to derive as much learning as possible, I am concerned the Trust’s inves ga on in this case was insufficiently rigorous or probing given: a. It has not focussed in any detail on the consequences arising for Linda (in terms of con nuity of care and more broadly) as a result of the fact that no bed was available for her locally; b. The inves ga on does not undertake any meaningful cri cal analysis of the decisionmaking process which resulted in her sec on being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled; and c. In respect of findings made in rela on to the care provided on the day before Linda’s death, it remains unclear even a er hearing all of the evidence how the inves gators concluded (at page 24 of 44) ‘[t]here was no reason to doubt Linda’s capacity at this stage’ in circumstances where the Trust was on no ce she not a ending to self-care, barely ea ng or drinking and refusing to speak with or see her Care Co-ordinator. 2. I am concerned that the current processes for ward rounds do not rou nely facilitate an opportunity for family members to disclose any concerns relevant to risk privately to the mul -disciplinary team.
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, 2026-0029
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use