“! heard evidence that there is currently no system in place at Pennine Care NHS…”
Dated 23 Oct 2020, from the coroner for Manchester North. 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 18 Dec 2020.
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 dated23 Oct 2020
- Deadline18 Dec 2020
- Published on judiciary.uk4 Dec 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Pennine Care NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
- ! heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen's admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication. The Discharge Letter that was sent to Mr Owen's GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been 'no issues or incidents' during the admission; that the Deceased 'never showed any DSH behaviour as an inpatient' and that 'we did not see any SH behaviour or expressed thought from Sean during his admission.' The letter made no reference to the significant risk associated with non-compliance.
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, 2020-0215
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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