Assumption about capacity context
Pennine Care NHS Trust received 2 coroners' reports about this hazard between 19 Nov 2022 and 20 Jan 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“the Consultant [name redacted] who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased's capacity were raised in the context of her withdrawal from alcohol.”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“During [the deceased]'s admission to Aspen Ward, there was not enough consideration of [the deceased]'s historical mental health diagnoses, contextual clinical information from previous inpatient admissions and community care and her overall complexity. There is evidence of the MDT completing an assessment of [the deceased]'s mental health and associated risks over the course of her admission to Aspen Ward.”
Stated timescale: 21/01/22
- 3 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“In respect of findings made in relation to the care provided on the day before [the deceased]'s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) '[t]here was no reason to doubt [the deceased]'s capacity at this stage'”
Original on judiciary.uk ↗ Repeated from the earlier report:madedeceased'scapacity
Pennine Care NHS Trust responded.Response (PDF) ↗
- All reports to Pennine Care NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2022 → 2026Linda Fury3 years 2 months after Sarah McGarrigle · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports criticize the Trust's assessment of a patient's capacity, noting that clinicians overlooked relevant contextual information and drew premature conclusions.
Sarah McGarrigle · 19 Nov 2022
“the Consultant [name redacted] who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased's capacity were raised in the context of her withdrawal from alcohol.”
Original on judiciary.uk ↗ Linda Fury · 20 Jan 2026
“In respect of findings made in relation to the care provided on the day before [the deceased]'s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) '[t]here was no reason to doubt [the deceased]'s capacity at this stage'”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“During [the deceased]'s admission to Aspen Ward, there was not enough consideration of [the deceased]'s historical mental health diagnoses, contextual clinical information from previous inpatient admissions and community care and her overall complexity. There is evidence of the MDT completing an assessment of [the deceased]'s mental health and associated risks over the course of her admission to Aspen Ward.”
Stated action · timescale: 21/01/22
“During [the deceased]'s admission to Aspen Ward, there was not enough consideration of [the deceased]'s historical mental health diagnoses, contextual clinical information from previous inpatient admissions and community care and her overall complexity. There is evidence of the MDT completing an assessment of [the deceased]'s mental health and associated risks over the course of her admission to Aspen Ward.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Pennine Care NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2022 → 2026 | 0.77 | 0.06 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Pennine Care NHS Trust
- Inadequate discharge decision analysis2 reports · 2020–2026
- Medication monitoring and discharge risk assessment failures4 reports · 2016–2024
- Incompatible electronic records hinder mental health information sharing4 reports · 2018–2023
- Inadequate record keeping compromising patient safety3 reports · 2014–2018
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.