Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate discharge decision analysis
The earlier warning
Gordon Fenton · 23 Apr 2020 · Adrian Farrow, Manchester South
“There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs.”
judiciary.uk/prevention-of-future-death-reports/gordon-fenton
What was promised
Stated action 1 · response to Gordon Fenton (23 Apr 2020) · stated timescale: end of August 2020
“It is planned that his will go live at the end of August 2020”
judiciary.uk/…/2020-0102-Response-from-Pennine-Care-NHS-Foundat…
What recurred
- 20 Jan 2026 · Linda Fury · Chris Morris · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Gordon Fenton · 23 Apr 2020
“There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs.”
Later · Linda Fury · 20 Jan 2026
“The investigation does not undertake any meaningful critical analysis of the decision- making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled”
What happened next
No web check of the stated actions has been published for this chain.