Recurance · prevention of future deaths reports
Pre-inquest brief
Assumption about capacity context
The earlier warning
Sarah McGarrigle · 19 Nov 2022 · Catherine McKenna, Manchester North
“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.”
judiciary.uk/…/sarah-mcgarrigle-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Sarah McGarrigle (19 Nov 2022) · stated 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.”
judiciary.uk/…/2022-0290-Response-from-NHS-Pennine-Care-FT.pdf
What recurred
- 20 Jan 2026 · Linda Fury · Chris Morris · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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'”
What happened next
No web check of the stated actions has been published for this chain.