Linda Fury
20 Jan 2026 · Coroner Chris Morris · Manchester South
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of local inpatient mental health beds
“It has not focussed in any detail on the consequences arising for [the deceased] (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally”
2. inadequate decision-making analysis
“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does not undertake any meaningful critical analysis of the decision- making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled”
3. unsubstantiated capacity assessment
“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' in circumstances where the Trust was on notice she not amending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator”
4. lack of private family risk disclosure
“the current processes for ward rounds do not routinely facilitate an opportunity for family members to disclose any concerns relevant to risk privately to the multi-disciplinary team”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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does not undertake any meaningful critical analysis of the decision- making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled”
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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'”