Linda Fury

Corporate Legal Services
Trust Headquarters
225 Old Street
Ashton Under Lyne
Lancashire
OL6 7SF

13th March 2026 

Private & Confidential 
Christopher Morris  
HM Area Coroner 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG 

Dear Mr Morris, 

RE: Inquest touching on the death of Linda Fury  

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation 
Trust  (PCFT)  and  the  issuing  of  a  Prevention  of  Future  Deaths  Notice  (Regulation 
28), arising from the inquest into the death of Linda Fury.  

May  I  take  this  opportunity  to  extend  my  own  condolences  to  Linda’s  family  and 
apologise that you had to raise concerns relating to the services she accessed prior 
to her sad death.  

The  Trust  sets  out  its  response  to  the  points  below  raised  by  HMC’s  as  areas  of 
concern: 

1.  In view of the importance of robust NHS investigation in preventing future 
deaths  undertaken  from  the  perspective  of  seeking  to  derive  as  much 
learning as possible, I am concerned the Trust’s investigation in this case 
was insufficiently rigorous or probing given:  

a)  It  has  not  focussed  in  any  detail  on  the  consequences  arising  for 
Linda (in terms of continuity of care and more broadly) as a result of 
the fact that no bed was available for her locally;  

b)  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rescinded and her therefore being discharged notwithstanding family 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; 
and leave had first been trialled; and 

c)  In  respect  of  findings  made  in  relation  to  the  care  provided  on  the 
day before Linda’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 Linda’s capacity at this stage’ in  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 circumstances  where  the  Trust  was  on  notice  she  not  attending  to 
self-care, barely eating or drinking and refusing to speak with or see 
her Care Co-ordinator. 

The Trust acknowledges the coroner’s concerns arising from Linda’s placement into 
the Tameside locality as the first available acute bed and that this meant a break in 
her continuity of care from the Stockport medical consultant who knew Linda. There 
was no change to her community provision.  

The Trust has an established practice of always seeking to ensure that an individual 
that requires an inpatient admission is admitted as soon as possible. The patient flow 
team  (a  team  that  manages  all  the  requests  for  access  to  beds)  will  start  from  the 
position  that  admission  to  the  patient’s  locality  bed  should  be  sought  first.  If  no 
immediate  bed  is  available,  then  the  team  will  seek  to  use  another  bed  within  the 
Trust’s available bed-base. This will mean an admission to another area, different to 
that of the patient’s locality. The Trust acknowledges the risk associated with out of 
area (outside of the Trust’s footprint and bed base) admissions and since 2024 has 
reduced  our  Out  of  Area  admissions  significantly.  We  note  the  most  recent  Care 
Quality  Commission’s  report  into  the  use  of  the  Mental  Health  Act  and  the  risks 
associated  with  out  of  area  placements  and  waiting  too  long  for  admissions  where 
clinical  indicated  -  Monitoring  the  Mental  Health  Act  in  2024/25  -  Care  Quality 
Commission. 

Our patient flow team support the process for admission and will work hard to ensure 
a continuity of care where possible. The clinical decision to admit a patient is always 
based  on  the  nature  and  degree  of  the  presenting  risk  and  that  to  delay  an 
admission until a locality bed is available, may present the patient and their family an 
intolerable risk and further potential harms of waiting at home. Once the gatekeeper 
makes the referral, they will be told by patient flow team where the available bed is. 
Its  then  up  to  the  gatekeeper  to  have  that  conversation  /  assessment  with  the 
patient/patients family if a local bed isn't available for them and to assess and judge 
on balance the admission to the local bed or another within the Trust. Every borough 
now has a discharge coordinator and a patient flow senior practitioner who would be 
responsible for liaising with local teams to ensure safe admissions and discharges. 

The  Trust’s  Executive’s  agreement  is  that  we  use  beds  across  the  trust  footprint 
rather  than  at  a  locality  level  and  this  actually  supports  reduced  out  of  area  bed 
usage. This is a common position used by Mental Health NHS Trusts. As a Trust our 
principle is such that whilst we repatriate patients where clinically indicated, our data 
demonstrates that movement between inpatient wards increases length of stay by an 
average  of  50%  and  essentially  starts  the  patient’s  clinical  journey  again,  unsettles 
patients with change.  

As  a  Trust  however,  we  acknowledge  the  importance  of  patient  choice,  of  carer 
access to their loved ones and the importance for some patients of the continuity of 
care. To clearly articulate the process and to deliver consistency for patients we are 
therefore  reviewing  our  Standard  Operating  Procedures  for  the  process  of 

 
 
 
 
 
 
 
 repatriation  to  reflect  this.  The  development  of  the  SOP  will  be  overseen  by  the 
senior patient flow lead (clinical) which will be approved by the relevant group.  

Having provided the rationale for the way in which beds are allocated, and processes 
in place for management and oversight of this, we acknowledge that analysis within 
our investigation could have been different. PCFT have identified a Trust wide risk in 
relation to ‘…a lack of MDT and SME involvement in patient safety investigations’. 
The risk specified that ‘If the correct MDT representation in investigation teams and 
subject matter expert involvement does not provide structured involvement in 
investigation, then the investigations may not capture correct learning, may have 
poor actions set and the investigation may not lead to improved patient outcomes 
and appropriate response for patients, carers and staff’ (risk ID 2513. Score 
likelihood-3x consequence 4=12).  

Part of the mitigation of this risk involves the undertaking of a subject matter expert 
mapping  exercise  to  identify  appropriate  subject  matter  experts  within  the  Trust 
their  visibility  of 
(including  appropriate  medical 
appropriate  incidents  and  their  roles  and  responsibilities  in  regard  incident 
investigation.  A  subject  matter  expert  draft  framework  and  contact  sheet  has  been 
created and the contact sheet has been trialled within the Trust Quality teams when 
identifying  appropriate  investigation  teams  for  patient  safety  incident  investigations 
(PSIIs).  

representatives), 

reviewing 

The  subject  matter  expert  framework  is  under  further  review  from  all  stakeholders 
and due to be ratified in Clinical Effectiveness Group on 21st April 2026. The quality 
improvement  project  also  has  focussed  on  the  correct  visibility  within  the  incident 
reporting  system  for  all  subject  matter experts  which  is  also  due  to  be  launched  at 
the end of April 2026.  

The  Quality  teams  for  all  investigations  (Patient  Safety  Incident  Investigation;  PSII) 
have identified subject matter experts to support in the PSII process moving forward 
and  this  is  being  monitored  through  the  Network  Quality  and  Safety  Panels  and 
through Central Safety Summit.  

Following  the  risk  identified,  the  Central  Safety  Summit  has  refreshed  it’s  terms  of 
reference  in  line  with  Patient  Safety  Incident  Response  Framework  principles  to 
oversee the terms of reference and learning response lead undertaking the PSII, to 
ensure appropriate parties are able to support the learning response lead to assess 
all appropriate avenues in a patient’s care that has sadly come to harm. The terms of 
reference were ratified on 5th March 2026.  

The  Trust  is  committed  to  ensuring  that  our  investigation  reports  are  subject  to 
appropriate levels of critical scrutiny and this occurs at the Network Quality & Safety 
panels. During this process a range of professional and non-professional individuals 
have the opportunity to comment on the draft report. At the Mental Health Network’s 
Quality  &  Safety  panel,  lived  experience  expertise  is  provided  by  our  carers 
representative.  The  panel  also  has  a  medical  representative  who  is  a  consultant 
psychiatrist;  all  members  of  the  panel  provide  a  critical  challenge  to  the  quality  of 

 
 
 
 
 
 
 
 investigation reports. These actions should strengthen our processes and reduce the 
likelihood of instances where you have cause to raise concerns such as these again.   

2.  I am concerned that 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. 

Risk Assessment 

The Trust has identified a trust wide risk in relation to a ‘lack of assurance regarding 
consistent  high  quality,  collaborative  clinical  risk  assessment,  formulation  and 
planning’ (Risk ID 2496- score likelihood 4 x consequence 4= 16). This is following 
further  learning  from  incidents  such  as  this,  the  overarching  incident  profile,  audit 
and learning from suicide thematic analysis. 

As part of the mitigation of this risk, the Trust commenced a task and finish group in 
July  2025  to  review  our  current  risk  assessment  processes,  policies  and  PARIS 
forms  in  line  with  NHS  England  staying  safe  from  suicide  best  practice  guidance 
NHS  England  »  Staying  safe  from  suicide  which  focuses  on  a  full  biopsychosocial 
risk assessment and safety plan collaboratively created with patients and carers.  

The  Trust’s  PARIS  form  has  been  revised,  policy,  Standard  Operating  Procedure 
(SOP) and suite of guides to support staff to review the full context of patient’s needs 
and  goals  involving  all  appropriate  loved  ones  within  the  planning  process.  Within 
this form is a more explicit area for carers views. The launch of the new PARIS form 
is  due  on  1st  April  2026  and  the  policy  and  SOP  is  due  for  ratification  at  Clinical 
Effectiveness Group on 21st April 2026.  

We fully acknowledge the issue raised in the Prevention of Future Deaths report and 
are  committed  to  strengthening  organisational  systems  to  ensure  that  families, 
carers  and  loves  ones  are  able  to  disclose  sensitive  concerns  safely,  privately and 
promptly. We recognise that clear communication pathways for carers are essential 
to maintaining patient safety. 

Ward Rounds:  

It is known and understood that our current ward-round structures do not consistently 
provide  families  with  an  accessible,  confidential  mechanism  to  raise  concerns 
separate  from  the  main  discussion.  While  some  teams  have  developed  local 
solutions,  approaches  vary  and  a  more  reliable,  standardised  trust  wide  process  is 
required. 

As  part of  both  our  trust  wide  improvement  programme  and  the  national  Culture  of 
Care  Programme 
(2024–2026),  commissioned  by  NHS  England,  we  are 
implementing a comprehensive set of actions directly aligned to the concerns raised. 

 
 
 
 
 
 
 
 
 
 
 
 
 We  have  initiated  trust  wide  improvement  work  to  ensure  Multi-Disciplinary  Team 
(MDT) documentation reliably captures patient and carer views. The identified aims 
of this are to: 

•  ensure  mandatory  use  of  the  MDT  ward-round  document  for  every  ward 
round  and  completion  of  all  relevant  sections,  including  the  family/carer 
section. 

•  Undertake  a  trust  wide  review  of  MDT  forms  to  identify  improvements  that 

better support the inclusion of patient and carer perspectives. 

•  Piloting a new questionnaire for carers about the MDT process, to help shape 

further improvement. 

•  Consideration of how we will Audit this  

A standardised Pre-Ward-Round Form for Patients and Carers has been developed 
with the support of the Culture of Care programme, who provide quality improvement 
(QI)  coaches  and  lived  experience  support.  These  have  been  implemented  in  pilot 
sites  and  is planned  to  be  rolled out to  all  inpatient  wards.    The  form  enables both 
patients and carers to feel heard when they are not able to attend ward round or feel 
unable  to  speak  in  a  ward  round  due  to  feeling  uncomfortable  or  worrying  about 
damaging relationships with their loved ones.  
The form is able to explore: 

•  Changes noticed in behaviour 
•  Concerns about risk or relapse 
•  Medication observations, 
•  Home environment considerations 
•  Questions around discharge planning 

Forms  can  be  submitted  discreetly  ahead  of  ward  rounds,  ensuring  information  is 
reviewed  confidentially  by  the  MDT,  even  when  carers  are  unable  to  attend  in 
person.  This  supports  collaborative  partnership  working  and  meets  the  Triangle  of 
Care principles.  

In  addition  to  this,  we  are  strengthening  the  expected  standards  through  which 
carers  can  share  risk-related  information  outside  the  main  ward-round  or  visiting 
environment,  this  includes  an  ability  to  contact  the  nurse-in-charge  or  delegated 
clinician privately, dedicated email/telephone routes for sharing concerns, the option 
to  request  a  short  one-to-one  discussion  with  the  MDT  outside  of  the  formal  ward 
round.  All  information  is  documented  in  the  PARIS  carer  space,  ensuring  visibility 
across the MDT. 

This  will  be  achieved  through  information  leaflets  that  have  been  reviewed  and 
updated.  These  have  been  printed  and  shared  with  wards  from  4th  March  2026 
onwards.  

As part of the trust wide Triangle of Care work, Standard 3: Confidentiality is being 
actively  worked  on.  The  Triangle  of  Care  is  a  nationally  recognised  framework 
developed  by  the  Carers  Trust  to  strengthen  collaboration  between  service  users, 
carers,  and  mental health professionals.  It  is  built  on  six key  standards  that  ensure 
carers  are  identified,  included,  informed,  and  supported  throughout  the  care 

 
  
 
 
 
 
 
 pathway. A working group has been established consisting of our Carer Experience 
Lead,  Involvement  Team  Manager,  Information  Governance  Lead  and  Carers  with 
lived experience. The group is updating the information-sharing section of the Trust 
confidentiality  policy,  guidance  for  staff  and  carers  on  confidentiality  and  revising 
Carer  awareness  training  content  to  ensure  it  includes  the  policy  update  and  staff 
guidance.  

In 2025 we developed a new Carer Lead Role, working across the Trust, to support 
the development of Triangle of Care. For 2026 an annual calendar has been devised 
to deliver a full self-assessment against the 6 standards, which will determine good 
practice  and  areas  for  development  and  will  inform  trust  wide  improvement  work 
streams.  

is  being  shared 

Alongside  this,  we  are  strengthening  how  information  from  carers  is  captured, 
recorded,  and  used.  Learning 
the  care  planning 
improvement work stream to shape improvements to the PARIS Carer Space. A trust 
wide  review  of  the  PARIS  Carer  Space  is  under  way  to  improve  visibility,  usability 
and guidance, and monthly audits will begin once the revised system is in place. In 
addition  to  this,  guidance  is  being  developed  to  support  staff  on  what  elements  of 
carer engagement should be captured. A new care-planning PARIS form will go live 
the  end  of  April  2026,  embedding  clearer  documentation  of  carer 
toward 
involvement. 

through 

Another way in which we will monitor this is via our  ward accreditation programme, 
which  has  been  developed  by  the  Deputy  Director  of  Nursing,  Quality  and  AHP’s 
with Board level oversight, commencing in April 2026. As part of this, inpatient wards 
will  be  assessed  against  agreed  standards,  including  documentation,  patient  and 
carer  involvement,  and  communication  processes.  While  this  is  too  late  to  change 
the  care  provided  to  Ms  Fury  and  the  experience  of  her  family,  I  hope  that  this 
provides  assurance  that  the  Trust  is  committed  to  developing  its  assurance 
mechanisms and improving the quality of care.  

Following  review  during  2025,  Carer  Awareness  Training  is  now  mandatory  for  all 
frontline  staff.  In  our  training  carer  involvement  and  support  is  asserted  with 
exploration of how understanding helps the service user toward a better outcome. It 
acknowledges that carers often have more knowledge and experience of the needs 
of the person they care for than anyone else, but also that even without consent, we 
can and should listen to carers.  

Conclusion 

We recognise and share the coroner’s concerns regarding the need for clear, reliable 
and confidential mechanisms for families and carers to raise risk-related information. 
The  actions  outlined  in  this  response  including  strengthened  MDT  documentation 
processes,  the  introduction  of  patient  and  carer  submission  forms,  enhanced 
ward-round  communication  pathways,  improvements  to  PARIS  functionality,  the 
ward peer-review programme, and mandatory carer-awareness training represent a 
comprehensive and sustainable trust wide approach.  

 
 
 
 
 
 
 
 Together,  these  measures  are  designed  to  improve  the  consistency,  transparency 
and quality of carer engagement and to reduce the likelihood of similar risks arising 
in  the  future.  We  remain  fully  committed  to  embedding  these  improvements  and 
maintaining robust oversight to ensure the safest possible care for our patients and 
their loved ones. 

I hope that the information within this response has provided you with the assurance 
that you were seeking in relation to learning from these events. Should you require 
any  further information  or clarification  on  the  details  within  this letter, please do  not 
hesitate to get in touch with me again.  

Yours sincerely 

Chief Executive