Pennine Care NHS Foundation Trust
PFD Addressee
Reports: 48
Earliest: Aug 2013
Latest: 20 Jan 2026
100% 2-year response rate (above 83% average). 55% of classified responses show concrete action taken.
PFD Reports
27 resultsLinda Fury
All Responded
2026-0029Deceased
20 Jan 2026
Manchester South
Suicide
Concerns summary (AI summary)
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.
Action Taken
(AI summary)
The Trust has made Carer Awareness Training mandatory for all frontline staff and implemented strengthened MDT documentation, patient and carer submission forms, enhanced ward-round communication pathways, and improvements to PARIS functionality to improve carer engagement and reduce risks.
Derek Crowther
All Responded
2025-0500
9 Oct 2025
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.
Action Planned
(AI summary)
The Trust is developing an eObs app with offline capabilities, planned for pilot testing in April 2026, to improve patient monitoring and data integrity. They will also improve communication with staff regarding such developments.
David Power
All Responded
2024-0499
18 Sep 2024
Greater Manchester South
Community health care and emergency services related deaths
Mental Health related deaths
Suicide
Concerns summary (AI summary)
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.
Action Taken
(AI summary)
Pennine Care Trust has addressed concerns regarding referral pathways by reiterating the importance of referring cases to SPOE meetings, updating the HTT SOP, and implementing monthly audits of discharges and referrals. The HTT SOP explains the new processes for referrals to the Living Well and TT SPOE, plus other agencies.
David Thompson
All Responded
2024-0443
12 Aug 2024
Manchester North
Mental Health related deaths
Concerns summary (AI summary)
The Priory Dorking's incident review indicated no My Safety Plan was commenced or completed prior to discharge, no engagement with the local Home Based Treatment Team occurred, and there was no consultation with consultants from the Priory in Altrincham; consultant-to-consultant communication was also absent across NHS and private care.
Action Taken
(AI summary)
Pennine Care NHS Foundation Trust outlined existing procedures for consultant communication, out-of-area placements, and quality assurance in private hospitals. They highlighted the role of Out of Area Practitioners in monitoring inpatient stays and linking with providers and consultants. The Priory Group outlined several actions taken in response to the coroner's concerns including audits of patient records, reminders to staff regarding procedures, and reviews of policies related to patient safety plans, discharge processes, and communication with families. They will continue monthly audits and share outcomes in clinical governance reports. NHS Greater Manchester Integrated Care has implemented a Multi-Agency Discharge Event (MaDE) process for overseeing Out of Area Placements (OAPs). Since April, they have seen a significant decrease in the amount of patients admitted to 'stop' providers.
Elizabeth McCann
All Responded
2024-0288
29 May 2024
Manchester South
Other related deaths
Concerns summary (AI summary)
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.
Noted
(AI summary)
The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.
Donna Donnellan
All Responded
2023-0493
30 Nov 2023
Manchester North
Other related deaths
Concerns summary (AI summary)
A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.
Action Taken
(AI summary)
The Trust has finalised and ratified the policy 'Management of Medical Emergencies in Adult Patients with Eating Disorders' and shared it with Pennine Care NHS FT. The policy clarifies roles, responsibilities, and referral pathways. The Trust has worked with Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.
Teresa Chmielek
All Responded
2023-0470
24 Nov 2023
Manchester North
Suicide
Concerns summary (AI summary)
The coroner raises concerns about the screening process for mental health referrals, including inadequate risk assessment, lack of multi-team discussion, and absence of direct contact with the deceased before referral rejection; there is also no standard operating procedure or audit system for referral management.
Action Taken
(AI summary)
The trust integrated the Single Point of Entry (SPoE) function into the Home Intensive Treatment Team (HITTS) and reviewed the Multidisciplinary Team (MDT) meeting to record all decisions on the electronic patient record. A Standard Operating Procedure on how referrals into the SPoE Older Adults should be managed has been drafted and is currently under final review.
Carl Thompson
All Responded
2023-0157
16 May 2023
Manchester South
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary (AI summary)
Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.
Action Taken
(AI summary)
The trust has revisited its investigation report to support review of action plans, re-established a Just Culture meeting, is considering updated training for investigation authors, established a PSIRF implementation group, made patient safety training available online, and planned to share learning slides around inquest preparation.
Drew Howe
All Responded
2023-0155
15 May 2023
Manchester South
Mental Health related deaths
Suicide
Concerns summary (AI summary)
The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.
Action Planned
(AI summary)
The Trust will address the coroner's concerns by several actions including; offering awareness sessions, trust wide learning, case reflection with teams and ensuring assessment information is shared between services. They will also explore training around understanding trauma.
Sarah McGarrigle
All Responded
2022-0290
19 Nov 2022
Manchester North
Alcohol, drug and medication related deaths
Action Planned
(AI summary)
The trust outlines actions taken and planned including; sharing learning from the inquest, increasing access to safeguarding professionals, implementing PARIS for electronic patient records, distributing the Oldham Adults Safeguarding Board Self-Neglect toolkit and a recommendation to the Oldham Safeguarding Adult Partnership Board to develop a multi-agency protocol.
Susan Regan
All Responded
2022-0256
17 Aug 2022
Manchester South
Mental Health related deaths
Suicide
Concerns summary (AI summary)
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown in properly recording and communicating the care plan with the family.
Action Taken
(AI summary)
Pennine Care NHS Foundation Trust has re-established supportive forums, established a Patient and Carer Involvement team, and developed a pathway for Lived Experience members to participate in paid roles, and implemented an updated information pack for carers. Also, HTT now has a substantive Consultant Psychiatrist in place and the MDM's have been adjusted to ensure regular attendance of the consultant.
Angela Frost
All Responded
2021-0183
28 May 2021
Manchester North
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care and risk planning.
Action Planned
(AI summary)
The Trust has drafted a process for requesting second opinions from consultant psychiatrists, healthcare professionals, patients, families, and carers which will be submitted to the Trust's Quality Group for scrutiny and sign-off and implemented across Pennine Care NHS Foundation Trust's services. They are also working to improve adherence to the Triangle of Care standards, including surveys, workshops, and relaunching the program trust-wide.
Sean Owen
All Responded
2020-0215
23 Oct 2020
Manchester North
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.
Action Taken
(AI summary)
The Clinical Director for the Borough has established a process that ensures that all new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries and a senior doctor checks the documentation. Pennine Care NHS Foundation Trust has issued all new trainees with laptops, and documentation review is now incorporated in trainees’ weekly supervision.
Gordon Fenton
All Responded
2020-0102
23 Apr 2020
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, hindering optimal integrated care.
Action Planned
(AI summary)
A new joint Standard Operating Procedure (SOP) is being developed between PCFT and TGICFT to improve shared care, with contingency plans including increased communication and guidance. The teams on Summers and Hague Wards are using Digital Health for advice and the inquest's outcome will be presented at a Tameside & Glossop CCG meeting. A new joint Standard Operating Procedure (SOP) is being developed between TGICFT and PCFT regarding shared care for patients with psychiatric and acute medical problems. Once approved, self-directed training will be carried out by all staff and the updated process and outcome of Mr Fenton's inquest will be presented at Divisional Governance Meetings.
Allan Cunliffe
All Responded
2020-0099
22 Apr 2020
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical observation recording, and staff confusion regarding oxygen administration and mandatory training.
Action Planned
(AI summary)
Pennine Care NHS Foundation Trust will circulate a 7-minute briefing to raise awareness of physical health and acute illness management training, and staff's responsibility to maintain compliance. The training covers assessment of deteriorating patients, including airway management and oxygen administration.
Muhammed Haleem
All Responded
2019-0316
24 Sep 2019
Manchester (North)
Emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.
Action Planned
(AI summary)
NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system.
Ian Bromley
All Responded
2019-0307
19 Sep 2019
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide
Concerns summary (AI summary)
The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was inconsistently effective due to varying individual approaches and workloads.
Action Taken
(AI summary)
The Home Treatment Team has an Advanced Practitioner and the team manager is now a qualified prescriber. The Home Treatment Team has acquired additional CCG funding to extend the medical cover, with the Trust Medical Director is providing part-time cover to the team.
Conor Crutchley
All Responded
2019-0032
28 Jan 2019
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention issues.
Action Taken
(AI summary)
The trust details steps taken to improve early intervention services, including funding an additional psychological therapist and training staff in family intervention. The management of the waiting list for psychological interventions has been reviewed and now includes a process of making monthly contact with individuals on the waiting list.
Gregory Rewkowski
All Responded
2018-0411
28 Dec 2018
Manchester (North)
Community health care and emergency services related deaths
Concerns summary (AI summary)
The coroner notes practical difficulties for nurses raising welfare concerns on an acute ward, unclear reasons for the clinical lead's inaction, failure to escalate to a senior manager, restrictions on ward telephones, limited NWAS investigation, and concerns about police handling of Section 136 cases.
Action Planned
(AI summary)
Pennine Care NHS Trust has increased staffing levels, issued a memo to staff for greater awareness of the requirement to seek support from On-Call managers, and are planning to update policies and practice on how to respond to information in the public domain in the most effective manner. Greater Manchester Police will participate in a task and finish group and is represented at senior level on the GM Health and Justice Operational Delivery Group and the Greater Manchester Health and Justice Board, with focus on reviewing multi-agency protocols, shared resources, and formal joint working action plans. The partnership has developed a pan-GM protocol for response to mental health crisis, aiming for a common understanding of roles and responsibilities, a shared view of risk, and improved communication.
Matthew Craven
All Responded
2018-0365
22 Nov 2018
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.
Action Planned
(AI summary)
The Trust will develop an escalation process for rejected referrals in Stockport, clarify and communicate target timescales for routine appointments, implement an escalation protocol for disagreements on face-to-face appointments, and co-locate alcohol liaison practitioners with the all-age liaison mental health service by the end of February 2019.
Paul Allan
All Responded
2018-0251
25 Jul 2018
London (Inner) West
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap in mental health support.
Action Planned
(AI summary)
The Trust will circulate a reminder to all staff regarding the CPA policy and how to access it. Pennine Care NHS is a signatory to the Greater Manchester Strategic suicide prevention strategy and will work collaboratively to bring the NCISH recommendations to practice.
Adrian Jennings
All Responded
2018-0111
19 Apr 2018
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.
Noted
(AI summary)
Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high levels of needs like Mr. Jennings as they consider them covered by existing secondary care services. They will follow up on the other concerns with Pennine Care Foundation Trust through quality and performance monitoring. The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar programme. It also mentions the Healthcare Safety Investigation Branch's investigation into care for patients with mental health problems in emergency departments. NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals (updated Emergency Department module in Lorenzo with mandatory data collection fields).
Catherine Kennedy
All Responded
2018-0075
13 Mar 2018
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.
Action Taken
(AI summary)
The Situation, Background, Assessment, Recommendation (Decision) tool is currently taught within several courses and the Organisation Learning and Development have been supplying learners with a copy of the A5 SBAR(D) telephone pads, to write on as handing over. The organisation has developed an action plan relating to the points raised during the inquest, which includes the re-design of Community Mental Health Services and an apology to Ms Kennedy's brother. The actions described in the letter are incorporated in an enclosed action plan.
David Hamilton
All Responded
2017-0180
5 Jun 2017
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.
Action Planned
(AI summary)
Healthy Minds service provides treatment options and offers advice. A log is kept on the system and patients can be "stepped up" during therapy. GPs can request consideration for assessment by a psychiatrist. The practice escalated concerns about mental health support to the Clinical Commissioning Group. They escalated the matter to the Mental Health Clinical Lead and Head of Mental Health regarding the referral pathway to psychiatrists and the lack of sleep clinics.
Sandra Brotherton
All Responded
2016-0400
8 Dec 2016
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan was not clearly documented or provided, and an urgent consultant psychiatrist appointment was difficult to obtain.
Action Taken
(AI summary)
The Trust has updated its audit tool to include questions about contingency plans for carers, reminded care coordinators to document these plans, and developed a 7-minute briefing on this topic for community mental health teams. The Trust's CPA policy was updated to describe the role of the Consultant Psychiatrist and a 7-minute briefing on responding to crisis calls has been shared with all community based mental health teams in the Trust.