Linda Fury: Prevention of future deaths report

The Chief Executive, Pennine Care NHS Foundation Trust    

I am Chris Morris, Area Coroner for Greater Manchester (South). 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and  regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7  http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

On 22^nd May 2025, an inquest was opened by Alison Mutch OBE, Senior Coroner for Greater  Manchester (South) into the death of Linda Fury who was found dead at home on 3^rd May 2025 aged 62 years. The investigation concluded with an inquest which I heard on 12^th and 13^th  January 2026. 

A post-mortem examination determined Linda died as a consequence of hanging. 

At the end of the inquest, I recorded a narrative conclusion, finding that Linda completed  suicide having been unsafely discharged from hospital without provision for step-down care.  

Linda Fury was found to have died at home on 3^rd May 2025 having suspended herself by the  neck with a ligature with the intention of causing death. 
 
Linda had a long history of severe and enduring mental illness and had been diagnosed with bipolar affective disorder. Linda had been admitted to hospital on numerous previous  occasions and was under the care of the Community Mental Health Team.  
 
Following a significant deterioration in Linda’s presentation which included what members of  her treating team regarded as self-neglect and the formulation of plans to end her life, Linda  was admitted to Taylor Ward at Tameside General Hospital on 11^th April 2025 under s2 Mental Health Act 1983 (as amended) as no beds were available more locally.  
 
In hospital, Linda took medication under supervision and participated to a limited extent in  ward-based activities whilst consistently voicing her wish to be discharged. Linda was granted  limited s17 leave but did not make use of this. Family members sought to convey their concerns that Linda was not getting better and would remain at risk if not in hospital. 
 
At a ward round on 28^th April 2025, the multidisciplinary team determined there was no longer  any justification to continue Linda’s detention under the Mental Health Act 1983 (as amended) but in doing so failed to:

1. Seek the views of her usual consultant 
2. Substantively involve Linda’s Care Co-ordinator in discharge planning throughout the  admission 
3. Critically consider and evaluate what Linda was telling them in the light of collateral  information provided by family members and contained within medical records as to  her most recent deterioration and previous instances of non-compliance with  medication in the community 
4. Speak with family members privately to fully understand their concerns 
5. Consider utilising a period of home leave under s17 Mental Health Act 1983 (as  amended) to inform whether or not detention remained indicated under legislation and Acknowledge
6. that Linda was unlikely to agree to any step-down care in the event the  section was rescinded.  
 
As such, the section was rescinded, and Linda was discharged from hospital in circumstances which were unsafe. 
 
Upon discharge, Linda returned to the care of the Community Mental Health Team and her Care Co-ordinator reviewed her within 72 hours of discharge on 30th April 2025 to discuss care and  safety planning. Whilst the Care Co-ordinator considered Linda appeared positive and denied  any active suicidal thoughts, family members remained concerned that she was not attending  to even basic self-care once out of hospital. On 2nd May 2025, this was communicated by e-mail to a member of Trust staff who promptly notified the Care Co-ordinator who in turn  endeavoured to speak to Linda who was unwilling to speak with her and sought to speak to  Linda’s usual consultant who was unavailable. No further Mental Health Act assessment took  place prior to Linda’s death.  

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.  

In my opinion action should be taken to prevent future deaths and I believe you and your  organisation have the power to take such action.   

You are under a duty to respond to this report within 56 days of the date of this report, namely  by 17^th March 2026 I, the coroner, may extend the period.  

Your response must contain details of action taken or proposed to be taken, setting out the  timetable for action. Otherwise, you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner, together with members of Linda’s family  and Greater Manchester Integrated Care Board and the Care Quality Commission who may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted or summary form. She  may send a copy of this report to any person who he believes may find it useful or of interest.  You may make representations to me, the coroner, at the time of your response, about the  release or the publication of your response by the Chief Coroner.