Manchester North

Concerns summary A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.

Concerns summary There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate midwife training.

Concerns summary A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.

Concerns summary There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.

Concerns summary The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in police response, and limited integration with NHS mental health pathways.

Concerns summary Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term carers and social services.

Concerns summary Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a serious risk to life.

Concerns summary Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.

Concerns summary Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability team.

Concerns summary Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between consultants, and lack of awareness of prior admissions or community support.

Concerns summary The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient safety risks and widespread role confusion.

Concerns summary Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs remain incomplete months after recommendation.

Concerns summary District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.

Concerns summary Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum is insufficient in these critical areas.

Concerns summary There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, leading to inconsistent policies and practical instructions for staff.

Concerns summary A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent oversight for rectifying systemic issues.

Concerns summary UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered for self-harm, with no mandatory notification or welfare checks before release.

Concerns summary Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.

Concerns summary A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying legal frameworks for individuals with chronic alcohol dependence, risking their protection.

Concerns summary Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.

Concerns 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.

Concerns summary Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged absences, and a lack of standard operating procedures and audit for decision-making.

Concerns summary Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.

Concerns summary The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests led to a missed diabetes diagnosis.