Manchester North

Concerns summary The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.

Concerns summary Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug checks or risk assessment updates. Welfare checks were inadequate due to staff shortages and poor escalation.

Concerns summary Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.

Concerns summary A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs from accessing a complete list of previous prescriptions.

Concerns summary Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need to explore all options, leading to unconsulted and potentially inappropriate treatment decisions.

Concerns summary Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for anaemia management and iron infusion observation were not followed, compounded by unrecorded pharmacist-clinician discussions.

Concerns summary A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means many are unaware of risks from older blinds, leading to child strangulation deaths.

Concerns summary Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when cardiac arrest officially begins.

Concerns summary The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.

Concerns summary The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.

Concerns summary Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and management.

Concerns summary Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect patient scores and policy non-adherence.

Concerns summary A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of custody protocols for controlled drugs pose risks.

Concerns summary Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental health services are also unsafely raising referral thresholds.

Concerns summary Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.

Concerns summary The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for medical assistance.

Concerns summary General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially impacting patient outcomes.

Concerns summary The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by a lack of independence and transparency due to being conducted by directly involved staff.

Concerns summary Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for children playing near the water.

Concerns summary The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis and treatment.

Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.

Concerns summary There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with dissemination, application, and applicability, particularly concerning informed consent.

Concerns summary The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.

Concerns summary Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle restraint protection or removal, posing a highway safety risk.

Concerns summary Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, hindering timely intervention and oversight.