Manchester North

Concerns summary Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate practitioner-detainee interaction, compromised effective risk management. A manager's review also lacked critical analysis or learning identification.

Concerns summary Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen testing for under 5s, creates diagnostic delays.

Concerns summary Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including attempted suicide.

Concerns summary Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff lacked mandatory refresher training.

Concerns summary The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.

Concerns summary There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.

Concerns summary There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.

Concerns summary There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure to progress critical steps like a warrant, delaying further intervention.

Concerns summary The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and tenant certificates are misleading.

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 Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.

Concerns summary The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.

Concerns summary The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.

Concerns 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.

Concerns summary GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.

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 The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.

Concerns summary The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their injury risk.

Concerns summary A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of an internal review, indicate a missed opportunity for learning.

Concerns summary A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have prolonged life.

Concerns summary Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.

Concerns 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.