Manchester North

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 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 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.

Concerns summary Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly led to inadequate risk assessments and missed opportunities for mental health intervention.

Concerns summary Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.

Concerns 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.

Concerns summary The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround times, leading to significant delays.

Concerns summary No specific safety concerns or systemic failures were detailed beyond the general mention of "Serious Further Offence Reviews" needing to be conducted.

Concerns summary Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.