Manchester North

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 The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.

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 The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.

Concerns summary Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and concerns over 'Hospital at Night' co-ordinators' qualifications for medical prioritisation.

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 GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.

Concerns summary Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due to an apparent lack of awareness regarding their complex needs.

Concerns summary Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a repeated concern due to commissioning issues and long waiting lists.

Concerns summary The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.

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 Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by raising the threshold for defect investigation and repair.

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 Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis and treatment.

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 An illuminated advertising board and overhanging tree canopies dangerously obstructed visibility for both pedestrians and drivers. Reduced tree lopping in the area was also a concern.

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 Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a risk to patient safety.

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 There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to future deaths.

Concerns summary Systemic failures included inadequate antenatal GBS screening and prophylaxis, alongside hospital issues such as poor communication, protocol non-adherence, missed examinations, incorrect early warning scores, and insufficient staff training.

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 Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for inpatient emergency calls, and a critical absence of inpatient clinical psychology services.