Manchester North

Coroner Area
Reports: 131 Earliest: Feb 2013 Latest: 4 Feb 2026

79% response rate (above 63% average).

Response Status
Responded 103 Historic 28
AI Classification
Action Taken 38%
Action Planned 37%
Noted 26%
Disputed 0%
Based on 176 classified responses
Top Categories
Hospital Death (Clinical Procedure… (48) Other related deaths (23) Community health care and emergenc… (20) Mental Health related deaths (19) Suicide (from 2015) (16)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: +11 reports · +16pp response rate
vs national average: +47 reports · +16pp response rate
131 results
Nadine Brookes-Walker
All Responded
2015-0463 16 Nov 2015
Teva UK Ltd
Product related deaths
Concerns summary (AI summary) Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading to patient misuse.
Noted (AI summary) Takeda believes the existing patient information leaflet adequately addresses the issue of damaged patches, and they have requested a review to determine if changes are needed; the MHRA also reviewed product information for fentanyl patches in April 2015.
Guy Robinson
All Responded
2015-0432 12 Nov 2015
Pennine Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical psychology access, disadvantaging vulnerable patients.
Action Taken (AI summary) The Trust reviewed and revised the Absence Without Leave (AWOL) policy, including additional guidance and a flowchart, and implemented it Trust-wide on April 1, 2015; Psychological therapies are available on the ward via referral from a Consultant Psychiatrist or nursing staff.
Emma Waring
All Responded
2015-0383 22 Sep 2015
Department for Communities and Local Go…
Other related deaths
Concerns summary (AI summary) The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
Action Taken (AI summary) Rochdale Boroughwide Housing has delivered domestic sprinklers in properties occupied by some of their most vulnerable tenants and is working with Rochdale Council’s Strategic Housing Service on a project designed to offer additional support to those identified as hoarders.
Joyce Hartford
All Responded
2015-0279 15 Jul 2015
Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.
Action Taken (AI summary) Pennine Acute Hospitals NHS Trust has been undertaking a review of current documentation and monthly audits of nursing metrics on Ward T7, and implemented measures trust-wide. They are also reviewing and ratifying nursing documents to implement a more rigorous governance process.
Colin Moulton
Partially Responded
2015-0267 10 Jul 2015
Department of Health and Social Care Messrs. Weightmans North West Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary) Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.
Noted (AI summary) The Department of Health acknowledges the concerns, noting local resolution and NWAS response. They provide national context including handover procedures, NHS England review of urgent and emergency care, enhanced summary care records, and the NMC's role in regulating nurses.
Dorothy McDermott
Historic (No Identified Response)
2015-0266 10 Jul 2015
Department of Health and Social Care Littleborough Care Home Pennine Care Trust +1 more
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Toni Piel
Partially Responded
2015-0263 9 Jul 2015
Department of Health and Social Care Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.
Noted (AI summary) The Department of Health acknowledges the concerns and Pennine Acute Hospitals NHS Trust's review, highlighting actions to improve management, supervision, assessment, and discharge of head injury patients. They note the work of Patient Safety Collaboratives, NICE guidance, and the Falls and Fragility Fracture National Audit Programme.
Baby Olsberg
All Responded
2015-0177 7 May 2015
Department of Health and Social Care National Institute for Health and Care … Royal College of Obstetricians +1 more
Child Death (from 2015)
Concerns summary (AI summary) Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.
Noted (AI summary) The RCOG acknowledges the concerns but refers to their guideline which aligns with the National Screening Committee's recommendation against routine screening for GBS. NICE acknowledges the concerns but refers to the UK National Screening Committee's current position that screening for GBS is not supported by the evidence, and that NICE's guideline does not recommend routine screening for GBS. The Department of Health acknowledges concerns about GBS screening but states that the UK National Screening Committee does not currently support universal screening due to insufficient evidence. They note that the NSC will be reviewing the evidence in 2015/16.
Thomas Beaty
Partially Responded
2015-0130 31 Mar 2015
Department of Health and Social Care Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and Gyna…
Child Death (from 2015)
Concerns summary (AI summary) Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', and the term 'gentle' traction was misleading; furthermore, it's difficult for Trusts to change guidance until the RCOG issues changes/improvements.
Noted (AI summary) The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG. The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The guideline was amended to state to abandon the procedure when there is no descent even after the 1st pull.
James McManus
All Responded
2015-0097 13 Mar 2015
Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to thrombolytic therapy and massive blood loss.
Action Taken (AI summary) The Trust drafted a new Thrombolysis Policy, circulated it on the Trust Intranet, and provided training sessions to Critical Care staff. They are also developing a training presentation and reviewing the Adult Critical Care Operational Policy.
Mohammed Yousaf
Historic (No Identified Response)
2015-0056 16 Feb 2015
Department of Health and Social Care Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and Gyna…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.
Anne Horner
Partially Responded
2015-0047 11 Feb 2015
Bury Metropolitan Borough Council Care Quality Commission Department of Health and Social Care +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts disabled toilet design guidance.
Action Taken (AI summary) The CQC requested and received information from the provider, who confirmed the toilet in question has been decommissioned. They also inspected the home on an unannounced basis.
Janette Insley
All Responded
2014-0574 16 Dec 2014
Department of Health and Social Care
Mental Health related deaths
Concerns summary (AI summary) Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, leaving vulnerable patients without support post-discharge.
Noted (AI summary) The Department of Health acknowledges the concerns but states that the issues raised are most appropriately addressed at a local level, while also noting national investment in psychological therapies and access targets.
Anthony Huggan
All Responded
2014-0517 26 Nov 2014
Bury Metropolitan Borough Council
Other related deaths
Concerns summary (AI summary) The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.
Noted (AI summary) The council provides contextual information about commissioned substance misuse services and describes the services available, but does not outline specific changes in response to the concerns.
Myra Goldman
Partially Responded
2014-0490 10 Nov 2014
Health and Safety Executive Spaces and Places Limited British Standards Institute
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being easily removed and ensure even load distribution.
Action Planned (AI summary) BSI has forwarded the coroner's letter to the chairman of the standing committee responsible for BS 1722-12:2006 to be included as part of their review and has asked the chairman to consider whether the proposed review of this Standard may be accelerated. The reviewed Standard is expected to be published in 2016.
Eliza Bashir
Partially Responded
2014-0461 24 Oct 2014
Central Manchester University Hospitals… Department of Health and Social Care Oldham Metropolitan Borough Council
Hospital Death (Clinical Procedures and medical management) related deaths Product related deaths
Concerns summary (AI summary) Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better guidance for such incidents.
Action Planned (AI summary) The Department of Health will share information on button battery risks with health visitors, school nurses, and child health leads at Public Health England's regional centers and will contact the National Social Partnership Forum to raise awareness of the issues.
Lucasz Lewandowski
Partially Responded
2014-0445 15 Oct 2014
Greater Manchester Police Green Surgery MEDACS Healthcare
Community health care and emergency services related deaths
Concerns summary (AI summary) The report identifies concerns regarding the timeliness of the police response, communication gaps between agencies, use of the Mental Health Act due to resource constraints, and a lack of correspondence from a psychiatric practice with the patient's GP.
Action Taken (AI summary) A protocol is being implemented for psychiatric practice, including risk assessment and communication with healthcare professionals, to be reviewed regularly. The referral system is being improved to flag occurrences like missed appointments, and the surgery will encourage a more inclusive approach from clinicians in patient care. The Operational Communications Branch (OCB) has reviewed its Escalation Policy, issued individual management advice to staff involved in the incident, and recirculated the policy with emphasis on accurate recording. The Custody Branch has circulated the MEDACs Escalation Policy to all staff and included it in its October 2014 Custody Branch Orders.
Derek Hawkins
Historic (No Identified Response)
2014-0425 30 Sep 2014
Not Listed
Other related deaths
Concerns summary (AI 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.
Georgina Taylor
Historic (No Identified Response)
2014-0328 9 Jul 2014
Department for Transport Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Muriel Naylor
Partially Responded
2014-0329 8 Jul 2014
Backhouse Jones Department for Transport Fentons +1 more
Road (Highways Safety) related deaths
Concerns summary (AI summary) Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander Dennis Enviro 400 bus design may have contributed to passenger injury.
Action Planned (AI summary) The Department for Transport has raised the issue of bus seat design with bus manufacturers and plans to encourage them to adopt additional safety features. They also intend to raise the issue within the international technical group responsible for pan-European construction requirements.
Beryl Brinkman
All Responded
2014-0314 2 Jul 2014
Rochdale Metropolitan Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and pedestrians.
Action Planned (AI summary) Rochdale Borough Council plans to remove parking bays and introduce 'At Any Time' restrictions on the A58 to improve visibility, with implementation expected within the next four months. They have no record of prior complaints about the location.
Sindy Woodhall
All Responded
2014-0292 1 Jul 2014
Department for Business Innovation and … Oldham Metropolitan Borough Council Public Health England +1 more
Other related deaths
Concerns summary (AI summary) A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that poses a health risk.
Noted (AI summary) The Trading Standards Institute states that it is a professional body without powers to get involved and that the matter is for local authority trading standards departments. It highlights a workforce survey demonstrating severe cuts to trading standards services. Oldham Council will ensure the trader concerned is visited and spoken to by officers on the safety/health implications and moral obligations related to addictions, and about sales to minors of age-restricted products. Public Health England has been working with the Department of Health to restrict access to volatile substances, has refined information collected on VSA as part of the National Treatment Monitoring System, and is looking to improve national collection of drug-related mortality data. The Department of Health acknowledges the concerns and refers to the response from Public Health England, expressing full support for their views and advice.
Mark Bartholomew
Historic (No Identified Response)
2014-0237 21 May 2014
Broudie Jackson Canter DAC Beachcroft Department of Health and Social Care +1 more
Mental Health related deaths
Concerns summary (AI 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.
Samiyo Farah
Partially Responded
2014-0202 30 Apr 2014
Affinity Healthcare Ltd Central Manchester University Hospitals… Department of Health and Social Care +3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Noted (AI summary) The Department of Health acknowledges the concerns raised and highlights existing NICE guidance on self-harm and a government suicide prevention strategy. They note that Trusts develop their own transfer protocols with the private sector and refer to existing guidance from the Royal Pharmaceutical Society on patient transfer.
David Chatburn
Partially Responded
2014-0126 18 Mar 2014
Department of Health and Social Care Pennine Care NHS Trust Rochdale Heywood and Middleton Clinical… +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Noted (AI summary) The Department of Health acknowledges the concerns raised regarding the patient's care and referral process, and notes that patients with a mental health condition have the same legal rights as physical health patients regarding choice of provider.