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
Derrick Rivers
Historic (No Identified Response)
2014-0104 10 Mar 2014
Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council
Care Home Health related deaths
Concerns summary (AI summary) The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Victoria Meppen-Walter
Historic (No Identified Response)
2014-0083 27 Feb 2014
Department of Health and Social Care Medicines and Healthcare Products Regul…
Product related deaths
Concerns summary (AI summary) Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of its misuse.
Barry James Lewis
All Responded
2013-0314 26 Nov 2013
Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate night staffing.
Action Taken (AI summary) The hospital updated emergency airway packs in A&E, ensuring availability of 'large' instruments. The role of night nurse practitioners was reviewed to ensure involvement in direct care of critically ill patients.
Lisa Jane Clayton
Historic (No Identified Response)
2013-0309 21 Nov 2013
Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chad… Savilles Management Resources (as the L… +1 more
Mental Health related deaths
Concerns summary (AI summary) Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight serious failures in suicide prevention measures.
Derek Brierley
Partially Responded
2013-0244 20 Aug 2013
England & Wales Pennine Acute Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for competence and training.
Action Taken (AI summary) The hospital has re-drafted the pathway for managing urinary retention, shared it with A&E staff, initiated a training program for inserting catheters outside of the urology division, and will continue to monitor catheter-related incidents.
Jack William Partington
Partially Responded
2013-0308 21 Feb 2013
Department of Health Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national policies for managing paralysing agents or neonatal ventilation.
Noted (AI summary) The Department of Health believes the issues are local and should be addressed by the Trust, noting existing guidance and the role of NHS England, but will notify the British Association of Perinatal Medicine.