Manchester South

Concerns summary Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for high-risk patients, created dangerous gaps, particularly over weekends.

Concerns summary A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing the risk of lives being lost due to organ unavailability.

Concerns summary NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.

Concerns summary Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.

Concerns summary A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal care support.

Concerns summary Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the Trust.

Concerns summary The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.

Concerns summary The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.

Concerns summary A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor documentation and compromised care.

Concerns summary The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.

Concerns summary Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an inappropriate police response.

Concerns summary Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.

Concerns summary Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.

Concerns summary Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.

Concerns summary There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful content promoting such misuse.

Concerns summary Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.

Concerns summary No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.

Concerns summary Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment for infection.

Concerns summary A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.

Concerns summary Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.

Concerns summary A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic testing.

Concerns summary Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.

Concerns summary A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.

Concerns summary A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.

Concerns summary A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital environment.