Manchester South

Coroner Area
Reports: 506 Earliest: Aug 2013 Latest: 14 Apr 2026

79% response rate (above 63% average).

Clear 358 results
Edith Millington
All Responded
2026-0183 27 Mar 2026
Sai SKN Ltd
Other related deaths
Concerns summary (AI summary) The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not fixed, there are no easily accessible handrails, and the ramp is too short, making the slope steeper.
Action Taken (AI summary) • The metal access ramp has been completely removed. • The entrance has been restructured to eliminate the previous ramp arrangement and replaced with a small, stable step. • Additional fixed grab rails have been installed on both sides of the entrance.
Madison Smith
All Responded
2026-0179 26 Mar 2026
Department of Health and Social Care
Child Death (from 2015)
Concerns summary (AI summary) There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term 'nurse' to a word such as 'maternity' without being a registered nurse, potentially misleading families; prone sleeping promotion by unqualified individuals poses a significant risk to babies.
Action Taken (AI summary) • Departmental officials made enquiries with NHS England to address the coroner's concerns. • The Department of Health and Social Care is taking action to address the misuse of the title 'nurse' by unregulated individuals.
Mark Hughes
All Responded
2026-0123 4 Mar 2026
Greater Manchester Mental Health NHS Fo…
Suicide (from 2015)
Concerns summary (AI 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.
Action Taken (AI summary) • The Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT. • Mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust.
Maisie Almond
All Responded
2026-0119 27 Feb 2026
Department of Health and Social Care NHS Blood and Transplant Service
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
2 responses from NHS Blood and Transplant Service, Department of Health Social Care
Yunus Hoque
All Responded
2026-0113 26 Feb 2026
North West Ambulance Service
Child Death (from 2015) Emergency services related deaths (2019 onwards)
Concerns summary (AI 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.
Action Taken (AI summary) • NWAS has implemented a number of steps to ensure more accurate estimated time of arrival information is provided to callers. • Estimated times of arrival are now provided based on information from each of the areas within the Trust: North Cumbria, South Cumbria and Lancashire, Greater Manchester, and Cheshire and Merseyside.
Lesley Krommendijk
All Responded
2026-0109 25 Feb 2026
Stockport NHS Foundation Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
1 response from Stockport NHS Foundation Trust
Patrick Griffin
All Responded
2026-0114 24 Feb 2026
Caring UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) • The organisation has thoroughly investigated the concerns and reflected seriously upon the contents of the report, the evidence heard, and the findings made at the inquest. • Investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025. • The following actions have been incorporated and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation.
Bruce Caulfield
All Responded
2026-0062 5 Feb 2026
Manchester University NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Manchester University NHS Foundation Trust has updated its Adult Early Warning Score and Intentional Ward Rounding policies, with staff reminders and mandatory training rolled out. The Trust has also launched an 'Active Hospitals' programme in several inpatient areas to promote patient physical activity and prevent deconditioning.
Linda Fury
All Responded
2026-0029Deceased 20 Jan 2026
Pennine Care NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI 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.
Action Taken (AI summary) The Trust has made Carer Awareness Training mandatory for all frontline staff and implemented strengthened MDT documentation, patient and carer submission forms, enhanced ward-round communication pathways, and improvements to PARIS functionality to improve carer engagement and reduce risks.
Andrew Hughes
All Responded
2026-0099 5 Dec 2025
Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board
Suicide (from 2015)
Concerns summary (AI 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.
Noted (AI summary) NHS Greater Manchester acknowledges concerns about the Right Care Right Person system and its implementation and highlights existing mental health crisis support. They state they will share learning from the PFD report and continue working with partners. The Deputy Mayor clarifies their role in overseeing the implementation of the RCRP system, stating that the responsibility for operational implementation lies with the Chief Constable. They will discuss the case with the Chief Constable and seek assurance that lessons have been learned.
Lewis Bates
All Responded
2025-0602 1 Dec 2025
Greater Manchester Police
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) GMP is undertaking a review of policies, delivering updated training to call handlers, reinforcing escalation protocols, and implementing quality assurance measures through supervisory reviews. The FCCO's in-house guidance system, Sherlock, will be updated and new training will incorporate these revisions.
Margaret Crooks
All Responded
2025-0581 14 Nov 2025
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) NHS Greater Manchester is reviewing and amending the Standard Operating Procedure (SOP) between the Comprehensive Stroke Centre (CSC) and other Greater Manchester stroke centres to clarify specialist stroke advice. The amended wording will be formally approved by the end of February 2026.
Ronald Perry
All Responded
2025-0580 14 Nov 2025
Lakes Care Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Lakes Care Centre has retrained all Senior Carers, reviewed and improved the use of their Digital Care Record system, and implemented a Falls Champion who will undertake a 5-week training program with Nottingham University. They also appointed a new manager in late December 2023.
Richard Worswick
All Responded
2025-0564 7 Nov 2025
Bamford Grange Care Home Stockport NHS Foundation Trust
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The care home has issued refresher guidance to staff on existing policies, emphasizing documentation of hospital communications, and implemented enhanced observations for unstageable pressure ulcers. They've also implemented a sepsis risk assessment for residents with chronic wounds and conduct regular audits of wound care entries. A Trust-wide alert was issued on 20 November 2025 regarding Transfer of Care documentation, ensuring two copies are printed. A Trust-wide audit will take place in February 2026 to check for documentation in patient records and a task and finish group will work on improving the quality of the discharge checklist starting January 2026.
Oliver Gorman
All Responded
2025-0558 4 Nov 2025
British Aerosol Manufacturers Associati… Department for Business and Trade Department for Culture, Media and Sport +1 more
Child Death (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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.
Noted (AI summary) The Department highlights the Online Safety Act (OSA) which requires companies to prevent users from encountering illegal content and remove such content swiftly. Ofcom can issue information notices at the coroner's request, requiring services to provide data and Data Preservation Notices to preserve a child's data. OPSS highlights industry led labelling initiatives to address risks. Officials will communicate the new industry labelling initiative to relevant groups to raise awareness. BAMA has developed a new caution mark and statement that can be used to provide additional detail on the potential problems which can arise if the aerosol dispenser is not used in accordance with the manufacturer’s instructions. The caution mark will be placed in the top two-thirds of the back of the pack copy to ensure that it is noticed by the consumer. The Department for Culture, Media and Sport acknowledges the report and confirms that the Department for Science, Innovation and Technology (DSIT) leads on online safety.
Derek Crowther
All Responded
2025-0500 9 Oct 2025
Pennine Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The Trust is developing an eObs app with offline capabilities, planned for pilot testing in April 2026, to improve patient monitoring and data integrity. They will also improve communication with staff regarding such developments.
Amanda Wood
All Responded
2025-0495 7 Oct 2025
Chief Executive, Tameside and Glossop I…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Action Taken (AI summary) Following an audit that identified documentation challenges, the Trust has implemented a new patient safety checklist, revised matrons' walk-arounds, redesigned the documentation audit process, and placed documentation reminders on nursing computers.
Honoria Culshaw (2)
All Responded
2025-0480 24 Sep 2025
Lancashire Teaching Hospitals NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
Action Planned (AI summary) Lancashire Teaching Hospitals NHS Foundation Trust will implement a 'wound swab' document to ensure that wound swab results are reviewed and communicated as part of the pre-operative process, and have an action plan to adhere to international guidelines regarding infection signs.
Honoria Culshaw (1)
All Responded
2025-0479 24 Sep 2025
Manchester University NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Manchester University NHS Foundation Trust will train Cardiology Residents on using the HIVE system to send discharge letters to relevant healthcare providers and create tip sheets and video guides for cardiology teams, which will be shared across the Trust.
Margaret Bailey
All Responded
2025-0448 3 Sep 2025
Chief Executive, Care Quality Commission Secretary of State for Health and Socia…
Community health care and emergency services related deaths
Concerns summary (AI 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.
Noted (AI summary) The Care Quality Commission explains its role and inspection methodology and states that it is outside CQC's scope to amend regulations to allow HCAs to take on medical or nursing observations, noting that the report has also been sent to The Secretary of State for Health and Social Care. The Department of Health and Social Care will ask NICE to consider developing a national standard on the prevention and management of choking hazards in domiciliary and residential care settings, after concerns were raised about a lack of basic observation ability of carers.
Audrey Newman
All Responded
2025-0443 29 Aug 2025
CEO, Stockport NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Stockport NHS Foundation Trust is rolling out training on using the IT booking system for theatres to medical staff, formulating a flowchart for escalating lumbar puncture procedures to anaesthetics, and ensuring patients awaiting lumbar punctures are not transferred off the acute medical unit or transferred off the unit on weekends to avoid delays.
Ricky O’Connell
All Responded
2025-0433 20 Aug 2025
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary (AI 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.
Noted (AI summary) The Department for Health and Social Care acknowledges the concerns and outlines the Government's commitment to improving urgent and emergency care, referencing the 10-Year Health Plan and the Urgent and Emergency Care Plan for 2025/26, as well as improvements to ambulance response and handover times. They do not describe specific actions taken or planned as a direct result of this case.
Kenneth Edwards
All Responded
2025-0414 7 Aug 2025
Stockport NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Stockport NHS Foundation Trust has reinforced standards for consent, handover, and clinical documentation, continued collaboration with Medica for shared learning, continued engagement in REALM, and maintained a robust incident review and escalation framework for radiology discrepancies.
Marion Jones
All Responded
2025-0413 7 Aug 2025
Care UK
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Care UK has updated its admission checklist, care plan forms, and audit processes to ensure pre-admission assessments for bed rails are completed and documented, and that care plans are comprehensive and up-to-date. They also clarified falls management and prevention policy and high/low beds should be considered as an alternative to bed rails.
Leslie Thompson
All Responded
2025-0385 29 Jul 2025
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The Department of Health and Social Care is strengthening partnerships between the NHS and social care and every acute hospital has access to a care transfer hub operating seven days a week. The Better Care Fund (BCF) will provide £9 billion to help ensure patients receive appropriate and timely care.