Manchester South

Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.

Concerns summary A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.

Concerns summary Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have been effectively shared.

Concerns summary The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.

Concerns summary The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.

Concerns summary Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.

Concerns summary The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. Vulnerable elderly patients sent to hospital alone faced significant communication barriers, hindering their care.

Concerns summary Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.

Concerns summary The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.

Concerns summary Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.

Concerns summary GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked national guidance on recognising and escalating dehydration risks.

Concerns summary Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.

Concerns summary The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.

Concerns summary Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.

Concerns summary The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.

Concerns summary Systemic failures in domestic abuse management included inadequate police training on risk assessment and coercive control, poor information sharing with CPS, and insufficient use of protective measures like bail and DVPNs.

Concerns summary Residential landlords are not required to inspect window coverings in private rental properties to ensure only safety cords are used, posing a risk of entanglement.

Concerns summary Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the provision of accurate baseline health data, risking treatment delays for vulnerable patients.

Concerns summary Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up of haematology advice led to significant care delays.

Concerns summary The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.

Concerns summary The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.

Concerns summary Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis and treatment.

Concerns summary Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays in arranging post-discharge care packages.

Concerns summary Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.

Concerns summary The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.