Manchester South

Concerns summary Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.

Concerns summary Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led to prolonged waits and inadequate care for vulnerable patients.

Concerns summary The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review medication side-effect monitoring protocols.

Concerns summary There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally required annual Care Act reviews due to resource constraints.

Concerns summary The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor inter-agency communication and a severe lack of specialist acute learning disability beds.

Concerns summary Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused distress with unbeneficial procedures, including End of Life Care decisions without proper assessment.

Concerns summary The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.

Concerns summary Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on unresponsive referrals.

Concerns summary A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.

Concerns summary There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.

Concerns summary Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear communication of risks or guidance to sentencing courts.

Concerns summary The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of a learning disability liaison role.

Concerns summary A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.

Concerns summary The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was inconsistently effective due to varying individual approaches and workloads.

Concerns summary The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system installation, despite evidence of their life-saving potential.

Concerns summary Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked a system for recording such information.

Concerns summary Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, inadequate custody record keeping, and conflicting guidance on prisoner positioning for aspiration risk were critical concerns.

Concerns summary Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts and a lack of a region-wide approach mean the problem is merely displaced rather than resolved.

Concerns summary The report identified unspecified matters of concern indicating a risk of future deaths.

Concerns summary The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.

Concerns summary There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.

Concerns summary The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.

Concerns summary Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, impacting the deceased's treatment.

Concerns summary Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs and understanding of individuals with learning disabilities.

Concerns summary Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing suicide risk.