Manchester South

Concerns summary The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention issues.

Concerns summary Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.

Concerns summary Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.

Concerns summary Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.

Concerns summary A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall evidence.

Concerns summary Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by an unavailable ICU outreach team and poor fluid chart completion.

Concerns summary Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.

Concerns summary Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack of audits, compromised public safety at the football ground.

Concerns summary Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, created unsafe care practices.

Concerns summary Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.

Concerns summary A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.

Concerns summary The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.

Concerns summary Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.

Concerns summary A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling to meet the patient's requirements.

Concerns summary The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking premature births.

Concerns summary Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face appointments, creating significant safety risks for vulnerable patients.

Concerns summary Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer Syntocinon, highlighting systemic issues in challenging inappropriate care.

Concerns summary A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological distress due to continued milk production.

Concerns summary Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

Concerns summary Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.

Concerns summary Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online sources.

Concerns summary Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.

Concerns summary British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.

Concerns summary Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.

Concerns summary Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was not commenced, despite his anxiety to complete it.