Manchester South
Coroner Area
Reports: 506
Earliest: Aug 2013
Latest: 14 Apr 2026
79% response rate (above 63% average).
Arnold Ward
All Responded
2019-0433
16 Dec 2019
Fernlea Nursing Home, Care Quality Comm…
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Stockport CCG reports that Fernlea Nursing Home now uses photographs to track the progress of pressure sores, and referrals to the Tissue Viability Team are escalated if not actioned within 2 working days. A "React to Red" training programme has been developed and rolled out across the Stockport Care Home community. The CQC inspected Fernlea Care Home and found the service had failed to send a statutory notification regarding Mr. Ward's pressure ulcer. They will consider further enforcement action regarding this and will provide a copy of the inspection report to HM Coroner. Fernlea Care Home has arranged for all Registered Nurses to undertake third party wound management refresher training and has extended "React to Red" training to 87% of the care team. They have adopted the NHS wound management document, changed referral processes to TVNs, and will notify the GP of all TVN referrals.
Clive Miles
All Responded
2019-0432
16 Dec 2019
Stockport Clinical Commissioning Group
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.
Action Planned
(AI summary)
Stockport CCG will remind all GPs across Stockport of the importance of recording clear and detailed notes explaining the basis on which any change to prescribing frequency has been made.
Andrew Hogg
All Responded
2019-0400-wp26913
27 Nov 2019
Borough Care Limited
Care Home Health related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
• All home managers will review falls on the Person Centered Software (PCS) system weekly and add notes regarding actions taken to the falls log and residents' support plans.
• For any resident with more than two falls within a two-week period, a review with their GP or CPN will be arranged.
• Area Managers will review this process as part of their monthly audit.
Averil Skoric
All Responded
2019-0383
15 Nov 2019
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Department of Health and Social Care notes the concerns and highlights existing regulations, guidance from NICE, and the role of the Social Care Institute for Excellence (SCIE).
Philip Owen
All Responded
2019-0330
2 Oct 2019
MOJ
Other related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
HMPPS issued Probation Instruction (PI 05/2018) setting out arrangements agreed between the Ministry of Justice and the Senior Presiding Judge for liaison between courts and probation providers.
Charles Williamson
All Responded
2019-0326
30 Sep 2019
Department of Health and Social Care
Greater Manchester Health and Social Ca…
Mayor of Greater Manchester
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.
Noted
(AI summary)
Greater Manchester neuro-rehabilitation services have been undergoing transformation since 2016, with investment in community neuro-rehabilitation services in seven out of 12 areas and implementation planning for inpatient service transformation commenced in July 2019. Actions include development of community and inpatient service standards, peer review of inpatient services, a GM-wide training program, and a patient & carer network. The Department of Health and Social Care states that the provision of neuro-rehabilitation services in Greater Manchester is a matter for local NHS commissioners. It acknowledges the GMHSCP is implementing a new model of care for neuro-rehabilitation services and improving the quality of inpatient and community services.
Julie Barrow
All Responded
2019-0325
30 Sep 2019
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Department of Health and Social Care is developing a learning disability and autism training package to be tested in 2020/21, with wider rollout planned after evaluation. They will also amend the Health and Social Care Act 2008 to mandate relevant training for NHS and social care staff.
Ian Bromley
All Responded
2019-0307
19 Sep 2019
Pennine Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Taken
(AI summary)
The Home Treatment Team has an Advanced Practitioner and the team manager is now a qualified prescriber. The Home Treatment Team has acquired additional CCG funding to extend the medical cover, with the Trust Medical Director is providing part-time cover to the team.
Christopher Hart
All Responded
2019-0272
14 Aug 2019
Johnnie Johnson Housing
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Johnnie Johnson Housing notes the comments regarding resident safety but states no further action is required as the property was built to standard in 1999 and no high risk was identified to install a sprinkler. They have updated their advisory information on fire safety regulations and continue to monitor emerging findings following the Hackitt Review.
Deborah Chapman
All Responded
2019-0280
1 Aug 2019
West Timperley Medical Centre
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The medical centre has implemented a regular search of the clinical system to identify patients taking regular opiate analgesia or Pregabalin with a past history of drug misuse and are contacting those patients to ensure an up to date record of their current illicit drug use.
Adam Harris
All Responded
2019-0247
23 Jul 2019
Greater Manchester Police
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Greater Manchester Police explained their procedures for allocating detainee cell space and the role of the cell allocation team and Custody Inspector. They also detailed officer training and procedures for handling detainees who may be confused or intoxicated, as well as explaining when a full custody record may not be completed immediately.
Sophie Lyons
All Responded
2019-0206
19 Jun 2019
Greater Manchester Combined Authority
Home Office
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Greater Manchester Combined Authority outlines its functions and relationship to policing, noting that the Chief Constable has operational independence. It acknowledges the need for a coordinated approach to car cruising across Greater Manchester and notes that developments are in train. The Home Office highlights the establishment of a national practitioners group for car cruising leads and states the National Police Chiefs' Council have also agreed to discuss car cruising at the next Roads Policing Intelligence Forum. The Home Office will continue to work closely with the police to improve the response to illegal activity at these events.
Alfred Sykes
All Responded
2019-0201
18 Jun 2019
Greater Manchester Police
Other related deaths
Concerns summary (AI summary)
The report identified unspecified matters of concern indicating a risk of future deaths.
Action Taken
(AI summary)
GMP will review all high-risk missing person searches daily with another officer and appraise the Force Search Coordinator. Annual PoISA/Search Manager CPD will include refresher training using incidents that have occurred within the force or nationally.
Mellin Beard
All Responded
2019-0157
17 May 2019
Tameside and Glossop Care NHS Trust
Tameside General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Tameside and Glossop Integrated Care NHS Trust states that the referral to District Nurses was made by hospital staff, contrary to evidence heard. They outline the Trust's processes for using Bank and Agency staff to fill vacancies and their recruitment/retention efforts.
David Price
All Responded
2019-0145
29 Apr 2019
Stockport Clinical Commissioning Group
Alcohol, drug and medication related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The CCG and Local Authority will continue promoting services for people with alcohol and substance misuse problems experiencing mental health problems, request regular updates on service promotions, and monitor access, activity, and outcomes for people with alcohol issues accessing mental health/psychological therapy services.
Danyon Chesters
All Responded
2019-0079
26 Feb 2019
Department of Health and Social Care
Alcohol, drug and medication related deaths
Mental Health related deaths
Railway related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Department acknowledges the concerns raised and explains the NHS's role in commissioning services and targets for psychological therapies. They reference guidance for therapists on managing client confidentiality and risk, emphasizing the importance of acting within their expertise and seeking advice when necessary. They highlight government initiatives for suicide prevention.
Nathan Mooney
All Responded
2019-0072
26 Feb 2019
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Action Planned
(AI summary)
Health Education England acknowledges the challenges of recruiting and retaining doctors. They mention a commitment to increasing medical school places and the development of a workforce implementation plan to address staffing and culture in the NHS.
Heather Carey
All Responded
2019-0046
12 Feb 2019
Department of Health and Social Care
NHS Tameside and Glossop Clinical Commi…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned
(AI summary)
The CCG has invested £600,000 to improve staffing on inpatient mental health wards. The service's waiting times have improved due to internal actions, with the current waiting time for Cognitive Analytical Therapy at 13 weeks. NHS England will test four-week waiting times to appropriate care and is expected to publish a Community Mental Health Framework to support local areas in the transformation of community mental health services. NHS England is also investing to improve the therapeutic skill mix of staff.
Conor Crutchley
All Responded
2019-0032
28 Jan 2019
Pennine Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The trust details steps taken to improve early intervention services, including funding an additional psychological therapist and training staff in family intervention. The management of the waiting list for psychological interventions has been reviewed and now includes a process of making monthly contact with individuals on the waiting list.
George Thompson
All Responded
2019-0022
16 Jan 2019
Highlands and Trafalgar Square Surgery
Community health care and emergency services related deaths
Concerns summary (AI summary)
Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.
Action Planned
(AI summary)
The practice will arrange telephone triage training, provide one-on-one training on systems and processes, re-communicate the operational manual, and create a formal channel for team members to raise concerns about operational readiness and workload pressure.
Ruth Gregory
All Responded
2019-0017
11 Jan 2019
Reinbek Care Home
Care Home Health related deaths
Concerns summary (AI summary)
Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Action Taken
(AI summary)
Borough Care has increased staffing levels in their homes, including a deputy manager and senior carer on each shift, to reduce the time communal areas are left unattended.
Jacqueline Elliott
All Responded
2019-0016
11 Jan 2019
Delamere Medical Practice
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The CCG provides context on medication management practices, GP workload challenges and national initiatives to increase the GP workforce, but doesn't describe specific local actions.
Michael Flynn
All Responded
2019-0008
10 Jan 2019
Tameside General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies a lack of EWS monitoring in the post-operative recovery area, failure to adhere to Trust policy regarding monitoring and trigger points for escalation, a lack of doctor review despite deteriorating EWS scores, and incomplete fluid balance charts.
Action Taken
(AI summary)
The Matron for Theatres has confirmed that vital signs are continuously monitored in the recovery area post operatively and documented at set intervals. New signage has been introduced at the bedside to further support staff in recognizing which patients have a fluid balance chart in place; and a trust wide audit of fluid balance chart compliance has been added to the Trust Audit Programme for 2019/2020.
Malcolm Shaw
All Responded
2019-0007
10 Jan 2019
Stockport NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The Trust has launched a revised programme of investigation training, including in-depth statement gathering and writing sessions, and implemented a checklist for investigation panel meetings to ensure key requirements are met. They also launched a Safer Mobility Collaborative aimed at reducing inpatient falls.
Joan Wright
All Responded
2018-0408
28 Dec 2018
Department of Health and Social Care
Care Home Health related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Department of Health outlines existing regulations and guidance regarding controlled drugs, referencing the Shipman Inquiry, the Controlled Drugs Regulations 2006, NICE guidelines and CQC guidance; the Department suggests taking up the concern about Greater Manchester Police's actions with the Home Secretary.