Manchester South

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 Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked patient safety.

Concerns summary No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.

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 Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not adequately understood or managed.

Concerns summary Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.

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 Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.

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 Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic adolescents create high-risk situations for mental health and self-harm.

Concerns summary Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.

Concerns summary GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.

Concerns summary GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.

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 An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.

Concerns summary Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.

Concerns summary Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.

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 GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.

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 CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

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.