Manchester South

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.

Concerns summary An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety during work at height.

Concerns summary A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.

Concerns summary There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation lacking detail on clinical decision-making.

Concerns summary Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.

Concerns summary The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a single, departed manager, with no audit or review since, despite missing documentation.

Concerns summary Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.

Concerns summary A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.

Concerns summary Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning and escalating patient deterioration to consultants.

Concerns summary A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.

Concerns summary High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers can operate these vehicles with a standard license, unlike the graduated system for motorcycles.

Concerns summary Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic scans.

Concerns summary A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.

Concerns summary Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.

Concerns summary Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home and district nurses, inadequate record-keeping, and non-adherence to pressure relieving strategies.

Concerns summary Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing urgent psychiatric appointments and follow-up after concerning incidents.

Concerns summary A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.

Concerns summary Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.

Concerns summary Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel symptoms. Poor inter-departmental communication and treating the least serious diagnosis first were also issues.

Concerns summary Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.

Concerns summary Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.

Concerns summary Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical delays in response times for seriously injured patients.

Concerns summary Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.

Concerns summary A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.

Concerns summary The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual profiles.