Manchester South

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 Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.

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 Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.

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 Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating choking episodes to speech and language therapy.

Concerns summary The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist shortages also contributed to backlogs.

Concerns summary Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding the guideline response time.

Concerns summary Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential mental health treatment.

Concerns summary Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite prior assurances of resolution.

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 The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.

Concerns summary The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does not improve within a specified period.

Concerns summary Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant demand.

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 Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from the land at night, posing a significant safety risk.

Concerns summary Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.