Manchester South

Concerns summary Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Concerns summary PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.

Concerns summary Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.

Concerns summary The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked essential diagnostic facilities.

Concerns summary The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.

Concerns summary Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.

Concerns summary Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.

Concerns summary Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.

Concerns summary Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist procedures. Additionally, poor communication, failure to assess mental capacity, and obtain consent for treatment were identified.

Concerns summary The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.

Concerns summary Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a statutory minimum amount to be left in accounts to prevent such situations.

Concerns summary Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.

Concerns summary Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.

Concerns summary Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.

Concerns summary The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.

Concerns summary Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a systemic failure risking patient safety and future deaths.

Concerns summary Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.

Concerns summary GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.

Concerns summary Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.

Concerns summary The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting ongoing issues with service demand and capacity.