Manchester South

Concerns summary No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided text.

Concerns summary Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing critical information in discharge letters.

Concerns summary Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and learning from incidents.

Concerns summary Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management protocols.

Concerns summary Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal resuscitation.

Concerns summary Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient deterioration trends.

Concerns summary The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR training was unchecked, and critical information sharing between prison and probation was ineffective.

Concerns summary Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the deceased's deteriorating condition.

Concerns summary A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed ladder, unlike the securely fenced westbound side.

Concerns summary Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially treated bacterial endocarditis.

Concerns summary Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.

Concerns summary A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in fragmented patient care.

Concerns summary A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place for residents.

Concerns summary DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in a lack of clear communication and exacerbating the patient's paranoia about the money.

Concerns summary The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.

Concerns summary Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.

Concerns summary Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing severe, life-changing health problems like urological and liver damage.

Concerns summary There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.

Concerns summary Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.

Concerns summary Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or monitoring of the significant relapse risks.

Concerns summary A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as a laryngeal cancer red flag by healthcare professionals or the public.

Concerns summary Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting atypically.

Concerns summary Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.

Concerns summary The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.

Concerns summary A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists and emergency vehicles, especially at dusk or in the dark.