Manchester South

Coroner Area

Reports: 504 Earliest: Aug 2013 Latest: 4 Mar 2026

78% response rate (above 62% average).

vs North West average: +385 reports · +16pp response rate

vs national average: +421 reports · +16pp response rate

Dorothy Townley

2013-0219 28 Aug 2013

Royal College of General Practitioners Royal College of Nursing

Community health care and emergency services related deaths

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.

Action taken summary The Royal College of General Practitioners clarifies its role in providing training and professional development to GPs, outlining existing curriculum sections relevant to inter-professional communica

Irene Esaw

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths

Concerns summary There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about responsibility between clinical and integrated care teams led to inadequate needs assessments.

Action taken summary Tameside MBC has implemented a new Mental Capacity Act Policy, Procedure, and Toolkit, issued a bulletin, and is undertaking a continuous programme to enhance staff knowledge. They also plan a …

Alphonso Shearer

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY GP" system hindered communication, and a lack of face-to-face GP assessments delayed recognition of patient deterioration.

Action taken summary The practice has reviewed patient records and made arrangements for reception staff to highlight issues with tablet medication to clinicians, reinforcing this message to all prescribers. They have als

Grenville Wait

Department of Health and Social Care

Emergency services related deaths (2019 onwards)

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.

Action taken summary The Department of Health and Social Care is planning significant investment, including an additional £3.3 billion, to improve ambulance response times and urgent care. This involves increasing bed cap