Manchester South
Coroner Area
Reports: 504
Earliest: Aug 2013
Latest: 4 Mar 2026
77% response rate (above 62% average).
Richard Brookes
All Responded
2024-0638
18 Nov 2024
Department of Work and Pensions
Suicide (from 2015)
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.
Action taken summary
The DWP has updated and republished guidance in December 2024 on making large payments to vulnerable adults, ensuring staff clarity on staggering payments and record-keeping. New guidance has also bee
Kumaran Chetty
All Responded
2024-0629
14 Nov 2024
Brinnington Surgery
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
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.
Action taken summary
The Brinnington Surgery has amended its incoming correspondence process to identify controlled drug prescriptions and updated its controlled drug policy to include maximum prescribing quantities. GPs
Simon Boyd
All Responded
2024-0604
6 Nov 2024
NHS England
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
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.
Action taken summary
NHS England explains the functioning of the NHS Pathways system and clarifies that exit script wording and ambulance cancellation procedures are determined locally, not nationally mandated. They sugge
James Boland
All Responded
2024-0599
5 Nov 2024
Home Office
Alcohol, drug and medication related deaths
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.
Action taken summary
The Home Office plans to commission the Advisory Council on the Misuse of Drugs (ACMD) to conduct an updated harms assessment of ketamine as part of its forthcoming three-year work …
Audrey Lambert
All Responded
2024-0600
5 Nov 2024
National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
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.
Action taken summary
NICE clarified that existing VTE guidance supports risk assessment and prophylaxis at discharge for immobile patients. They will review their guidance on stopping and starting VTE prophylaxis to asses
Leslie Swindells
All Responded
2024-0559
17 Oct 2024
Department of Health and Social Care
GTD Healthcare
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
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.
Action taken summary
GTD Healthcare has introduced new robust processes requiring all patients to be triaged by a registered clinician before booking appointments with Assistant Practitioners. They have also updated stand
Paul Clark
All Responded
2024-0558
16 Oct 2024
Greater Manchester Integrated Care Board
Royal College of General Practitioners
Alcohol, drug and medication related deaths
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.
Action taken summary
Archwood Medical Practice has audited patient records to identify those with a history of drug addiction, implementing a 'pop-up' alert on their records. A masterclass on opioid prescribing was delive
Stephen Stringer
All Responded
2024-0555
15 Oct 2024
Department of Health and Social Care
Derby and Derbyshire Integrated Care Bo…
Hospital Death (Clinical Procedures and medical management) related deaths
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.
Action taken summary
The DHSC acknowledges the concerning circumstances regarding patient access systems and stresses the importance of clarity, reminding providers of existing CQC regulations. NHS England has offered sup
John Turner
All Responded
2024-0525
3 Oct 2024
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
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.
Action taken summary
The Department of Health and Social Care reports that Tameside and Glossop Integrated Care NHS Foundation Trust has opened a rebuilt, larger emergency department to improve patient flow. Nationally, t
Sean Heath
All Responded
2024-0524
2 Oct 2024
College of Policing
Trafford Council
NHS England
+6 more
Mental Health related deaths
Suicide (from 2015)
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.
Action taken summary
NHS England largely clarified its limited ability to mandate information sharing from overseas healthcare providers and deferred to local organizations for other concerns. It confirmed its internal Re
Ryan Campbell
All Responded
2024-0519
1 Oct 2024
Department of Health and Social Care
Stepping Hill Hospital
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
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.
Action taken summary
NHS England confirms the opening of a community diagnostic centre in September 2024 to reduce plain echocardiogram waiting times. They also detail plans by Stockport Trust to add 20 weekend …
Scott Davies
All Responded
2024-0521
1 Oct 2024
Department for Transport
Stockport Metropolitan Borough Council
Road (Highways Safety) related deaths
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.
Action taken summary
Stockport Council has already affixed reflective panels and tape to the barrier in Alexandra Park to improve visibility as of November 2024. They are also auditing lighting in surrounding areas …
Jyoti Rao
All Responded
2024-0513
25 Sep 2024
Manchester University Hospitals NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.
Action taken summary
Manchester University Hospitals NHS Foundation Trust has modified their weekly Ward Patient Review meeting into a multidisciplinary team (MDT) for complex patients, now including the outpatient team.
George Coulthard
All Responded
2024-0510
24 Sep 2024
Greater Manchester Integrated Care
Department of Health and Social Care
Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community wound care access further exacerbated health risks.
Action taken summary
Hilltop Hall has changed its practice to consistently undertake pre-admission assessments, a direct result of this case. The Department of Health and Social Care also highlighted discharge guidance pu
Suzanne Eccles
All Responded
2024-0502
19 Sep 2024
Tameside and Glossop Integrated Care NH…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.
Action taken summary
The Trust has implemented an alert process on Lorenzo to prompt ED staff to review Virtual Ward patient positions, provides daily hard copies of virtual ward lists to ED, and …
David Power
All Responded
2024-0499
18 Sep 2024
Pennine Care NHS Trust
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.
Action taken summary
Pennine Care Trust has revised the Healthy Minds (now NHS Talking Therapies) stability criteria for referrals, allowing for multidisciplinary discussions and discretion. The Home Treatment Team has im
Nisren Abdul-Karim
All Responded
2024-0491
11 Sep 2024
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the provision of neurology advice and overall patient management.
Action taken summary
NHS Greater Manchester plans to ensure all neurology advice is provided via the Patient Pass system, update Patient Pass to include a mandatory telephone number field, and update communication guides.
James Astley
All Responded
2024-0486
10 Sep 2024
Care Quality Commission
Downshaw Lodge
Care Home Health related deaths
Concerns summary
Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.
Action taken summary
CQC has commenced an inspection of Downshaw Lodge on 16 October 2024 to review ongoing risks and documentation. An initial assessment for criminal enforcement found no registered provider level failur
Emilia Allsopp
All Responded
2024-0482
6 Sep 2024
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary
A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.
Action taken summary
DHSC outlines the government's 10-Year Health Plan (to be published Spring 2025) which aims for shifts from hospital to community care. It also highlights existing funding for Disabled Facilities Gran
John Howlett
All Responded
2024-0483
6 Sep 2024
Lakes Care Centre
Care Quality Commission
Department of Health and Social Care
Care Home Health related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.
Action taken summary
DHSC reports that Tameside Hospital completed a redevelopment of its urgent and emergency departments in July 2024, implemented 'front-door streaming', and an Urgent Care Transformation Programme has
Allan Hamilton
All Responded
2024-0468
23 Aug 2024
SSP Health
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.
Action taken summary
DHSC acknowledges concerns regarding online patient communication in general practice. They state that NHS Greater Manchester ICB will work with SSP Health to ensure digitised services meet national c
Mary Horgan
All Responded
2024-0437
8 Aug 2024
Northern Care Alliance NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer protocols.
Action taken summary
Northern Care Alliance has issued a 7-minute briefing on the Patient Pass system to Greater Manchester Trusts and reviewed transfer policies. They are collaborating with Patient Pass developers to imp
Sasha Drysdale
All Responded
2024-0384
18 Jul 2024
Viatris UK Healthcare Ltd
Leyden Delta Ltd
Britannia Pharmaceutical Ltd
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain blood cancers, given international study suggestions.
Action taken summary
NICE acknowledged concerns about Clozapine and blood cancer risk but clarified that regulatory approval and safety surveillance fall under the MHRA, and clinical research under the NIHR. They have adv
Lorraine Procter
All Responded
2024-0378
17 Jul 2024
Department of Health and Social Care
Other related deaths
Concerns summary
Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing the risk of complications and death.
Action taken summary
The DHSC reports that additional capital funding has been provided for diagnostic capacity, resulting in over 99,000 extra cardiology diagnostic tests in June 2024. Targeted national support is given
David Almond
All Responded
2024-0381
17 Jul 2024
East Cheshire NHS Trust
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite the patient's history.
Action taken summary
NHS England is actively pursuing several programmes, including the evolving National Care Records Service and Shared Care Records, to improve interoperable record-sharing for patients across different