Manchester South

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Concerns summary National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused critical delays in treatment and assessment for life-saving surgery.

Concerns summary Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual inaccuracies.

Concerns summary Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability was not recognised, increasing her risk.

Concerns summary Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external services, and a national shortage of specialist rehabilitation units.

Concerns summary Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear guidance on discontinuing long-term medication for patients in remission.

Concerns summary The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside failures in ambulance service assessment and timely response for a critical cardiac condition.

Concerns summary A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment and treatment according to their health needs.

Concerns summary High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.

Concerns summary A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, community and primary care teams lack training to identify critical deterioration in fracture patients.

Concerns summary Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and Emergency departments promptly.

Concerns summary Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.

Concerns summary Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.