Manchester South

Coroner Area
Reports: 506 Earliest: Aug 2013 Latest: 14 Apr 2026

79% response rate (above 63% average).

506 results
Sasha Drysdale
All Responded
2024-0384 18 Jul 2024
Britannia Pharmaceutical Ltd Leyden Delta Ltd National Institute for Health and Care … +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted (AI summary) NICE acknowledges the concerns regarding clozapine and blood cancers but states that the MHRA is the responsible body for medicine regulation and safety. NICE welcomes any findings that may impact its current recommendations and advice. Viatris states its clozapine product is safe when used as prescribed and that ongoing monitoring shows no change in the benefit risk profile, so no action is proposed. Response contains no text. Response text consists only of A6 and A7.
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 (AI 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 Planned (AI summary) NHS England highlights work to improve record-sharing through the National Care Records Service (NCRS) and Shared Care Records, which are being developed locally by Integrated Care Boards (ICBs) with plans for future interoperability across England. NHS England's Regulation 28 Working Group discusses all reports received to share learnings and identify emerging trends. East Cheshire NHS Trust has enabled access to GP records for the wider footprint of the trust. The trust will reinforce the importance of documenting family history and considering thrombophilia in management plans, share learning from the case via clinical bulletins and forums, and review ACP caseloads.
Lorraine Procter
All Responded
2024-0378 17 Jul 2024
Department of Health and Social Care
Other related deaths
Concerns summary (AI 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 Planned (AI summary) The Department of Health and Social Care aims to meet the NHS Constitutional standard of 92% of patients waiting no longer than 18 weeks from Referral to Treatment (RTT) by the end of parliament. NHS Greater Manchester is working to prevent CVD through the NHS GM CVD Prevention Plan.
Lee McHale
All Responded
2024-0356 3 Jul 2024
Ministry of Housing, Communities & Loca…
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary (AI summary) The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a former foster parent, contributing to their fatal overdose.
Noted (AI summary) DWP expresses condolences and explains the policy regarding spare room subsidy, but states they cannot comment on the specifics of the case. They state that the policy is clear and additional support is available through the DHP scheme.
James Cockburn
All Responded
2024-0352 2 Jul 2024
Greater Manchester Integrated Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) NHS England is working at a national level to deliver the Long-Term Workforce Plan to address staffing shortages. They also mention plans for collaboration between Patient Safety and Digital Clinical Safety Teams to improve EPR implementations, and for GM ICB to improve the interface between secondary and tertiary care systems. NHS Greater Manchester acknowledges concerns about delays in cardiac services and highlights the GM Care Record. They will challenge leaders supporting digital transformation to improve the interface between secondary and tertiary care systems and share learnings in September 2024.
John Howe
All Responded
2024-0339 25 Jun 2024
East Midlands Ambulance Service Manchester City Council Manchester University NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) MFT has developed a draft "Out of Hours Discharge Avoidance" SOP to manage delayed discharges, which is due to be presented for ratification at the MRI Quality and Safety Committee. They also intend to formally communicate this SOP to external transport providers once ratified across relevant sites. EMAS will continue to contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. The organisation amended inaccuracies in the Serious Incident Review (SIR) and reshared it with relevant safeguarding boards and the Manchester Foundation Trust Safeguarding Team. They have implemented a system to ensure investigations are completed in a timely manner and are reviewing processes for discharges to 'out of area' localities.
Lee-Ann Ince
All Responded
2024-0333 20 Jun 2024
Greater Manchester Integrated Care
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) NHS Greater Manchester Integrated Care (NHS GM) and partners will translate recommendations into tangible actions, and the Community Safety Partnership Board will retain local governance to ensure actions are met and report back on progress. Trafford Council and NHS GM are planning specialist training on the Care Act & Domestic Abuse, and a dedicated task & finish group to develop their approach to supporting victims of domestic abuse with physical disabilities/health needs, with the training to be launched by April 2025.
Thomas Gibson
Partially Responded
2024-0327 19 Jun 2024
Manchester University NHS Foundation Tr… National Institution for Health and Car…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between specialisms. There's no clear guidance for clinicians or senior review of incongruous test results.
Noted (AI summary) NICE states they will not be creating guidance on ECG interpretation, suggesting other bodies are more appropriate. MFT describes updates to their electronic discharge summary template to include medication updates and concerns.
Amina Ismail
All Responded
2024-0320 14 Jun 2024
Department of Health and Social Care NHS England
Suicide (from 2015)
Concerns summary (AI 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.
Noted (AI summary) NHS England highlights the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, designed to localize and realign care. They have published a Commissioning Framework and required ICBs to develop 3-year plans to cease sending people to distant or outdated inpatient services and are working with the Greater Manchester ICB re oversight of The Priory Cheadle. The DHSC acknowledges concerns about mental health service funding, reliance on independent providers, and availability of specialist units. They highlight existing initiatives to improve patient flow, localise care, and ensure quality regardless of provider.
Linda McLaughlin
All Responded
2024-0316 13 Jun 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted (AI summary) NHS England acknowledges the concerns and explains that interstitial lung disease is listed as a side effect in relevant resources. They suggest the coroner direct concerns about nilotinib and guidance to the MHRA. They also note work is being done nationally to share learnings from PFD reports. The MHRA has added the side effects experienced by Mrs. Mclaughlin to the Yellow Card database and requested the BNF editorial team consider including interstitial lung disease as a separate side-effect term in the nilotinib drug monograph; this will be included in the January 2025 online updates of BNF and BNFC.
Bernard Compton
All Responded
2024-0304 5 Jun 2024
NHS England
Emergency services related deaths (2019 onwards)
Concerns summary (AI 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.
Noted (AI summary) NHS England expresses condolences and states that concerns have been listened to and reflected upon. They highlight the remit of other organisations (NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust) regarding some of the concerns, and reference workstreams to increase ambulance capacity and improvements to Tameside's ED. They also note the discussion of PFD reports by their Regulation 28 Working Group to share learnings.
George Broadhurst
All Responded
2024-0292 29 May 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The NHS has observed a significant and sustained expansion in recruitment to specialty training places; a programme of international recruitment also ran in 2023/24 to enable Community Diagnostic Centres (CDCs) to deliver diagnostics. Following the establishment of CDCs and the planned roll out of a national picture archiving and communication system (PACS) it is planned that this will support the development of wider 24/7 reporting services for general X-rays.
Elizabeth McCann
All Responded
2024-0288 29 May 2024
Department of Health and Social Care Greater Manchester Police Home Office +2 more
Other related deaths
Concerns summary (AI 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.
Noted (AI summary) The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.
John Hartey
All Responded
2024-0287 29 May 2024
Department Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Manchester University NHS Foundation Trust launched a recruitment and retention strategy, service transformation across the Trafford locality has brought together care to support discharge and provide urgent community response services, and the Trafford district nursing service operates clinical triage.
Bobilya Mulonge
All Responded
2024-0250 8 May 2024
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and Emergency departments promptly.
Action Taken (AI summary) The Department of Health and Social Care outlines actions being taken nationally to improve ambulance response times and patient flow, including additional funding and targets for faster ambulance response times and hospital handover. They highlight the reduction in average Category 2 ambulance response times in the North West Ambulance Service region in 2023/24.
Colin Waterhouse
All Responded
2024-0248 7 May 2024
Ministry of Housing, Communities & Loca…
Suicide (from 2015)
Concerns summary (AI summary) Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in unsuitable accommodation, negatively impacting his wellbeing.
Action Planned (AI summary) The Ministry acknowledges concerns about the social housing bidding process and availability of social housing. They state they have increased flexibilities on how councils can use their Right to Buy receipts. They confirmed £450 million investment in councils across England under the third round of the Local Authority Housing Fund. They are committed to introducing Awaab’s Law to the social rented sector.
Michael Clarke
Partially Responded
2024-0245 3 May 2024
Greater Manchester Integrated Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly for suspected sepsis.
Action Planned (AI summary) NHS England is prioritising improving ambulance performance and is working on improving handover times. The Integrated Care Board will work with CWP and GP colleagues to improve the timeliness and content of correspondence when an individual has contacted the Crisis Line.
Frederick Boyd
All Responded
2024-0240 2 May 2024
Care Quality Commission Lakes Care Centre
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Lakes Care Centre has ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. The CQC is following up with the manager to register them as soon as possible.
Jordan Howarth
All Responded
2024-0236 1 May 2024
Department of Health and Social Care Tameside General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted (AI summary) The Department of Health and Social Care outlines the planned phased implementation of Martha's Rule, giving patients the right to request a rapid review of their case by someone outside their immediate care team, and describes NHS England's broader Managing Deterioration Safety Improvement Programme. The response contains no text and cannot be classified.
Richard Hardman
Partially Responded
2024-0207 19 Apr 2024
Greater Manchester Integrated Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a clear mechanism for a single lead practitioner to coordinate and integrate care across various medical disciplines and hospital sites in complex cases poses a risk.
Action Planned (AI summary) NHS England and GMIC will follow up with the Manchester University NHS Foundation Trust after a Clinical Effectiveness Group meeting in July 2024. NHS England will also promote its Digital Clinical Safety Strategy and training modules.
William Erskine
All Responded
2024-0204 17 Apr 2024
Ministry of Housing, Communities & Loca…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows to open fully and posing a significant fall risk.
Noted (AI summary) The Ministry of Housing acknowledges the concerns regarding window restrictors but argues that current legislative arrangements are proportionate and appropriate. They state that the Building Safety Regulator will consider how Building Regulations and Approved Documents ensure protection from falling.
Ian Dixon
All Responded
2024-0151 19 Mar 2024
Stockport Homes Stockport Metropolitan Borough Council
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted works.
Action Planned (AI summary) Stockport Homes will develop target timescales for adaptations, monitor major adaptations via a monthly panel, and develop a Sharepoint site for monitoring minor adaptations, all by the end of May 2024. Stockport Metropolitan Borough Council will ensure workers follow up on adaptation requests, document them on the case management system, and strengthen the SLA with Stockport Homes by the end of June. Target timescales will be developed, agreed with SMBC and published by the end of May 2024.
Tobias Mannering-Jones
All Responded
2024-0143 14 Mar 2024
Department for Local Government Department of Health and Social Care Greater Manchester Integrated Care
Suicide (from 2015)
Concerns summary (AI summary) Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency coordination.
Noted (AI summary) The Department of Health and Social Care highlights the role of Integrated Care Systems (ICSs) in planning and delivering integrated health and care services. It notes a Joint Action Plan is being developed to improve mental health treatment for people using drugs and alcohol, and DHSC and DLUHC will write to Directors of Housing, Adult Social Services, and Chairs of Safeguarding Adult Boards to emphasize their role in the homelessness system. The Tameside Adults Safeguarding Partnership Board (TASPB) is developing an action plan based on a Safeguarding Adults Review, with a workshop planned and an Action Plan Review Group monitoring progress. Additionally, TASPB launched the TASPB-Tiered-Assessment-and-Management-(TRAM) Protocol in November 2023 to support practitioners working with adults at high risk. The response contains no text.
Joseph Miller
All Responded
2024-0142 14 Mar 2024
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Noted (AI summary) The Department of Health and Social Care acknowledges the concerns regarding ambulance call triage systems and notes that NHS England has a process to map 999 call triage system outcomes against ambulance response time categories. The Emergency Call Prioritisation Advisory Group (ECPAG) keeps the categorisation of calls under continual review.
Alan Smith
All Responded
2024-0140 13 Mar 2024
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT systems.
Action Planned (AI summary) A Masterclass learning event will be delivered in September 2024 to include advice and guidance in relation to the circumstances in which to refer and the information required within a referral to ensure timely triage and progression to care under the vascular surgery team as appropriate.