Manchester South
Coroner Area
Reports: 504
Earliest: Aug 2013
Latest: 4 Mar 2026
77% response rate (above 62% average).
Ian Dixon
All Responded
2024-0151
19 Mar 2024
Stockport Homes
Stockport Metropolitan Borough Council
Alcohol, drug and medication related deaths
Concerns 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.
Joseph Miller
All Responded
2024-0142
14 Mar 2024
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Tobias Mannering-Jones
All Responded
2024-0143
14 Mar 2024
Greater Manchester Integrated Care
Department of Health and Social Care
Department for Local Government
Suicide (from 2015)
Concerns 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.
Alan Smith
All Responded
2024-0140
13 Mar 2024
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Elizabeth Brown
All Responded
2024-0135
12 Mar 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks to patient health.
Peter Beresford
All Responded
2024-0138
12 Mar 2024
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.
Samuel Curless
All Responded
2024-0089
19 Feb 2024
College of Policing
Greater Manchester Police
Suicide (from 2015)
Concerns summary
Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Alfie Nicholls
All Responded
2024-0084
14 Feb 2024
Department of Health and Social Care
Department for Education
Greater Manchester Integrated Care
+1 more
Child Death (from 2015)
Concerns summary
Poor understanding and recognition of Avoidant Restrictive Food Intake Disorder (ARFID) among professionals, coupled with inadequate cross-sector strategies and non-holistic care planning, increased risks for vulnerable children.
James Day
All Responded
2024-0061
7 Feb 2024
Ministry of Defence
Alcohol, drug and medication related deaths
Service Personnel related deaths
Concerns summary
Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.
Susan Bracegirdle
All Responded
2024-0052
2 Feb 2024
Care Quality Commission
Care Home Health related deaths
Concerns summary
Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for pressure ulcers. Inadequate internal reviews and remote expert input further compromised timely intervention for a deteriorating patient.
Shahzadi Khan
All Responded
2024-0046
31 Jan 2024
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary
National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also a lack of awareness regarding menopause as a factor in mental health deterioration.
Terence Briney
All Responded
2024-0042
29 Jan 2024
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of conducting thorough investigations.
Rhys Hill
All Responded
2024-0021
15 Jan 2024
Lancashire Teaching Hospitals
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.
Elizabeth Roberts
All Responded
2024-0006
4 Jan 2024
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a local trust level.
Claire Briggs
All Responded
2023-0513
8 Dec 2023
Lancashire and South Cumbria Integrated…
Greater Manchester Police
Cheshire Constabulary
+10 more
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Concerns summary
A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.
Anthony Williams
All Responded
2023-0491
1 Dec 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and treatments, resulting in poorer patient outcomes and advanced disease.
Luca Yates
All Responded
2023-0437
9 Nov 2023
Royal College of Paediatrics and Child …
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general paediatricians having inadequate practical experience in neonatal resuscitation.
Kirsty Hendry
All Responded
2023-0394
20 Oct 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.
Terence Davenport
All Responded
2023-0389
17 Oct 2023
Greater Manchester Integrated Care
Care Home Health related deaths
Concerns summary
A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing between authorities also failed to recognize a safeguarding risk, endangering residents and staff.
Holly Mullan
All Responded
2023-0390
17 Oct 2023
NHS England
Suicide (from 2015)
Concerns summary
Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and impeding crucial treatment for patients with severe conditions.
David Hall
All Responded
2023-0382
12 Oct 2023
One Stockport Health and Care Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic social care shortages.
Mark McKessy
All Responded
2023-0377
9 Oct 2023
One Stockport Health and Care Board
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.
Sandra Curran
All Responded
2023-0378
9 Oct 2023
ABTA – The Travel Association
Foreign, Commonwealth & Development Off…
Other related deaths
Concerns summary
UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea swimming and snorkelling in unfamiliar locations with strong currents.
Lauren Bridges
All Responded
2023-0438
19 Sep 2023
Department of Health and Social Care
NHS England
Mental Health related deaths
Concerns summary
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant communication failures.
Thomas Barton
All Responded
2023-0264
21 Jul 2023
Greater Manchester Integrated Care
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.