Manchester South

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

77% response rate (above 62% average).

Clear 346 results
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.