Manchester South
Coroner Area
Reports: 506
Earliest: Aug 2013
Latest: 14 Apr 2026
79% response rate (above 63% average).
Shahzadi Khan
All Responded
2024-0046
31 Jan 2024
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Department of Health and Social Care outlines initiatives being implemented in Greater Manchester to address mental health bed shortages and improve awareness of menopause for healthcare staff. NHSGM ICB has a weekly meeting about out of area placements and is implementing a trajectory of improvement with NHS Trusts to reduce these placements.
Terence Briney
All Responded
2024-0042
29 Jan 2024
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of conducting thorough investigations.
Noted
(AI summary)
Greater Manchester Integrated Care reports on a review of Mr. Briney's case with the GP and hospital, noting efforts to identify treatable causes and investigations ordered. They acknowledged that communication with the family was not always timely and offered apologies for the delay in contacting them at the end of Mr. Briney's life.
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 (AI 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.
Action Planned
(AI summary)
The organisation has formulated an action plan in response to the concerns raised and shared it with the deceased's family. NHS England highlights existing national guidance on VTE prophylaxis and medicines optimisation, and states that it engages with ICBs on concerns raised in reports. They note that all reports received are discussed by the Regulation 28 Working Group.
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 (AI summary)
Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a local trust level.
Action Taken
(AI summary)
NHS England has developed a national Community Nursing Safer Staffing Tool, and the region has asked Greater Manchester Integrated Care Board to discuss the case further. The government has increased nurse numbers, and the NHS Long Term Workforce Plan aims to increase district nurse training places by 150% by 2031/32.
Claire Briggs
All Responded
2023-0513
8 Dec 2023
British Transport Police
Cheshire and Merseyside Integrated Care…
Cheshire Constabulary
+10 more
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Concerns summary (AI 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.
Noted
(AI summary)
North West Fire Control is supporting the embedding of Joint Emergency Services Interoperability Principles (JESIP) and working with partners to implement electronic data transfer for improved information sharing, expected by March 2024. NHS England outlines existing guidance for ambulance services relating to overdoses and suicidal intent issued in April 2021, and describes ongoing work to improve ambulance performance. Cheshire Constabulary has signed the Joint Operating Protocol (JOP) with NWAS and supports its endorsement by other parties, with a coordination meeting scheduled for January 16, 2024. Lancashire and South Cumbria ICB reports that four North West police forces have agreed and gone live with their Joint Operating Protocols (JOPs) with NWAS, with Greater Manchester Police in the final stages of agreement, and learning will be overseen by the NWAS Regional Clinical Quality Assurance Committee. Cumbria Constabulary has signed a regional Information Sharing Agreement (ISA) and has been working under a Joint Operating Procedure (JOP) since October 2023; it also provides clinical support through its "treat and hear" facility. Lancashire Fire and Rescue Service states that it was not involved in the incident, but is committed to improvement and learning. The service outlines its support for JESIP, reviews policies/procedures/training, and has an Immediate Emergency Care SOP with guidance on various areas. The North West Ambulance Service (NWAS) have engaged with all the North West Police Forces to develop a Joint Operating Protocol (JOP). Four forces have agreed and gone live with their JOPs, ensuring clear process for sharing information, primacy understanding, and a clear escalation process for any operational issues. Four of the North West police forces, including Cheshire Constabulary and Merseyside Police, have agreed and implemented Joint Operating Protocols (JOPs) with the North West Ambulance Service to improve information sharing and escalation processes. BTP has adopted the "Ten Second Triage" (TST) tool nationally and is delivering associated training in 2024. They also use ESICTRL radio talk groups for direct communication between emergency service control rooms. NWAS reports that a Joint Operating Protocol (JOP) has gone live with Cheshire, Cumbria, Lancashire and Merseyside Police Forces, and that an updated version has been agreed with Greater Manchester Police and is scheduled for implementation across the whole North West following a meeting in late February 2024; also, the JOP has been extended to include British Transport Police, North West Fire Control, and Fire and Rescue Services. Merseyside Fire and Rescue Service states that its existing procedures for communicating casualty information to NWAS are sufficient, including written instructions and escalation options. Response not parsable Lancashire Police has agreed to Version 1.3 of a Joint Operating Protocol (JOP) with regional forces and NWAS to provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays; awaiting final sign-off from GMP and Fire and Rescue.
Anthony Williams
All Responded
2023-0491
1 Dec 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
NHS England published image report turnaround time guidance and a delivery plan for tackling the COVID-19 backlog of elective care. They are also supporting Trusts to increase reporting capacity and increasing capacity to diagnostic tests through a planned Community Diagnostic Centre (CDC).
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 (AI 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.
Action Planned
(AI summary)
The Royal College of Paediatrics and Child Health will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and discuss it with the RCPCH Clinical Quality in Practice group in early Spring.
Kirsty Hendry
All Responded
2023-0394
20 Oct 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.
Action Planned
(AI summary)
NHS England will share the report with colleagues in their Primary Care, Nursing, and Neurology teams, and raise awareness through existing forums. NHS England has also engaged with Tameside and Glossop Integrated Care NHS Foundation Trust regarding the circumstances surrounding the care.
Holly Mullan
All Responded
2023-0390
17 Oct 2023
NHS England
Suicide (from 2015)
Concerns summary (AI 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.
Action Taken
(AI summary)
NHS England acknowledges concerns about increased waiting times for gastroenterology and gynaecology, and outlines the Delivery Plan for Tackling the COVID-19 Backlog of Elective Care. They are implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, and encouraging services to use pathways that allow patients to book their own follow-up care.
Terence Davenport
All Responded
2023-0389
17 Oct 2023
Greater Manchester Integrated Care
Care Home Health related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Learning from the report will be presented to Tameside Care Home Managers in December 2023 and ICFT Trust Colleagues in February 2024, focusing on sharing risk information and discharge issues. The learning will also be taken via the Tameside System Quality Group and shared via the GM System Quality to ensure robust information sharing across settings.
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 (AI 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.
Noted
(AI summary)
The Council provides a summary of Adult Social Care involvement prior to Mr. Hall's admission and highlights existing procedures and challenges in the social care market, including working with the independent sector and addressing gaps. It acknowledges challenges in the social care market and are continually working to address these through more flexible, sustainable and outcome focussed services.
Sandra Curran
All Responded
2023-0378
9 Oct 2023
ABTA – The Travel Association
Foreign, Commonwealth and Development O…
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
ABTA acknowledges the coroner's concerns and outlines its role in providing guidance to travel industry members and consumers, particularly regarding health and safety. They highlight their work with the FCDO and their consumer safety information, but state they are not aware of the full facts in the specific case. The FCDO has enhanced its Travel Advice on swimming safety to include a link to the Royal Life Saving Society’s (RLSS) “Water Safety on Holiday” page in the “Swimming safety” section of the “Safety and Security” page.
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 (AI 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.
Action Planned
(AI summary)
Stockport Integrated Care Partnership acknowledges the concerns and highlights that a joint learning event is planned for January 2024 to strengthen information sharing and improve practice related to supporting people with learning disabilities. They also plan to engage with the family to share experiences.
Lauren Bridges
All Responded
2023-0438
19 Sep 2023
Department of Health and Social Care
NHS England
Mental Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
NHS England reports on actions taken by Dorset Healthcare University NHS Foundation Trust: improvement to data and oversight, appointment of an out of area co-ordinator and a programme of quality assurance of providers used by the Trust. They have also secured planning permission to rebuild some of their mental health inpatient facilities and increase the availability of PICU for adults and younger people. Dorset HealthCare has made changes to the Hospital Overview document, enhanced the daily Hospital Overview situation report, improved communication between Clinical Site Managers and introduced monthly audits to ensure standards are met in patients receiving out of area care. The Department of Health and Social Care notes actions taken by NHS England and Dorset Healthcare University NHS Foundation Trust. They are investing in community mental health care and have published statutory guidance for discharge from all mental health inpatient settings.
Marion Nickson
All Responded
2023-0265
21 Jul 2023
Care Quality Commission
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that hinder effective falls prevention.
Action Planned
(AI summary)
NHS England commissions the National Audit of Inpatient Falls (NAIF) and has been significantly involved in the FallSafe training module produced by the RCP. The Trust have made recommendations to ensure staff have a refresher on the protocols and assessments available and that there are divisional leadership walk rounds with a focus on bay nursing, adherence to policy and the wearing of tabards. CQC has contacted Stockport NHS Foundation Trust and East Cheshire NHS Trust to request written confirmation and evidence of action taken to date, and any additional action they intend to take in response to the prevention of future death report. CQC is reviewing the facts and evidence to determine whether there are grounds to suspect that a criminal offence may have been committed, and whether a formal criminal investigation will be undertaken by the CQC.
Thomas Barton
All Responded
2023-0264
21 Jul 2023
Department of Health and Social Care
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
NHS Greater Manchester Integrated Care acknowledges concerns about the demand and availability of social care and has connected with Trafford Local Authority. Supported by NHS GM funding, localities have commissioned home from hospital support; NHS GM has undertaken capacity and demand modelling of home care and care home markets and will share learning across Greater Manchester. The Department of Health and Social Care acknowledges concerns over delayed hospital discharge due to social care package challenges. It notes that Trafford Council has redesigned the homecare offer, and Greater Manchester ICB has undertaken capacity and demand modelling of home care. The response also mentions national initiatives like the Hospital Discharge and Community Support Guidance.
Albert Dovey
All Responded
2023-0263
20 Jul 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after a fall.
Action Taken
(AI summary)
NHS England acknowledges concerns about ambulance delays at Tameside General Hospital, highlighting the Delivery plan for recovering urgent and emergency care services and the work of the North West Every Minute Matters Hospital Handover Collaborative, which has led to improved response times in Greater Manchester.
Marianne Erika
All Responded
2023-0262
20 Jul 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.
Action Planned
(AI summary)
NHS England highlights actions being taken to improve ambulance performance, hospital flow, and discharge processes under the UEC recovery plan. The GM Imaging Network is supporting upskilling of the imaging workforce and coordinating international recruitment to address radiologist vacancies.
Elliott Harratt
All Responded
2023-0261
20 Jul 2023
Greater Manchester Integrated Care
Child Death (from 2015)
Concerns summary (AI summary)
Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn babies.
Action Planned
(AI summary)
NHS Greater Manchester Integrated Care will share learning from the case with the Greater Manchester System Quality Group and at the Local Maternity and Neonatal Network Safety Assurance Panel to ensure learning is incorporated into commissioned services.
Michael Amesbury
All Responded
2023-0259
19 Jul 2023
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.
Action Planned
(AI summary)
NHS Greater Manchester plans to scale and spread the Patient Pass model of care within the GM ICS, leveraging the installed user base and existing clinical pathways. Deployment at an ICS level would enable complex case transfers and out-patient planning to be managed at a higher and more efficient level.
Sylvia Pollitt
All Responded
2023-0258
19 Jul 2023
L&Q Group Housing
Other related deaths
Concerns summary (AI summary)
The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.
Action Taken
(AI summary)
L&Q took immediate action following the inquest, including self-referring to the Regulator for Social Housing. They have implemented additional processes and checks, including aligning call recording processes, instituting weekly meetings with Liberty to review all jobs raised, and automatically following up on incomplete jobs with welfare checks.
Bernhard Marek
All Responded
2023-0257
19 Jul 2023
Department of Health and Social Care
Greater Manchester Integrated Care
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The report cites concerns about ambulance service delays due to high demand and resource issues, which are exacerbated by long waits to offload patients at Emergency Departments, impacting frail elderly patients with hip fractures.
Action Taken
(AI summary)
NHS Greater Manchester Integrated Care shared learning from the case with the Greater Manchester System Quality Group and cascaded it to professionals through relevant governance and learning forums. Ambulance performance is reviewed regularly, and they are committed to achieving ARP standards. The DHSC describes national actions to improve urgent and emergency care, including ambulance resources, increasing hospital bed capacity, scaling up virtual wards, and funding for timely discharge. They report improvements in ambulance response times.
Thelma Radmore
All Responded
2023-0256
19 Jul 2023
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail patients.
Action Taken
(AI summary)
The DHSC outlines actions taken nationally to improve urgent and emergency care, including dedicated funding, scaling up virtual ward capacity, and providing funding for timely discharge from hospitals. They report improvements in ambulance response times and A&E waiting times.
Evelyn Dutton
All Responded
2023-0254
19 Jul 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their health.
Action Taken
(AI summary)
NHS England acknowledges the pressures on ambulance services and highlights the Delivery plan for recovering urgent and emergency care services. The North West Every Minute Matters Hospital Handover Collaborative has seen improvements in Greater Manchester, and ambulance performance is reviewed regularly.
Christine Dickinson
All Responded
2023-0255
18 Jul 2023
Stockport NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Action Taken
(AI summary)
The Trust is piloting a new paper-based 'Sepsis Six' assessment, with plans to digitize it, and has purchased additional computers on wheels for nurses to document at the patient's side. They are also participating in an electronic patient record (EPR) programme with the aim to procure and implement a single electronic patient solution to replace the majority of the Trust’s clinical systems.