Manchester South

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

79% response rate (above 63% average).

Response Status
Responded 400 No Response 2 Historic 103 Pending 1
AI Classification
Action Taken 40%
Action Planned 34%
Noted 26%
Disputed 1%
Based on 598 classified responses
Top Categories
Hospital Death (Clinical Procedure… (261) Community health care and emergenc… (75) Suicide (from 2015) (60) Care Home Health related deaths (56) Other related deaths (53)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: +386 reports · +16pp response rate
vs national average: +422 reports · +16pp response rate
Clear 358 results
Jane Wadsworth
All Responded
2023-0251Deceased 17 Jul 2023
NHS England Tameside and Glossop Integrated Care NH…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.
Noted (AI summary) NHS England acknowledges the concerns and states that the Tameside and Glossop Integrated Care NHS Foundation Trust is the appropriate organisation to respond. They note the Trust's response addresses the concerns and that they have been implementing improvement work. The Critical Care Unit has amended their daily review chart to provide additional clarity and comprehensive documentation regarding referrals to the Liver Unit. Also clinical induction training includes intravenous (IV) cannulation for all registered staff.
Andre Moura
All Responded
2023-0348 3 Jul 2023
College of Policing National Police Chiefs Council
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.
Action Planned (AI summary) The College of Policing has revised its First Aid Learning Programme (FALP) and the new Public and Personal Safety Training (PPST) training implementation went live in 2023, and the revised ABD training package will be published mid-September 2023. The NPCC is revising the Body Worn Video (BWV) guidance to include that BWV should be left running during periods of prisoner transport. This guidance will be published in October.
Anita Graves
All Responded
2023-0201 20 Jun 2023
Medicines & Healthcare products Regulat…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.
Action Planned (AI summary) The MHRA has sought advice from the DHSC, GPhC and RPS and describes planned changes to medicine packaging and dispensing, including the introduction of mandatory Patient Information Leaflets and monitoring of carbimazole overdoses.
Michael Sullivan
All Responded
2023-0200 20 Jun 2023
Stockport Integrated Care Partnership
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding GP understanding, CRT prioritization, or triage effectiveness, causing patients to become seriously unwell before assessment.
Action Planned (AI summary) NHS Greater Manchester Integrated Care will present learning from this case to the Greater Manchester System Quality Group on 21st September 2023. Shared learning from this and similar cases will be cascaded to professionals through relevant governance and learning forums.
Joan Corcoran
All Responded
2023-0197 20 Jun 2023
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Widespread, significant ambulance response delays for Category 2 calls, drastically exceeding target times, are caused by multifactorial issues including high demand and prolonged A&E handover times, directly contributing to patient deterioration and death.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance response times. The response references the 'Delivery plan for recovering urgent and emergency care services' and notes improvements in ambulance response times and handover delays but acknowledges more work is needed.
Roger Southwick
All Responded
2023-0158 16 May 2023
Tameside and Glossop Integrated Care NH…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies failures to accurately complete a Falls Risk Assessment and to reassess the risk after family members reported the deceased's compromised mobility; the Trust's Investigation Report also failed to address these issues.
Action Taken (AI summary) The Trust already holds daily ward safety huddles to discuss patients at risk of falls, and has a number of existing practices and processes for falls prevention in place. They also held a "Focus on Falls Week" in September 2022 which is now an annual event.
Carl Thompson
All Responded
2023-0157 16 May 2023
Pennine Care NHS Foundation Trust
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.
Action Taken (AI summary) The trust has revisited its investigation report to support review of action plans, re-established a Just Culture meeting, is considering updated training for investigation authors, established a PSIRF implementation group, made patient safety training available online, and planned to share learning slides around inquest preparation.
Benedict Peters
All Responded
2023-0156 16 May 2023
Manchester University NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.
Action Planned (AI summary) The Trust will remind all Physician Associates of the need to discuss patients for discharge with senior medical colleagues and reiterate to all junior medical staff and non-medical clinical practitioners, that it remains good practice to discuss cases with their seniors for learning and development.
Drew Howe
All Responded
2023-0155 15 May 2023
Pennine Care NHS Foundation Trust
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.
Action Planned (AI summary) The Trust will address the coroner's concerns by several actions including; offering awareness sessions, trust wide learning, case reflection with teams and ensuring assessment information is shared between services. They will also explore training around understanding trauma.
Rebecca Fisher
All Responded
2023-0154 15 May 2023
Greater Manchester Police
Suicide (from 2015)
Concerns summary (AI summary) GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information sharing. The effectiveness of new training and tools remains unconfirmed.
Action Taken (AI summary) GMP has rolled out an Aide Memoire system, enhanced training, developed a supervisor's checklist, and conducts audits every six months to improve responses to missing persons. District performance is reviewed quarterly.
Raymond Lee
All Responded
2023-0151 15 May 2023
National Institute for Health and Care … NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus stenting and associated perforation risks.
Noted (AI summary) NHS England acknowledges the need for better guidance on managing oesophageal stenting and will work with AUGIS and NICE to develop national, evidence-based advice. The Greater Manchester Cancer Alliance will develop a clear pathway for the management of oesophageal stenting. NICE acknowledges the concerns about oesophageal strictures and limited guidance and will log the report and consider further the concerns regarding contraindications for stenting.
Jordan Clare
All Responded
2023-0104Deceased 26 Mar 2023
Department of Health and Social Care
Alcohol, drug and medication related deaths Other related deaths Suicide (from 2015)
Concerns summary (AI summary) There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care frameworks, leading to fragmented support and increased risk during crises.
Action Taken (AI summary) Following the death, Stockport introduced a new Adult Complex Safeguarding Strategy endorsed by ADASS. The Stockport Safeguarding Adults Partnership’s Multi Agency Policy for Safeguarding Adults at Risk lays out locally agreed multi-agency procedures.
Celia Sanderson
All Responded
2023-0052Deceased 10 Feb 2023
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to trauma centers.
Noted (AI summary) NHS England acknowledges the concerns, discusses Greater Manchester Integrated Care's challenges, and points to national guidance on UEC recovery. The Regulation 28 Working Group will share learnings nationally. The Department of Health and Social Care acknowledges the concerns raised, noting that NHS England has addressed them, including action taken locally and a Major Trauma Network. They highlight national initiatives for urgent and emergency care improvements.
Sandra Lomax
All Responded
2023-0051Deceased 10 Feb 2023
Greater Manchester Integrated Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
Action Planned (AI summary) Greater Manchester Integrated Care will present learning from the case with the Greater Manchester System Quality Group. Shared learning from this and similar cases will be cascaded to professionals through governance and learning forums. NHS England will share the coroner's report with System Quality Groups and review proposals from The Christie regarding chemo-radiotherapy and stenting services. The Regulation 28 Working Group will discuss all reports received to identify key learnings and emerging trends.
Patricia Green
All Responded
2023-0044Deceased 4 Feb 2023
Department of Health and Social Care
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and deterioration of frail, elderly patients.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance demand and delays in Greater Manchester, highlighting national efforts to improve ambulance response times, increase hospital bed capacity, and ensure timely hospital discharge.
Kirsty McKie
All Responded
2023-0043Deceased 4 Feb 2023
Foreign Secretary
Other related deaths
Concerns summary (AI summary) There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Action Planned (AI summary) The British Consulate in Bali will place an information banner about methanol poisoning risks in the international arrival area of the local airport from June to December, and the FCDO will engage with the UK Travel Industry and Student Brand Ambassadors to raise awareness.
Benjamin Stanley
All Responded
2023-0042Deceased 4 Feb 2023
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack of hospital beds, delaying patient care and ward admissions.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about A&E waiting times and bed capacity at Stepping Hill Hospital, highlighting national efforts to improve emergency care through increased bed capacity, virtual wards, and funding for timely hospital discharge.
Philip Day
All Responded
2022-0351 4 Nov 2022
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack of awareness for neutropenic sepsis guidance also led to missed red flags and delayed critical treatment.
Action Taken (AI summary) NHS England (NHSE) is committed to finding ways to make awareness of the potential for sepsis, and the response to it, ever more consistent. The department has seen improvement in A&E waiting times this year following the Delivery Plan’s publication.
Ellen MacFarlane
All Responded
2022-0350 4 Nov 2022
Department of Health and Social Care
Care Home Health related deaths Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests at district general hospitals delays urgent surgery, contradicting best practice.
Noted (AI summary) The Department of Health and Social Care notes the concerns regarding ambulance response times and access to hospital services and says that ambulance performance is reviewed regularly. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance
Graham Flindle
All Responded
2022-0349 4 Nov 2022
Greater Manchester Health and Social Ca…
Other related deaths
Concerns summary (AI summary) Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled to identify critical haemoglobin test results amidst high volumes, highlighting a need for better prompts and education.
Action Planned (AI summary) Greater Manchester Integrated Care's Cancer Alliance recirculated a webinar and resources on cancer and anemia to primary care clinicians and is developing clinical decision support tools for GPs to "think cancer" when certain codes are entered. Learning will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
John Fallon
All Responded
2022-0348 4 Nov 2022
Greater Manchester Health and Social Ca…
Care Home Health related deaths Other related deaths
Concerns summary (AI summary) Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Action Planned (AI summary) NHS Greater Manchester Integrated Care will share learning from this case with the Greater Manchester System Quality Group and cascade it to professionals through relevant governance and learning forums. The Team are currently looking into any additional training in relation to obstructed airways that can be undertaken by care home staff.
Kenneth Goodwin
All Responded
2022-0318 14 Oct 2022
Stockport NHS Foundation trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate handover for falls risk patients, slow completion of falls risk assessments on new wards, and inconsistent use of visual fall-risk signs on beds posed a safety concern.
Action Taken (AI summary) Stockport NHS Foundation Trust relaunched its formal patient handover document and the use of maple leaf signs for patients at risk of falls across the Trust on 15 November 2022, adding the latter to agency staff induction checklists.
Grenville Wait
All Responded
2022-0195
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting ongoing issues with service demand and capacity.
Action Taken (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance pressures and details significant ongoing actions, including an additional £3.3 billion investment, increased bed capacity, a £500 million discharge fund, and targeted support for hospitals to improve ambulance handover delays and expand the paramedic workforce.
Diane Austin-Martin
All Responded
2022-0286 14 Sep 2022
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary) The report identifies a lack of mechanisms to ensure Social Services were aware of a vulnerable person's move, to ensure private care arrangements are of sufficient quality, and to maintain contact with agencies after initial claims and visits.
Noted (AI summary) The Department outlines duties and policies in Northern Ireland regarding support for vulnerable individuals moving locations and clarifies that NHS England has processes in place for managing newly registered patients, including initial assessments and referrals, noting that a consultation with Ms. Austin-Martin occurred shortly after registration.
Maureen Harrop
All Responded
2022-0285 14 Sep 2022
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Prolonged waits in the Emergency Department due to bed shortages and delays in essential surgery due to theatre capacity severely impacted the patient's physiological reserves and overall outcome.
Action Taken (AI summary) Tameside and Glossop ICFT has implemented a fractured neck of femur improvement programme, monitors compliance daily via the Divisional senior leadership team, and submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture.