Manchester South

Concerns summary The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high demand on EDs, fueled by broader health and social care failures.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Extended surgery wait times due to COVID backlogs and severe ambulance availability issues led to significant delays in critical care, causing distress and impacting patient outcomes.

Concerns 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.

Concerns summary There was a critical systemic failure in inter-agency communication, leaving a vulnerable person's relocation unknown to social services and without oversight of the quality of her private care arrangements.

Concerns summary The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental health conditions and substance misuse issues.

Concerns summary Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information sharing and holistic patient views.

Concerns summary The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown in properly recording and communicating the care plan with the family.

Concerns summary The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when he continued private practice. A critical lack of multi-disciplinary review, relying on the medical hierarchy, was noted given the gravity and prior similar cases.

Concerns summary A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to confusion, unclear communication, and misperceptions of authority. This created a significant safety risk, despite not directly contributing to these deaths.

Concerns summary Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be un-followed. The failure to escalate concerns was unclear.

Concerns summary Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. This impacts patient outcomes and mortality.

Concerns summary Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist nurse service's role was also poorly understood by community healthcare providers.

Concerns summary There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.

Concerns summary Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, and further compounded by theatre capacity and High Dependency Unit bed shortages.

Concerns summary There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.

Concerns summary Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care training.

Concerns summary A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate this lapse, missing critical opportunities for learning and systemic improvement in acting on abnormal imaging.

Concerns summary Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a failure in appreciating emerging patient risks.

Concerns summary The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow and comprehensive patient assessment within mental health teams.

Concerns summary Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain and discomfort.