Manchester South

Concerns summary A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.

Concerns summary The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also concerns about limited access to specialist pain clinics and underutilization of practice pharmacists for complex pain management.

Concerns summary Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private ambulance was dispatched due to miscategorization, leading to further delays.

Concerns summary A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.

Concerns summary Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.

Concerns summary While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary care.

Concerns summary National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.

Concerns summary Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing timely ambulance clearance.

Concerns summary Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention and parental awareness.

Concerns summary An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.

Concerns summary Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.

Concerns summary Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.

Concerns summary A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding of the inherent risks.

Concerns summary A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.

Concerns summary Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting observations lacked professional regulatory oversight.

Concerns summary There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the community and when a mandatory referral to a pain specialist is required.

Concerns summary Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.

Concerns summary Following forced police entry, an occupied house was left with its main exit boarded up and the secondary exit unusable, creating a significant fire safety risk by denying residents alternative escape routes.

Concerns summary A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.

Concerns summary Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer patients to crisis teams.

Concerns summary Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.

Concerns summary Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage instructions, posing a significant risk.

Concerns summary Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating health.

Concerns summary Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and incomplete information. There is no specific NICE guidance for elderly femur fracture management.

Concerns summary COVID-19 restrictions significantly impacted care delivery, leading to insufficient face-to-face GP consultations and delayed mental health support, preventing early recognition of deteriorating health.