Manchester South
Coroner Area
Reports: 506
Earliest: Aug 2013
Latest: 14 Apr 2026
79% response rate (above 63% average).
Oliver Lindsay
All Responded
2022-0103
6 Apr 2022
Department of Health and Social Care
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
NHSEI published a Core Competency Framework to address variation in maternity and neonatal training and competency assessment, including training on the Saving Babies Lives Care Bundle Version 2, which includes monitoring fetal growth restriction.
Matthew McManus
All Responded
2022-0044
11 Feb 2022
Department of Health and Social Care
Greater Manchester Health and Social Ca…
Alcohol, drug and medication related deaths
Mental Health related deaths
Other related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned
(AI summary)
Greater Manchester Health & Social Care Partnership acknowledges the potential gap in support for patients with complex needs and describes initiatives to improve data sharing, training, and oversight. They plan to present learning to the Greater Manchester Quality Board and cascade learning through governance and learning forums. The Department of Health and Social Care is implementing the Community Mental Health Framework (CMHF) to improve joined-up support across health and social care, aiming for all areas to have these models in place by the end of 2023/24. It also highlights increased collaboration through the Health and Care Act 2022 and the government's integration white paper.
Joy Burgess
All Responded
2022-0038
4 Feb 2022
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned
(AI summary)
The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following the consultation.
Mark Jones
All Responded
2022-0040
3 Feb 2022
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Chief Dental Officer will reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners, and will cascade similar communication and guidance to NHS general medical practitioners.
Jos Tartese-Joy
All Responded
2021-0435
31 Dec 2021
Department of Health and Social Care
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
DHSC notes that £52 million was announced to fast track the provision of online maternity records and NHSE has updated the maternity early warning score (NEWS2) chart and the updated element seeks to focus more attention on pregnancies at high-risk of fetal growth restriction. A standardised risk assessment tool that all trust should use at the onset of labour has been developed.
Yousef Makki
All Responded
2021-0434
31 Dec 2021
Department for Education
Other related deaths
Product related deaths
Concerns summary (AI summary)
The coroner notes a culture among some teenagers of viewing knife possession as impressive without understanding the risks, and that the knife used in the stabbing was easily purchased during school break time, highlighting the vital role of schools and education in addressing attitudes towards knife carrying.
Action Planned
(AI summary)
The Department for Education is investing in educational resources to address knife crime and serious youth violence, and investing £45 million in two new programmes including Alternative Provision Specialist Taskforces and the SAFE Taskforces programme.
Malcolm Dixon
All Responded
2021-0396
25 Nov 2021
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
The DHSC acknowledges concerns raised and outlines the roles of the CQC, NHS England, and NHS Digital in ensuring patient safety and appropriate training and supervision of healthcare staff, particularly Health Care Assistants, and refers to guidance on clinical risk management for health IT systems.
Michelle Jeffries
All Responded
2021-0395
22 Nov 2021
Trafford Clinical Commissioning Group a…
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
NHS Trafford CCG has recently highlighted to practices that prescribing of analgesia is an area they could work collaboratively on to ensure that patients get the best outcomes from their treatment and has included it in their “Practice Briefing” for Primary Care staff, highlighting a number of risks that can occur in healthcare where potent and high risk medicines are prescribed. NHS Greater Manchester will share learning from this and similar cases via governance forums, and CCGs will report on reducing over-prescribing of analgesia. They will also share advice and guidance and increase staff awareness regarding available materials, and monitor key learning points.
Alan Hunter
All Responded
2021-0369
25 Oct 2021
Stockport NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The Trust had already begun improvement work related to MUST, nutrition and hydration prior to the inquest, including monthly steering group meetings, training (90.76% compliance), ward audits, and nutrition/hydration information boards. Quality assurance checks and daily safety huddles now include a review of nutrition and hydration concerns and weight completion where appropriate; the Trust also participated in Malnutrition Awareness Week in October 2021.
Donna Constantine
All Responded
2021-0350
19 Oct 2021
National Police Chiefs’ Council, Home O…
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit trails for communication.
Noted
(AI summary)
The Home Office acknowledges the concerns and states that police forces are operationally independent and it is for Greater Manchester Police, the NPCC and the College of Policing to address the issues raised. The NPCC and College of Policing note the concerns and explain that the Victims Code was updated in April 2021. They state that forces are not encouraged to give out mobile phone numbers and provide guidance for officers receiving emergency calls.
Irene Esaw
All Responded
2021-0307
Tameside and Glossop Integrated Care NH…
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about responsibility between clinical and integrated care teams led to inadequate needs assessments.
Action Planned
(AI summary)
Tameside MBC has developed a comprehensive multi-agency action plan to address concerns regarding mental capacity assessment and multi-agency working, which will be shared in December 2021. A Multiagency Action Plan Group and a Quarterly Multiagency Learning Forum will be established to monitor and support learning.
Barry Martin
All Responded
2021-0302
10 Sep 2021
Jigsaw Homes Tameside
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Jigsaw Homes Tameside states that its technician checked for alternative exits before boarding the door and the tenant had keys to the rear door.
Maureen Johnson
All Responded
2021-0298
7 Sep 2021
National Institute for Health and Care …
Community health care and emergency services related deaths
Concerns summary (AI 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.
Noted
(AI summary)
NICE states they have a Clinical Knowledge Summary on gastroenteritis, which they believe gives appropriate advice, and that no action is required of them.
Bituin Pimlott
All Responded
2021-0293
6 Sep 2021
NHS England
Stockport Clinical Commissioning Group
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer patients to crisis teams.
Noted
(AI summary)
Stockport Clinical Commissioning Group states that face-to-face GP consultations are available where clinically appropriate or requested. They have re-circulated information sheets detailing referral options to GP practices and delivered presentations on suicide prevention. The practice involved in the case has completed a reflection exercise. NHS England acknowledges concerns about telephone consultations and referral guidance, referencing existing national guidance on safety netting. They note the local CCG has provided a separate response detailing relevant information and steps taken, and do not propose responding further on a national level.
Elaine Inns
All Responded
2021-0285
26 Aug 2021
Stockport Clinical Commissioning Group
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The Stockport CCG reports that the GP practice involved had already undertaken a detailed significant event analysis. The practice has changed its administrative process to refer all out of hours correspondence for patients with a safeguarding alert to GPs for review within 48 hours, and has provided staff training focused on opiate prescribing and identification of patients at risk.
James Golds
All Responded
2021-0284
26 Aug 2021
Ministry of Communities, Housing and Lo…
Care Home Health related deaths
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Department for Levelling Up, Housing & Communities references existing building regulations, guidance, and the role of fire and rescue authorities, but does not commit to further action.
Maurice Leech
All Responded
2021-0279
23 Aug 2021
Department of Health and Social Care
NHS England
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
NHS England and NHS Improvement references existing guidance for telephone consultations, safety measures, and pain management of fractures; they indicate learning from the death will be shared. The Department of Health and Social Care acknowledges concerns raised, explains changes to general practice during the pandemic, and highlights existing NICE guidance and resources for remote consultations.
Norma Rushworth
All Responded
2021-0278
23 Aug 2021
Greater Manchester Health and Social Ca…
NHS England
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Greater Manchester Health and Social Care Partnership will present learning from the case to the Greater Manchester Quality Board, communicate advice and guidance to relevant providers, and share learning through governance and learning forums. NHS England expresses condolences, acknowledges the concerns, and highlights national guidance and resources for wound care and remote consultations, including the National Wound Care Strategy Programme.
Stanislaw Zielinski
All Responded
2021-0277
20 Aug 2021
Department of Health and Social Care
NHS England
Secretary of State of Health
+1 more
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Tameside and Glossop CCG acknowledges the concerns, explains the challenges faced during the pandemic, and states it will work with providers to optimise access times to mental health services. The response expresses condolences and acknowledges the concerns regarding the impact of COVID-19 restrictions on healthcare delivery. It notes that general practice has been delivering services according to national Standard Operating Procedures, and provides a list of support services. The Minister acknowledges the concerns raised and highlights existing NHS England guidance for general practices, including offering face-to-face appointments and managing mental health patients. It also mentions a consultation on new waiting time standards for community-based mental health services.
Lesley Mawby
All Responded
2021-0208
18 Jun 2021
Stockport NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.
Action Planned
(AI summary)
The Trust has implemented twice-daily triage by a senior dietitian, prioritising patients, and is updating its enteral feeding policy with specific guidelines for administration. The CCG is satisfied with the Trust's response, and has requested a commissioning led review to ensure service levels can be consistently delivered.
Brian Mottram
All Responded
2021-0201
11 Jun 2021
Tameside Clinical Commissioning Group
Community health care and emergency services related deaths
Concerns summary (AI summary)
GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for vulnerable patients.
Action Taken
(AI summary)
Tameside and Glossop CCG developed a COVID Oximetry @home service to monitor patients, providing safety netting information for low-risk patients and home oxygen monitoring for others, with escalation to hospital if needed. This service includes monitoring for 14 days and adapting to evolving pandemic circumstances.
Clive Rivers
All Responded
2021-0199
10 Jun 2021
Department of Health and Social Care
NHS England
Care Home Health related deaths
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.
Noted
(AI summary)
NHS England explains that vaccinations were initially prioritized for staff, discusses discharge policies aligned with national guidance, and highlights the use of Criteria to Reside for discharge decisions, with efforts to expedite discharges where possible. The Department of Health and Social Care extends condolences and explains the JCVI's role in vaccine prioritisation, highlighting the initial focus on reducing mortality and protecting healthcare staff. It also mentions support for hospital discharge pathways and ongoing reviews of COVID-19 deaths.
Emiel Malinski
All Responded
2021-0198
10 Jun 2021
Home Office
Other related deaths
Product related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Action Planned
(AI summary)
The Home Office is reviewing the firearms licensing exemption for miniature rifle ranges, prompted by the incident. They conducted a public consultation on tightening controls and will consider the responses before deciding on further measures.
Steven Allen
All Responded
2021-0190
2 Jun 2021
Stockport Clinical Commissioning Group
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
Action Planned
(AI summary)
Stockport CCG's Medicines Management Team is in discussion with Primary Care Network Leads to explore how the Stockport Integrated Pharmacy Service can support practices in medication reviews for vulnerable patients. Stockport GPs will be reminded of available resources for opioid prescribing support.
Roger Ballard
All Responded
2021-0168
24 May 2021
Tameside & Glossop Integrated Care NHS …
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.
Action Planned
(AI summary)
The trust plans to implement an electronic flagging system to identify when clinicians are not reviewing imaging reports in a timely manner, share the case at Clinician forums and has mandated personal learning and reflection for those involved in the care.