Manchester South

Concerns summary Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health bed waits were also exacerbated by fragmented commissioning.

Concerns summary Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs were also not integrated into long-term plans.

Concerns summary Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external reporting service, Medica, has not committed to implementing this essential practice, leaving patients at risk.

Concerns summary Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk of critical information loss.

Concerns summary Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear multi-agency strategy for complex cases involving trauma and alcohol misuse.

Concerns summary Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also no escalation process for medication refusal, exacerbated by a national bed shortage.

Concerns summary National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls and contracting nosocomial infections.

Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.

Concerns summary A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.

Concerns summary The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.

Concerns summary The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.

Concerns summary Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.

Concerns summary The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. Vulnerable elderly patients sent to hospital alone faced significant communication barriers, hindering their care.

Concerns summary Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.

Concerns summary The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.

Concerns summary GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked national guidance on recognising and escalating dehydration risks.

Concerns summary Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.

Concerns summary The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.

Concerns summary Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.