Manchester South

Concerns summary Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID wards, a risk potentially unresolved in other trusts.

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 A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.

Concerns summary Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits hindered comprehensive risk assessment and family involvement.

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.

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 Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.

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 Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.

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.