Manchester South

Concerns summary The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.

Concerns summary Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and Hydration Committee suffers from inconsistent support and attendance.

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 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 The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.

Concerns summary Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.

Concerns summary Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of clinical discussions pose significant risks to patient care.

Concerns summary Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and a lack of follow-up systems for referrals hindered effective patient care and risk identification.

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 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 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 Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.

Concerns summary Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.

Concerns summary A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid protocol adherence, creating a significant gap in supervision for vulnerable individuals falling between service remits.

Concerns summary There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.

Concerns summary Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked patient safety.

Concerns summary No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.

Concerns summary Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not adequately understood or managed.

Concerns summary Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.

Concerns summary Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.

Concerns summary Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic adolescents create high-risk situations for mental health and self-harm.

Concerns summary Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.

Concerns summary GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.