Manchester South
Coroner Area
Reports: 504
Earliest: Aug 2013
Latest: 4 Mar 2026
77% response rate (above 62% average).
Andrew Hughes
All Responded
2026-0099
5 Dec 2025
Deputy Mayor of Greater Manchester
Greater Manchester Integrated Care Board
Suicide (from 2015)
Concerns summary
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.
Action taken summary
Greater Manchester Integrated Care clarified that mental health services provide a crisis response, not an emergency response, which is the responsibility of 999 services. They acknowledge an ongoing
Lewis Bates
All Responded
2025-0602
1 Dec 2025
Greater Manchester Police
Suicide (from 2015)
Concerns summary
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an inappropriate police response.
Action taken summary
Greater Manchester Police commits to drafting new policy and guidance by April 2026 to define "reasonable enquiries" and address advising callers to contact medical professionals. They will also provi
Ronald Perry
All Responded
2025-0580
14 Nov 2025
Lakes Care Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Action taken summary
The Lakes Care Centre has appointed a new manager, completed 7 weeks of induction training for all Senior Carers, and improved the use of their Digital Care Record system for …
Margaret Crooks
All Responded
2025-0581
14 Nov 2025
Greater Manchester Integrated Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
Action taken summary
Greater Manchester Integrated Care has reviewed its Comprehensive Stroke Centre service specification and Standard Operating Procedure. Following this, the network plans to add further detail to the S
Richard Worswick
All Responded
2025-0564
7 Nov 2025
Bamford Grange Care Home
Stockport NHS Foundation Trust
Care Home Health related deaths
Concerns summary
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Action taken summary
Bamford Grange Care Home has issued refresher guidance on existing policies for re-admission and wound care monitoring, ensuring all calls to external teams are documented (including unsuccessful ones
Oliver Gorman
All Responded
2025-0558
4 Nov 2025
Department for Culture
Department for Business and Trade
Innovation and Technology
+3 more
Child Death (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful content promoting such misuse.
Action taken summary
The Office for Product Safety and Standards (OPSS) is working with industry to develop a new voluntary initiative to introduce prominent safety warnings on aerosol products, with anticipated implement
Derek Crowther
All Responded
2025-0500
9 Oct 2025
Pennine Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.
Action taken summary
The Trust has launched a new Mandatory Training Policy and a monitoring dashboard to ensure staff complete required Intermediate Life Support training. They have also established a project group to …
Honoria Culshaw (1)
All Responded
2025-0479
24 Sep 2025
Manchester University NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment for infection.
Action taken summary
Manchester University NHS Foundation Trust is currently implementing new processes within its electronic patient record (HIVE) to allow discharge letters to be sent to additional healthcare providers.
Honoria Culshaw (2)
All Responded
2025-0480
24 Sep 2025
Lancashire Teaching Hospitals NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
Action taken summary
The Trust has implemented a new 'Wound Swab Policy and Guidance for Device Related Infections' and delivered training to cardiology staff on expected management. A Standard Operating Procedure for pre
Ricky O’Connell
All Responded
2025-0433
20 Aug 2025
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.
Action taken summary
The Department references its June 2025 10-Year Health Plan and Urgent and Emergency Care Plan for 2025/26, which includes nearly £450 million in capital investment for emergency care and new …
Marion Jones
All Responded
2025-0413
7 Aug 2025
Care UK
Care Home Health related deaths
Concerns summary
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.
Action taken summary
Care UK has revised pre-admission assessment forms to include a specific bed rail section, introduced mandatory staff training on the updated Bed Rail Policy and Risk Assessment Form, and updated …
Kenneth Edwards
All Responded
2025-0414
7 Aug 2025
Stockport NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Action taken summary
The Trust has reinforced standards for consent, handover, and clinical documentation, and continues close collaboration with its out-of-hours radiology service and engagement in Radiology Education an
Leslie Thompson
All Responded
2025-0385
29 Jul 2025
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital environment.
Action taken summary
The Department of Health and Social Care is strengthening partnerships between NHS and social care, outlined in the recently published 10 Year Health Plan, to reduce hospital discharge delays. They …
Doreen Swann
All Responded
2025-0359
10 Jul 2025
Greater Manchester Integrated Care
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.
Action taken summary
The department acknowledges the impact of social care capacity on delayed hospital discharges, highlighting existing strategies like care transfer hubs, the Better Care Fund, and over £4 billion addit
Neil Clarke
All Responded
2025-0332
2 Jul 2025
Stepping Hill Hospital
NHS England
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.
Action taken summary
NHS England provided context on existing tools for assessing frailty and supporting shared decision-making for elderly patients and referred to Stockport NHS Foundation Trust for details on handover c
Brenda Fisher
All Responded
2025-0327
27 Jun 2025
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.
Action taken summary
The Department for Health and Social Care notes Stockport NHS Foundation Trust has opened a new Emergency and Urgent Care Campus with updated escalation plans and an SOP for corridor …
Valerie Hampson
All Responded
2025-0306
18 Jun 2025
Tameside and Glossop Integrated Care NH…
Community health care and emergency services related deaths
Concerns summary
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.
Action taken summary
The Trust clarifies that no fracture clinic follow-up appointment was made for Mrs Hampson as no fracture was identified, contrary to the coroner's concern. For district nursing care, a review …
Lila Marsland
All Responded
2025-0291
11 Jun 2025
Tameside and Glossop Integrated Care NH…
Department of Health and Social Care
Child Death (from 2015)
Concerns summary
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being lost.
Action taken summary
Tameside and Glossop Integrated Care NHS Foundation Trust has implemented daily audits for PEWS and sepsis, devised individual and Trust-wide sepsis action plans, and developed a bespoke Paediatric Se
Andrew Connolly
All Responded
2025-0290
10 Jun 2025
Greater Manchester Integrated Care Board
Suicide (from 2015)
Concerns summary
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these situations.
Action taken summary
NHS Greater Manchester Integrated Care will produce and distribute an advice briefing for GPs reminding them of responsibilities for mental health patients, appropriate appointment modes, and family i
Esme Atkinson
All Responded
2025-0284
6 Jun 2025
Department of Health and Social Care
Greater Manchester Integrated Care Board
Child Death (from 2015)
Concerns summary
Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed diagnosis.
Action taken summary
The Department of Health and Social Care (DHSC) states NHS England has commissioned a review of congenital heart disease (CHD) pathways, due in Q4 2025/26, to inform future national guidance …
Janet Anderson
All Responded
2025-0219
9 May 2025
Greater Manchester Mental Health
Greater Manchester Integrated Care Board
Manchester University NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.
Action taken summary
Manchester University NHS Foundation Trust has held discussions with Greater Manchester Mental Health (GMMH) and developed a clearer escalation pathway for delayed mental health patient discharges. GM
Jake Lawler
All Responded
2025-0220
9 May 2025
Department of Health and Social Care
Child Death (from 2015)
Concerns summary
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed cardiac conditions in children.
Action taken summary
The Department of Health and Social Care reports that NHS England is reviewing national guidance and has published guidance to support implementation of neighbourhood multidisciplinary teams for impro
Louise Rosendale
All Responded
2025-0207
30 Apr 2025
Flixton Road Medical Centre
Greater Manchester Integrated Care Board
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed planning for such patients.
Action taken summary
Flixton Road Medical Centre has reviewed its practices and will provide additional staff education and guidance to reinforce safe opiate prescribing, monitoring, and administration. They will also imp
Robert Smith
All Responded
2025-0181
10 Apr 2025
Greater Manchester Integrated Care Board
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due to demand exceeding commissioned capacity.
Action taken summary
NHS Greater Manchester Integrated Care has invested in expanding its psychological therapy workforce, introduced enhanced access to out-of-hours community mental health services, and established a 24/
Bernard Lyon
All Responded
2025-0179
9 Apr 2025
Tameside Metropolitan Borough Council
Care Quality Commission
Department of Health and Social Care
Care Home Health related deaths
Concerns summary
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment delays.
Action taken summary
The CQC disputes concerns regarding the care home's reliance on agency staff with communication issues and their attendance at Multi-Agency Concern meetings, stating inspections found no such evidence