Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 10 Feb 2026
69% response rate (above 62% average).
Owen Donnelly
All Responded
2025-0532
17 Oct 2025
Department of Health and Social Care
Suicide (from 2015)
Concerns summary
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons while legislation is pending.
Action taken summary
The Home Office confirms that the Border Security, Asylum and Immigration Bill, expected to achieve Royal Assent by December, will make it a criminal offence to import, make, adapt, supply, …
Melanie Walker
All Responded
2025-0529
17 Oct 2025
NHS England
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.
Action taken summary
Philips reset the 'ECG Leads Off' alarm at the specific hospital to its factory default medium priority. However, Philips disputes the need for wider changes to their product's default settings, …
David Hayes
All Responded
2025-0371
18 Jul 2025
Royal Society for Prevention of Acciden…
Department of Environment Food and Rura…
Product related deaths
Concerns summary
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, due to inadequate warnings and public awareness.
Action taken summary
Dementia UK states its 'Keeping safe at home' leaflet already provides information on safe use and storage of laundry products. They are actively engaging with the UK Cleaning Products Industry …
Elaine Tarbuck
All Responded
2025-0342
7 Jul 2025
Greater Manchester Police
College Of Policing
Police related deaths
Concerns summary
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Action taken summary
Greater Manchester Police (GMP) states they have implemented the Right Care Right Person (RCRP) model for managing concern for welfare calls. Since May 2025, they have implemented measures including r
Matthew O’Reilly
All Responded
2025-0251
23 May 2025
Home Office
Alcohol, drug and medication related deaths
Concerns summary
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action taken summary
The Home Office refers to a previous response outlining existing measures. It highlights the cross-Government Suicide Prevention Strategy and the Concerning Methods Working Group. The Online Safety Ac
Samuel Dickenson
All Responded
2025-0252
23 May 2025
Home Office
Alcohol, drug and medication related deaths
Suicide (from 2015)
Concerns summary
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action taken summary
The Home Office refers to a previous response outlining existing measures. It highlights the cross-Government Suicide Prevention Strategy and the Concerning Methods Working Group. The Online Safety Ac
Shaun Bass
All Responded
2025-0253
23 May 2025
Home Office
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action taken summary
The Home Office refers to a previous response outlining existing measures. It highlights the cross-Government Suicide Prevention Strategy and the Concerning Methods Working Group. The Online Safety Ac
Mathew Price
All Responded
2025-0254
23 May 2025
Home Office
Alcohol, drug and medication related deaths
Suicide (from 2015)
Concerns summary
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action taken summary
The Home Office refers to a previous response outlining existing measures. It highlights the cross-Government Suicide Prevention Strategy and the Concerning Methods Working Group. The Online Safety Ac
Chantelle Williams
All Responded
2025-0255
23 May 2025
Home Office
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action taken summary
The Home Office refers to a previous response outlining existing measures. It highlights the cross-Government Suicide Prevention Strategy and the Concerning Methods Working Group. The Online Safety Ac
Andrew Brown
All Responded
2025-0258
23 May 2025
Home Office
Alcohol, drug and medication related deaths
Concerns summary
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action taken summary
The Home Office highlights the implemented Online Safety Act and Ofcom's enforcement powers to address online harms and suicide content. It notes the cross-Government Suicide Prevention Strategy and a
Hailey Thompson
All Responded
2025-0171
4 Apr 2025
SSP HEALTH
WIGAN INTERGRATED CARE BOARD
ASHTON MEDICAL PRACTICE
Child Death (from 2015)
Community health care and emergency services related deaths
Concerns summary
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record of the handling.
Action taken summary
SSP Health and Ashton Medical Practice reinforced training for all staff regarding the correct process for child medication enquiries, ensuring pharmacists manage adult prescriptions only. They also n
Alexander Eastwood
All Responded
2025-0142
14 Mar 2025
Department For Culture
Department for Culture, Media and Sport
Child Death (from 2015)
Concerns summary
There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum standards for safeguarding, medical support, and risk management.
Action taken summary
The Department is exploring ways to urgently improve child safety in martial arts, including asking Sport England to work with stakeholders to ensure parents understand regulated vs. unregulated compe
Alex Crook
All Responded
2025-0062
30 Jan 2025
Wigan Metropolitan Borough Council
Child Death (from 2015)
Concerns summary
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving throw lines.
Action taken summary
Wigan Council is working with three schools to secure statutory swimming provision by end of academic year 2024/25, having secured funding for a Water Safety Education Officer. The Council has …
Andrew Heys
All Responded
2025-0073
24 Jan 2025
Department of Health and Social Care
BARDOC
Suicide (from 2015)
Concerns summary
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient data.
Action taken summary
DHSC has invested £1.9bn since 2022 to roll out Electronic Patient Records (EPRs) across NHS trusts, with 93% of secondary care trusts now having one, and conducts annual digital maturity …
Craig Spiby
All Responded
2024-0694
10 Dec 2024
Bolton Cares
Care Home Health related deaths
Concerns summary
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.
Action taken summary
Bolton Cares has provided new guidance to staff on the distinction between 'monitoring' and 'supervision' at mealtimes. They have also implemented an electronic 'Read and Sign' record for SALT guideli
Charlotte Roscoe
All Responded
2024-0639
20 Nov 2024
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for specific requests. This issue, not fully addressed in an After Action Report, risks future diagnostic errors.
Action taken summary
NHS Bolton noted the concerns regarding CTPA vs VQ scans for PE diagnosis and radiology request processes. It clarified that radiologists determine scan modality based on national guidance, explaining
Anne Taylor
All Responded
2024-0614
8 Nov 2024
NHS ENGLAND
SALFORD ROYAL HOSPITAL FOUNDATION TRUST
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.
Action taken summary
NHS England notes the concerns, stating that Salford Royal Hospital Foundation Trust is the appropriate organisation to respond. They describe ongoing quality oversight by GM ICB and a planned quality
Emma Harper
All Responded
2024-0500
11 Sep 2024
Salford City Council
National Highways
Road (Highways Safety) related deaths
Suicide (from 2015)
Concerns summary
A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls onto the motorway. The rationale for this exclusion is unclear.
Action taken summary
National Highways disputes the need for increased barrier height at the specific footbridge, citing high costs, prioritisation of sites with more incidents, and a low number of recorded incidents (non
Shaun Houghton
All Responded
2023-0350
25 Sep 2023
Greater Manchester Mental Health NHS Fo…
Mental Health related deaths
Concerns summary
A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the decision-making process.
Action taken summary
The Trust has developed a new Standard Operating Procedure for patients self-discharging against medical advice, which includes mandatory consultant review for Mental Health Act consideration, a junio
Robert Leigh
All Responded
2023-0464
25 Sep 2023
Greater Manchester mental Health NHS Fo…
Suicide (from 2015)
Concerns summary
Systemic failures in care coordination led to numerous missed patient visits, with no interim cover or resilience plans to manage staff absences.
Action taken summary
The Trust has established a Service Manager and Senior Practitioner role to review caseloads during care coordinator absences and developed a new flow chart/checklist to ensure patients are contacted.
Angeline Phillips
All Responded
2022-0412Deceased
21 Dec 2022
Greater Manchester Police
Emergency services related deaths (2019 onwards)
Concerns summary
The provided text only states that police incident response policy governs priority and response times, without detailing any specific concerns or failures related to this policy.
Michael Draper and Rafal Wojdyl
All Responded
2022-0143
13 May 2022
Salford City Council
Road (Highways Safety) related deaths
Concerns summary
A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, exacerbated by a 50mph speed limit on the main road, risking collisions.
Hannah Beardshaw
All Responded
2022-0111
13 Apr 2022
Independent Office for Police Conduct
Greater Manchester Police
Mental Health related deaths
Police related deaths
Suicide (from 2015)
Concerns summary
Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.
Joan Wright
All Responded
2021-0420
17 Dec 2021
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial clinical information.
Amy Ganner
All Responded
2021-0218
24 Jun 2021
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary
Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods of abstinence.