Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 15 Mar 2026
72% response rate (above 63% average).
Elaine Horrocks
Historic (No Identified Response)
2018-0169
31 May 2018
Joseph Holt Ltd.
Brewery
Other related deaths
Concerns summary (AI summary)
Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a safety risk.
James Sheffield
All Responded
2018-0214
12 Apr 2018
Salford Royal NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.
Action Taken
(AI summary)
The Trust updated its electronic patient record system's ward-to-ward transfer document and circulated a safety alert to staff informing them of the changes. These changes have been fully implemented.
Andrew Reid
All Responded
10 Apr 2018
Trafford Clinical Commissioning Group
Greater Manchester
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.
2 responses
from Andrew REID Response2, Andrew REID
Peter O’Donnell
All Responded
2018-0201
20 Mar 2018
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.
Noted
(AI summary)
The Department of Health acknowledges concerns regarding independent hospitals and refers to existing standards, CQC ratings, and quality monitoring data submissions, also noting the ongoing Paterson Inquiry looking into accountability and quality of care in the independent sector.
Jean Griffiths
All Responded
2018-0080
15 Mar 2018
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.
Action Planned
(AI summary)
The Department of Health acknowledges concerns regarding oxygen prescribing practices. NICE is updating its guideline CG101 to tighten prescribing practice and the BTS and Royal Colleges will have opportunity to participate in the development and comment on the draft guidance.
William Lound
All Responded
2018-0022
19 Jan 2018
Greater Manchester Mental Health NHS Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Action Taken
(AI summary)
The Trust has filled all substantive consultant appointments across inpatient areas within Manchester services and is developing proposals for forensic in-reach to support consultants and CMHTs; a rolling programme for all healthcare professionals promoting the importance of good record keeping is currently being delivered.
Kathleen Devine
Partially Responded
2017-0411
22 Nov 2017
Arden Court Nursing Home
Bloomcare
Care Home Health related deaths
Concerns summary (AI summary)
A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.
Action Taken
(AI summary)
The care home has implemented several changes including creating care plans for residents with crash/sensor mats, adding information to handover sheets, adding an extra column on mattress check sheets, updated moving and handling training, changed accident forms, reduced agency staff, and implemented hourly observation charts.
Paul Mullen
Partially Responded
2017-0403
17 Nov 2017
Greater Manchester Mental Health NHS Tr…
Hindley Health Centre Pharmacy
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner organisations further hinders communication.
Noted
(AI summary)
This response is not classifiable as it consists of nonsensical characters and cannot be understood.
Wycliffe Matthews
Historic (No Identified Response)
2017-0299
18 Oct 2017
Grange Care Home
Care Home Health related deaths
Concerns summary (AI summary)
Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.
Ruth Thompson
Historic (No Identified Response)
2017-0297
12 Oct 2017
Insure and Co
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Carol Buchanan
All Responded
2017-0294
12 Oct 2017
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Noted
(AI summary)
Response contains only illegible characters.
Pauline Hayston
Partially Responded
2017-0278
28 Sep 2017
Department of Health and Social Care
Rambleguard Ltd
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Noted
(AI summary)
Response discusses various points of contact for families to engage with regarding a patient's well-being.
Rodney Hampshire
All Responded
2017-0236
26 Sep 2017
Salford Royal Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.
Action Taken
(AI summary)
Salford Royal NHS Foundation Trust implemented an 8-bed H6 Monitored Unit in June 2017 and is planning an Extended Recovery Unit to optimize post-surgical patient care, reduce complications, and facilitate appropriate use of critical care beds.
Frances Greenhalgh
Historic (No Identified Response)
2017-0221
12 Sep 2017
Heaton Medical Centre
Community health care and emergency services related deaths
Concerns summary (AI summary)
A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical records and computer system, leading to a lack of awareness and follow-up.
Patricia Forshaw
All Responded
2017-0262
8 Sep 2017
Wrightington, Wigan and Leigh NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.
Action Taken
(AI summary)
Wrightington, Wigan and Leigh NHS Trust has notified emergency care staff that calls should not be put through to minors or majors, that treatment advice should not be given, and is reminding nursing staff of the requirement to document relevant care. The Accident & Emergency weekly mortality review will now include a review of any hospital attendances in the last four weeks.
Terence Ryan
All Responded
2017-0225
8 Sep 2017
Grasmere Surgery
Wrightington, Wigan and Leigh NHS Trust
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The hospital also lacked a protocol for vulnerable patients who self-discharge, particularly regarding follow-up and essential medication.
Noted
(AI summary)
Wrightington, Wigan and Leigh NHS Trust has reviewed its self-discharge policy and is communicating its requirements to staff. They are developing auditing of the Hospital Information System to ensure timely provision of discharge summaries and monitoring actions via the Trust's Quality & Safety Committee. The organization provided a blank response.
Sharon Halliwell
All Responded
2017-0319
4 Aug 2017
North West Boroughs Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.
Action Taken
(AI summary)
A "theme of the week" communication has been shared across the organisation regarding connectivity of electronic care systems. IAPT staff have received RiO training.
Cameron Chadwick
All Responded
2017-0436
6 Jul 2017
Wigan Council
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.
Action Taken
(AI summary)
Following the report, the council measured the pothole depth and repaired it, both temporarily and permanently. They assert this was done despite the pothole not meeting the threshold for intervention under their Highway Safety Inspection Policy.
John Ramsden
Historic (No Identified Response)
2017-0437
6 Jul 2017
Agrade Community Care Services
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Katherine Derbyshire
All Responded
2017-0199
16 Jun 2017
Salford Royal Hospital
Royal Albert Edward Infirmary
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed opportunities for timely life-saving treatment.
Action Planned
(AI summary)
A working group will create a pathway for safe patient transfers to Salford Royal, and SRFT renal consultants will provide weekly in-reach sessions. An on-call electronic service will be introduced for timely referrals. Salford Royal NHS Foundation Trust is implementing a new electronic referral system for renal patients by September 2017 and will work collaboratively with WWL to address the gap in providing a timely service.
Antony Abbott
Historic (No Identified Response)
2017-0092
23 Mar 2017
Foreign, Commonwealth & Development Off…
Other related deaths
Concerns summary (AI summary)
Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.
Thomas Unsworth
All Responded
2017-0039
1 Mar 2017
Bolton Council, Highways Division
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising safety concerns during crossings.
Action Planned
(AI summary)
Bolton Council will request that Transport for Greater Manchester review the pedestrian stage indicators at the junction of Bradshawgate and Great Moor Street, with a view to changing from far side to nearside indicators.
Gordon Arthur
All Responded
2017-0009
2 Feb 2017
Salford Royal Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.
Action Taken
(AI summary)
Salford Royal NHS Trust reviewed policies and confirmed existing protocols for rapid notification of unsuspected pathology. These protocols have been disseminated by email and discussed at the Orthopaedic clinical governance meeting on 29th March 2017.
Joyce Crompton
All Responded
2016-0434
6 Dec 2016
CLS Care Services
Care Home Health related deaths
Concerns summary (AI summary)
The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.
Action Taken
(AI summary)
Belong has reminded managers and nurses of policy adherence, requested reassessment of residents' choking risk, updated staff training, and will review policies in a meeting with registered managers. Staff at Belong Atherton have received updated training about Dysphagia which will be cascaded throughout the organization.
Patrick Steer
All Responded
2016-0427
23 Nov 2016
Warrington, Wigan and Leigh NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.
Noted
(AI summary)
Response could not be classified due to illegible document.