Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 15 Mar 2026
72% response rate (above 63% average).
Colin Garth
All Responded
2016-0372
20 Oct 2016
Bolton NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report text does not detail specific concerns.
Action Planned
(AI summary)
Bolton NHS Trust is developing a new generic leaflet for all patients with central lines, based on the Macmillan leaflet, expected to be available by the end of February 2017. The Deputy Director of Infection Control is reviewing the Central Venous Catheter (CVC) policy to provide further clarity on the management of line infections with approval expected in January 2017.
Lee Grimes
All Responded
2016-wp25332
26 Jul 2016
5 Boroughs Partnership NHS Foundation T…
Next Stage
Community health care and emergency services related deaths
Concerns summary (AI summary)
Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
2 responses
from Response 5 Borough Partnership NHS Trust, Next Stage
Margaret Gleeson
All Responded
2016-0255
15 Jul 2016
Wrightington, Wigan and Leigh Teaching …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.
Action Taken
(AI summary)
The Trust reviewed staffing levels, provided refresher training on the MEWS tool, and conducted sepsis training, including drop-in sessions and mandatory attendance at a Sepsis Study Day for nursing staff, and is monitoring these actions via the Quality and Safety Committee.
Steven Billington
All Responded
2016-0247
12 Jul 2016
Home Office
Secretary for Communities and Local Gov…
Other related deaths
Concerns summary (AI summary)
No specific concerns are detailed in the provided text.
Noted
(AI summary)
The Minister offers condolences to the family and friends of Mr. Billington. The Department acknowledges the report and notes that current guidance requires isolators for fire alarm systems to be secured against unauthorised tampering, and suggests the system in question may have been an older system. They suggest any weaknesses in standards be brought to the attention of the British Standards Institution.
Clarice Hilton
All Responded
2016-0207
2 Jun 2016
5 Borough Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical delays in medical assessment.
Action Taken
(AI summary)
The Trust has reviewed and revised its Modified Early Warning Scores (MEWS) operational guidance to include instruction for staff on assessing those who refuse to engage with MEWS monitoring, including conducting general assessments using the A(airway) B (breathing) C (circulation) D (disability) E (exposure) approach; the revised guidance is currently in draft form and will be issued once ratified.
Mary Walker
All Responded
2016-0150
21 Apr 2016
Belong Village
Care Quality Commission
Community health care and emergency services related deaths
Concerns summary (AI summary)
Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both procedures require urgent review.
Action Taken
(AI summary)
Belong Wigan has provided refresher training to all staff on 'Safe Management of Records' policy and procedures, emphasizing accurate recording. All support workers have been reminded of procedures to escalate health concerns. The CQC undertook a comprehensive ratings inspection at Belong Wigan Care Village and found a flow chart for unexpected changes in health had been developed and given to every member of staff and was displayed within each household. Also, a night time record sheet had been introduced.
Joyce Carney
All Responded
2016-0140
7 Apr 2016
Department of Health and Social Care
Greater Manchester Police
Home Office
+2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and a failure to assess risks to other patients and staff. There were no agreed protocols or senior oversight.
Action Planned
(AI summary)
The Trust has been working with Greater Manchester Police to learn lessons and address concerns including the security of patients under arrest and the protection of other patients. A final draft of the 'Patient Under Escort Record' is to be agreed and training on its use will be rolled out. The Department of Health has shared a report with NHS Protect to support a joint DH Home Office initiative to develop protocols, policies and procedures, to provide a national framework for joint risk assessments between police and NHS staff for patients detained at a hospital under arrest. The Minister for Policing will write to the National Policing Lead for Custody, Chief Constable to raise the matter with Chief Constables across England and Wales. The College of Policing is leading a programme of work aiming to set a national framework clarifying the roles and responsibilities of health and policing partners to maintain safety in mental health settings.
Helen England
All Responded
2016-0141
16 Mar 2016
Department of Health and Social Care
Suicide (from 2015)
Concerns summary (AI summary)
No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating a significant risk.
Action Taken
(AI summary)
The Trust has amended its Community Treatment Order Procedure in light of the coroner's concerns and is communicating this to staff.
Eric Gaskell
All Responded
2016-0057
16 Feb 2016
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy hours.
Action Planned
(AI summary)
The hospital will review the existing stock list of over-labelled and pre-packed medicines with the Accident and Emergency Department by 31 May 2016. They also plan to advertise the opening hours and process for obtaining medicines out of hours with the Accident and Emergency Department in April 2016.
Samantha MacDonald
All Responded
2016-0036
5 Feb 2016
Campus Living Villages
Department for Education
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.
Action Planned
(AI summary)
CLV has reviewed its risk assessment and measures in place to protect student safety relating to opening windows, provided training to CLV staff on mental health, put in place key communication channels to support staff, and developed a Residential Life Programme to foster a sense of community; a clear crisis management procedure has been introduced. The Department proposes to write to UUK and GuildHE by early July to ask them to ensure that HEIs are doing all they can to ensure the safety of students in such accommodation, including the points made concerning risk assessment and replacing window restrictors.
Norah Fairhurst
All Responded
2016-0012
18 Jan 2016
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly in front, making pedestrians invisible to the driver and increasing collision risk.
Action Planned
(AI summary)
The Department for Transport is working to improve direct and indirect vision for drivers, including international agreement to allow camera systems instead of mirrors, developing aerodynamic HGVs, and working with stakeholders on safer lorry designs.
Suzanne Greenwood
All Responded
2015-0370
9 Oct 2015
Priory Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.
Action Taken
(AI summary)
The Priory Group amended its policy regarding independent doctors, requiring prompt GP contact for missed appointments and detailed discharge letters. The amended policy has been circulated, discussed at meetings, and will be included in a learning bulletin.
Maureen Chatterley
All Responded
2015-0404
8 Oct 2015
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.
Action Planned
(AI summary)
Bolton NHS Trust will introduce a new Wardex for pharmacists to record reviews and develop a local endorsement policy by February 2016. Safe and Secure Handling of Medicines Audits (Duthie) will be presented to Medicines Safety Group for discussion and agreement of action plans by December 2015.
Harry Pryal
All Responded
2015-0391
28 Sep 2015
5 Boroughs Partnership NHS Trust
Wrightington Wigan & Leigh, Royal Alber…
Department of Health and Social Care
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.
Noted
(AI summary)
The response acknowledges concerns, noting that local providers are best placed to address system issues. It highlights the move to digital care records and the development of standards for clinical structure and content of patient records by the Academy of Royal Medical Colleges. The CCG has requested that SBP have a service agreement in place with a provider for physiotherapy and occupational therapy; SBP has confirmed that all requests for these therapies will be flagged to their Clinical Director. The Trust has developed a proforma for telephone advice, has updated the radiology information system and implemented 'hot reporting' during weekdays. Specialist Radiographer chest X-ray reporting has been introduced. The Trust has developed a standardised proforma for transfer between Trusts, shared with colleagues in Wrightington, Wigan and Leigh NHS Foundation Trust and discussed at the Wigan Medical Staff Committee. Discussions are taking place between 5 Boroughs Partnership NHS Foundation Trust and Bridgewater NHS Foundation Trust to clarify arrangements for the provision of physiotherapy and occupational therapy.
Stanley Oliver
All Responded
2015-0281
16 Jul 2015
Department of Health and Social Care
Salford Royal NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying this as a risk.
Action Planned
(AI summary)
Salford Royal NHS Foundation Trust plans to develop a 7-day consultant-level non-vascular intervention rota by April 2016. In the short term they will use an ad hoc service with support from Central Manchester NHS Foundation Trust, documented in an updated SOP. The Department of Health commissioned the Centre for Workforce Intelligence to gather evidence on possible shortage occupations, leading to radiologists being added to the Shortage Occupation List in April 2015. Health Education England has also increased the number of radiology training places, advertising 212 posts in 2015 with a 100% fill rate.
Davina Tavener
All Responded
2015-0252
3 Jul 2015
Civil Aviation Authority
European Aviation Authority
Irish Aviation Authority
Other related deaths
Concerns summary (AI summary)
Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight cardiac arrest despite such equipment being available and simple to operate.
Action Planned
(AI summary)
The IAA notes the current practices of Irish air operators regarding AEDs and aircraft, and states that the Chief Executive of the IAA has written to the Chief Executive of Ryanair on the matter of carrying AED's on their fleet. Ryanair is now positively reviewing this carriage on their fleet. EASA acknowledges the concerns and will engage with Member States to reconsider the situation through analysis of available data, launching a first discussion at the next meeting with air operations thematic advisory group in September 2015. The CAA will raise the issue of mandatory medical equipment on aircraft, including defibrillators, at the Flight Operations Liaison Group, to obtain an industry view and assess whether operators should review their risk assessments. They will share data with EASA and support legislative changes if an evidence-based case emerges.
Jacques Lakeman and Torin Lakeman
All Responded
2015-0191
15 May 2015
Home Office
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.
Noted
(AI summary)
The Home Office acknowledges the concerns, describes actions taken by the NCA and Border Force to combat online drug supply, and states that law enforcement agencies have powers to act against suppliers, but does not commit to new actions.
Margaret Wright
All Responded
2015-0183
11 May 2015
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary (AI summary)
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Action Planned
(AI summary)
NHS England's Primary Care Patient Safety Expert Group will consider home visits at their next meeting. NICE is drawing up guidance on Home Care with planned publication in September 2015.
Jorge Castro
All Responded
2015-0170
29 Apr 2015
Springfield Medical Practice
Community health care and emergency services related deaths
Concerns summary (AI summary)
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to highlight uncollected prescriptions, especially for dependent patients.
Action Taken
(AI summary)
Springfield Medical Centre has implemented an alert system in patient records for compliance issues, amended the IT system to highlight overdue prescriptions, created a register of patients on weekly prescriptions, and notified/discussed the event with local pharmacies. They also held a training workshop for staff on repeat prescribing.
Aleysha McLoughlin
All Responded
2015-0136
8 Apr 2015
Department for Education
Department of Health and Social Care
Ministry of Housing, Communities & Loca…
Child Death (from 2015)
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.
Action Planned
(AI summary)
The Department for Education is developing an assessment and accreditation system for child and family social workers. DCLG is focussed on supporting local services to provide early, integrated support for people who need the most help and supports local authorities on the delivery of the expanded troubled families programme.
Jason Houghton
All Responded
2015-0127
30 Mar 2015
Home Office
Product related deaths
Concerns summary (AI summary)
The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of future deaths.
Action Taken
(AI summary)
The Home Office acknowledges concerns about online drug supply, notes ongoing efforts by law enforcement to close UK-based websites and work with international partners. Since the death, the MHRA closed down the website Wmedipk com.
Mary Marshall
All Responded
2015-0084
6 Mar 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.
Action Planned
(AI summary)
NHS England will work with partners to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including GDH testing. NHS England will also consider the specific circumstances of this case to determine if any further action is merited and explore methods to support local health communities in the reporting and sharing of information in relation to a patient's CDI status.
Daniel McCallum Keane
All Responded
2014-0260
9 Jun 2014
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary (AI summary)
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Noted
(AI summary)
The Department of Health has passed concerns about a GP's conduct to the GMC and CQC; NHS England is addressing transfers of care with its patient safety expert group and considering the long-term implications of the role of GPs in managing Type 1 diabetes.
Katie Davies
All Responded
2014-0255
6 Jun 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed appropriate care.
Action Planned
(AI summary)
The Department of Health will send a safety alert to all Trusts in England about potential 'blind spots' for bleepers and pagers, and the National Clinical Director for Stroke at NHS England has agreed to review concerns about stroke guidance as part of developing the next edition of the National Clinical Guidelines for stroke.
Magdalen Dwerryhouse
All Responded
2014-0244
29 May 2014
5 Boroughs Partnership NHS Foundation T…
Community health care and emergency services related deaths
Concerns summary (AI summary)
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.
Action Taken
(AI summary)
The Trust has reviewed and amended operational guidance for community teams, specifically regarding actions when service users miss appointments. They have also established an information-sharing agreement and reciprocal training arrangements with the Greater Manchester Fire and Rescue Service.