Manchester West

Concerns summary No specific concerns are detailed in the provided text.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the dose or conduct necessary blood tests.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.

Concerns summary Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.