Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 15 Mar 2026
72% response rate (above 63% average).
Karen Thorne
All Responded
2016-0408
11 Nov 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.
Action Planned
(AI summary)
Health Education England is working in partnership to develop a shared vision and strategy for the diagnostics workforce and is committed to recruiting more trainees into diagnostics, including radiologists.
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.
Margaret Rogerson
Historic (No Identified Response)
2016-0155
21 Apr 2016
BUPA
Mill View Nursing Home
Right Honourable Jeremy Hunt MP
Care Home Health related deaths
Concerns summary (AI summary)
Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. Family members also lacked access to essential feeding training.
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.
Betty Addison
Historic (No Identified Response)
2016-0071
25 Feb 2016
Cuerden care Homes
Care Home Health related deaths
Concerns summary (AI summary)
A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
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.
Javaid Iqbal
Historic (No Identified Response)
2016-0023
22 Jan 2016
Tesco Store PLC
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from carbon monoxide poisoning.
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.
Lee Rigby
Historic (No Identified Response)
2016-0011
14 Jan 2016
United Response
Community health care and emergency services related deaths
Concerns summary (AI summary)
The report identifies potential risks in resident care, including support workers not having keys for timely access, adequacy of staffing levels, review of risk procedures and staff training.
Mollie Bentham
Historic (No Identified Response)
30 Dec 2015
Royal Bolton Hospital NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a significant delay in diagnosing a critical condition.
Marie Quinn
Historic (No Identified Response)
2015-0423
2 Nov 2015
HC-One Limited
Richmond House Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Christopher Smith
Historic (No Identified Response)
2015-0455
28 Oct 2015
Greater Manchester Police
Other related deaths
Concerns summary (AI summary)
A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.
Catherine Findlay
Partially Responded
2015-0372
13 Oct 2015
Advisory Council on the Misuse of Drugs
Home Office
Minister of State for Crime Prevention
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.
Action Taken
(AI summary)
The Minister notes the concern about MXP and refers to the Psychoactive Substances Bill creating a blanket ban on the supply of NPS. The government has launched a toolkit to help local areas prevent and respond to the use of NPS and published clinical guidelines to aid in the detection, assessment and management of NPS users.
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.
Dorothy Delaney
Historic (No Identified Response)
2015-0402
23 Sep 2015
Alexander House Health Centre
Platt Bridge Health Centre
Community health care and emergency services related deaths
Concerns summary (AI summary)
The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.
George Ainsworth
Historic (No Identified Response)
11 Sep 2015
Bolton Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at risk, compounded by potentially insufficient crossing times.