Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 15 Mar 2026
72% response rate (above 63% average).
Margaret Walker
All Responded
2014-0134
25 Mar 2014
5 Boroughs Partnership
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Action Taken
(AI summary)
The Trust has reviewed its medicines policy, will issue further guidance on medicines reconciliation, has implemented Trust-wide initiatives for managing physical health and diabetes, developed diabetes guidelines, introduced Diabetes Link Nurses/Associates and provided the Hospital at Home service.
Caroline Pilkington
All Responded
2014-0269
25 Mar 2014
Department of Health and Social Care
North West Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different approaches, and offers support to NWAS in training initiatives. NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control and restraint is a specialised skill best left to the police. The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint. The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not needed or beneficial.
Simon Sankey
All Responded
2013-0361
27 Dec 2013
5 Boroughs Partnership NHS Foundation T…
Mental Health related deaths
Concerns summary (AI summary)
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and the electronic system for prioritising referrals was not available to all senior nurse practitioners.
1 response
from Download2013-0558-Response.pdffile
Keith Samuel Peters
All Responded
2013-0378
20 Dec 2013
Bolton Council
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Action Planned
(AI summary)
Bolton Council has cascaded lessons learned and has an action plan in place to improve systems, processes, and officer training, which they will oversee the full implementation of.