Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 15 Mar 2026
72% response rate (above 63% average).
Thomas Nicholls
Historic (No Identified Response)
11 Sep 2015
Orchard Care Homes The Hamlet
Care Home Health related deaths
Concerns summary (AI summary)
The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure to report a related incident, prompting a review of policies and training.
Adam Connelly
Partially Responded
2015-0284
17 Jul 2015
British Transport Police
Network Rail
Railway related deaths
Concerns summary (AI summary)
The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities that Network Rail needs to address.
Action Planned
(AI summary)
Network Rail will install shorter palisade pales and raise the height of the stepped parapet with engineering brick. The works are expected to be completed by the end of October 2015.
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.
Brian Gillard
Historic (No Identified Response)
2015-0244
26 Jun 2015
Royal Bolton Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.
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.
Anthony Garrett
Historic (No Identified Response)
2015-0153
21 Apr 2015
Ministry of Justice
Advisory Council on the Misuse of Drugs
Home Office
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.
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.
Emmeline Hampson
Historic (No Identified Response)
2015-0083
6 Mar 2015
Pindy Enterprises Limited
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.
Robert Yarnell
Historic (No Identified Response)
2015-0052
13 Feb 2015
Lancashire Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient attempts to contact him or his family, and care was not effectively transferred to the Trafford Crisis Resolution Home Treatment Team.
Patricia Edge
Partially Responded
2014-0531
10 Dec 2014
Mark Reynolds Solicitors
Royal Bolton Hospital NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Following an investigation, the Trust identified variations in paracetamol prescribing across the organisation, and the Medical Devices Committee and Medications Safety Group have thoroughly reviewed the prescribing process. The Trust has revised its practice to ensure regular monitoring of patients prescribed Paracetamol, communicated via SBAR slides distributed to medical staff and incorporated into the Medicines Management e-learning module.
Martin Dean
Historic (No Identified Response)
2014-0416
22 Sep 2014
Salford Royal Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.
Jake Hardy
Historic (No Identified Response)
2014-0305
30 Jun 2014
HM Youth Offenders Institute Hindley
Ministry of Justice
National Offenders Management Service
+1 more
State Custody related deaths
Concerns summary (AI summary)
Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.
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.
Loui Aspinall
Historic (No Identified Response)
2014-0243
29 May 2014
Federation of British Tour Operators
Other related deaths
Concerns summary (AI summary)
Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, highlighting a critical gap between audit findings and actual safety provisions.
Paul Ashton
Partially Responded
2014-0170
14 Apr 2014
Department of Health and Social Care
Medicines and Healthcare Products Regul…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to insufficient awareness of specific risks.
Action Planned
(AI summary)
NHS England will task its Rare Disease Advisory Group to prepare recommendations within six months for practical steps to improve care for heart transplant patients. NHS England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients.
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.
Lee Curran
Historic (No Identified Response)
2014-0079
25 Feb 2014
Department of Health and Social Care
HMP-YOI Forrest Bank
Ministry of Justice
+2 more
State Custody related deaths
Concerns summary (AI summary)
PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.