Manchester West
Coroner Area
Reports: 131
Earliest: Aug 2013
Latest: 10 Feb 2026
69% response rate (above 62% average).
Kyle Ashley Smith
Historic (No Identified Response)
2014-0028
21 Jan 2014
Longshoot Health Centre
Community health care and emergency services related deaths
Concerns summary
An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.
Simon Sankey
All Responded
2013-0361-wp24075
27 Dec 2013
5 Boroughs Partnership NHS Foundation T…
Mental Health related deaths
Keith Samuel Peters
All Responded
2013-0378
20 Dec 2013
Bolton Council
Community health care and emergency services related deaths
Concerns 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 taken summary
Bolton Council has cascaded lessons learned throughout the organisation and implemented measures to improve systems, processes, and officer training. They will also oversee the full implementation of
Kenneth Smalley
Partially Responded
2013-0367
19 Dec 2013
Eschmann Holdings Limited
Medicines and Healthcare Products Regul…
Wrightington, Wigan and Leigh Teaching …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or hospital-wide review for similar equipment.
Action taken summary
Wrightington Wigan and Leigh NHS Foundation Trust has inspected all operating tables, carried out repairs, and implemented a more robust training system for theatre staff. Visual checks of operating t
Anthony Brian Flynn
Partially Responded
2013-0297
14 Nov 2013
HMP Forest Bank
Department of Health and Social Care
State Custody related deaths
Concerns summary
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.
Action taken summary
Sodexo has re-issued an operational instruction to staff regarding handling prisoner correspondence. They have also planned awareness days and a new training programme for prison officers on escort an
Jean Miller
Historic (No Identified Response)
2013-0191
7 Aug 2013
Pennine Care Trust
Community health care and emergency services related deaths
Concerns summary
District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not issued with thermometers.