Manchester West

Coroner Area
Reports: 131 Earliest: Aug 2013 Latest: 15 Mar 2026

72% response rate (above 63% average).

Response Status
Responded 94 No Response 2 Historic 34 Pending 1
AI Classification
Action Taken 46%
Action Planned 33%
Noted 20%
Disputed 1%
Based on 124 classified responses
Top Categories
Hospital Death (Clinical Procedure… (48) Community health care and emergenc… (21) Alcohol, drug and medication relat… (18) Suicide (from 2015) (17) Mental Health related deaths (15)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: +11 reports · +9pp response rate
vs national average: +47 reports · +9pp response rate
131 results
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 (AI 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 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.
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 (AI 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 (AI summary) The Trust has reviewed operating tables and handsets, changed pre-operative checks and inspections, implemented a more robust system and matrix for training theatre staff, and expanded the data base within theatres to cover all medical devices. The Trust has also contacted the MHRA to request a discussion to strengthen communication and sharing of information.
Anthony Brian Flynn
Partially Responded
2013-0297 14 Nov 2013
Department of Health and Social Care HMP Forest Bank
State Custody related deaths
Concerns summary (AI 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 Planned (AI summary) Sodexo is planning Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch awareness days and a training programme for prison officers who conduct escorts, particularly during hospital visits. They have also re-issued an Operational Instruction regarding prisoner correspondence.
Jean Miller
Historic (No Identified Response)
2013-0191 7 Aug 2013
Pennine Care Trust
Community health care and emergency services related deaths
Concerns summary (AI 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.