Manchester West

Concerns summary There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in a patient with complex needs being sent to unsuitable accommodation against clinical recommendations.

Concerns summary Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed risks to patient safety.

Concerns summary Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk management and leave authorization. Decision-making for self-discharge and Mental Health Act detention also lacked sufficient senior input.

Concerns summary Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.

Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.

Concerns summary Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a safety risk.

Concerns summary Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.

Concerns summary A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical records and computer system, leading to a lack of awareness and follow-up.

Concerns summary Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.

Concerns summary Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.

Concerns 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.

Concerns 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.

Concerns summary Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from carbon monoxide poisoning.

Concerns summary Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, and procedural adherence regarding care plans and risk management.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, failed inter-team referral, and a prolonged lack of patient contact.