Manchester City

Concerns summary An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.

Concerns summary Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.

Concerns summary Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or authorised containers, lacking staff oversight.

Concerns summary The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety concern.

Concerns summary It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.

Concerns summary An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to reduce these risks.

Concerns summary There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and legal tests for clinicians to apply.

Concerns summary Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better use of audit tools by NHS Trusts.

Concerns summary Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely recognition and treatment.

Concerns summary Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate community support and clinical rationale.

Concerns summary Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.

Concerns summary National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at risk.

Concerns summary Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.

Concerns summary Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.

Concerns summary Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.

Concerns summary Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.

Concerns summary The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.

Concerns summary A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.

Concerns summary National guidelines and the Red Book lack specific directives for Vitamin D supplementation advice for babies by Health Visitors and for at-risk women, particularly those breastfeeding or with increased skin pigmentation.

Concerns summary Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.

Concerns summary There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Concerns summary A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal investigation findings. An essential transfer protocol also remained uncompleted, risking inappropriate discharges.

Concerns summary The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.

Concerns summary Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.

Concerns summary Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was not assessed by a consultant psychiatrist, nor given clear advice for persistent suicidal feelings.