Manchester City

Coroner Area
Reports: 66 Earliest: Oct 2013 Latest: 22 Jan 2026

62% response rate (below 63% average).

Response Status
Responded 41 Historic 24
AI Classification
Action Taken 38%
Action Planned 27%
Noted 30%
Disputed 5%
Based on 60 classified responses
Top Categories
Hospital Death (Clinical Procedure… (31) Other related deaths (14) Community health care and emergenc… (12) Mental Health related deaths (12) Suicide (from 2015) (11)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: -54 reports · -1pp response rate
vs national average: -18 reports · -1pp response rate
66 results
Alistair McDonald
Historic (No Identified Response)
2019-0257 29 Jul 2019
Worcestershire Health Care and NHS Trust
Suicide (from 2015)
Concerns summary (AI 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.
Ann Corfield
Historic (No Identified Response)
2019-0107 29 Mar 2019
Greater Manchester Mental Health NHS Tr… Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health unit staff untrained in IV fluid administration were significant issues.
Graham Tailby
All Responded
2019-0092 19 Mar 2019
Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Disputed (AI summary) Northern Care Alliance NHS Group states that the trolleys are not serviced by themselves and the staff member who gave evidence was not working for the Trust. They also state that they were not made an Interested Person or provided with disclosure.
Margaret Wilson
Historic (No Identified Response)
2019-0163 11 Mar 2019
MET MFT
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis and delayed treatment that would likely have resulted in a different outcome.
Peter Carroll
All Responded
2019-0162 11 Mar 2019
MFT
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was a lack of leading physician sign-off on reports.
Action Taken (AI summary) The Department of Histopathology has implemented measures to redirect cases outside a pathologist's area of expertise, list all confirmed cancer cases for discussion at multidisciplinary team meetings, and directly email reports to the responsible clinician when there are delays. The MFT Chameleon Electronic Patient Record system has been improved to include operation notes, and a fully electronic paperless system of reporting test results, facilitating electronic results acknowledgement and tracking of clinician performance in reviewing results is being introduced.
Janie McFadyen
All Responded
2019-0474 27 Feb 2019
Head of Safeguarding
Alcohol, drug and medication related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Action Planned (AI summary) Victory Outreach Manchester has reviewed its policies and procedures, and implemented changes to comply with current regulations, including improvements to communication and reporting channels. They have also experienced a similar incident and demonstrated how the new procedures worked. The Charity Commission has provided regulatory advice to Victory Outreach Manchester and requires that implemented changes are embedded. A program of diversified training is to be agreed and delivered, charges are to be reviewed annually, and the charity is to clarify when it will accompany residents to their GP.
Janice Keelan
All Responded
2019-0057 19 Feb 2019
Manchester City Council Manchester Mental Health NHS Trust
Mental Health related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Action Planned (AI summary) Manchester City Council conducted a review and will implement an overview and assessment of the MSIL's waiting list, agreeing on a prioritization process by May 30th, 2019. They will also review agency escalation processes with GMMH and include effective joint working and information sharing as a standing agenda item in monthly partnership meetings.
Marie Millward-Winter
Partially Responded
2019-0020 15 Jan 2019
Each Step Nursing Home NORTH WEST AMBULANCE SERVICE
Care Home Health related deaths
Concerns summary (AI summary) Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Disputed (AI summary) The Ambulance Service argues the Regulation 28 report was issued prematurely because they were not notified of the inquest date or granted Interested Person status. They maintain the EMT acted outside their scope of practice to advise on medication.
Veronica Gregory
All Responded
2018-0377 6 Dec 2018
Zinnia Healthcare Limited
Care Home Health related deaths
Concerns summary (AI summary) Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.
Action Taken (AI summary) Care plans now incorporate specific risk issues like falls, with monthly reviews and audits. Staff have been retrained and reminded to record incidents, and a new qualified nurse has been employed as Manager since February 2018.
Sheila Ridgway
Historic (No Identified Response)
2018-0229-wp26291 16 Jul 2018
Care Quality Commission Manchester University NHS Trust NHS England +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.
Lindsey Tyrrell
Historic (No Identified Response)
2018-0208 29 Jun 2018
Department of Health and Social Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.
Stephen Coulson
Partially Responded
2017-0307 27 Oct 2017
Care Quality Commission Central Manchester University Hospitals NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Action Taken (AI summary) The Trust has updated its Controlled Drug Policy, updated the Opiate Patch Monitoring Form, amended nursing admission documentation, developed education around delirium and neurological assessment, implemented a new electronic neurological observation chart, and educated doctors on fentanyl patch prescribing. The CDAO reports incidents into a reporting system to share lessons learned. CQC obtained and reviewed the Trust's revised action plan and will monitor its implementation during quarterly engagement meetings and future inspections. They also considered whether further regulatory action was needed but found no evidence of a systemic issue.
John Griffiths
Partially Responded
2017-0222 11 Sep 2017
Comish Way Group Practise UHSM
Community health care and emergency services related deaths
Concerns summary (AI summary) The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.
Action Planned (AI summary) UHSM acknowledges concerns regarding checking for recent patient presentations in the emergency department. They state the ED system alerts clinicians to previous attendances and that the Electronic Patient Record System (EPR), to be phased in later in the year, will enhance this.
Brian MaClean
Partially Responded
2017-0223 11 Sep 2017
Great Places Housing Association Director of Housing Department for Adult Social Services +1 more
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install automatic water suppression systems and appropriate alarms for high-risk individuals.
Action Planned (AI summary) In response to concerns, Manchester City Council has reviewed closed contacts, is undertaking an audit of 'No Further Action' cases, will provide further training for Contact Centre staff, will have the Quality Assurance Team undertake regular audits, is exploring increasing social work supervision of Contact Centre officers, will continue to raise awareness of GMFRS services among adult social care staff, and will refer the matter to the Manchester Safeguarding Adults Board.
Anthony McCormack
Partially Responded
2017-0241 4 Sep 2017
Department of Health and Social Care DLA Piper Solicitors Emirates Airlines +2 more
Other related deaths
Concerns summary (AI summary) Airline staff training in cardiac arrest recognition and CPR was inadequate, while ambulance services failed to meet response targets, exacerbated by only one paramedic on duty at the airport, preventing advanced life support.
Noted (AI summary) The Department explains that paramedic cover at Manchester International Airport is by commercial arrangement, notes that a review is underway to understand the impact of the airport expansion and highlights the implementation of an improved ambulance performance framework nationally. Emirates states that First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis and that the CPR training conducted by Emirates meets the rigorous standards set by leading international bodies. Emirates also monitors the latest research and developments in pre-hospital emergency care and resuscitation on an ongoing basis.
Helen Cannon
Partially Responded
2017-0260 16 Aug 2017
Care Quality Commission Department for Community and Local Gove… Department of Health and Social Care +2 more
Community health care and emergency services related deaths
Concerns summary (AI summary) Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.
Noted (AI summary) Illegible response.
Ben Jukes
All Responded
2017-0335 24 Jul 2017
Ministry of Defence
Service Personnel related deaths
Concerns summary (AI summary) The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random or unannounced, allowing evasion.
Action Planned (AI summary) The need for absolute discretion during drug testing will be reiterated to units during initial notification.
Lucy Goldstone
Historic (No Identified Response)
2017-0168 26 May 2017
Department for Transport Department of Health and Social Care
Other related deaths Railway related deaths
Concerns summary (AI summary) There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.
Maud Patrick
Historic (No Identified Response)
2017-0151 8 May 2017
Care Quality Commission Manchester Clinical Commissioning Group University of South Manchester Hospital…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.
Kathleen Cooper
Historic (No Identified Response)
2017-0063 8 Mar 2017
Department of Health Pennine Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS Trust, with errors and missed opportunities to treat the deceased, and poor communication between clinicians and nurses.
Raymond Shepherd
Partially Responded
2016-0467 30 Dec 2016
Home Care Support Limited Trafford Borough Council
Community health care and emergency services related deaths
Concerns summary (AI summary) Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or a mental capacity assessment.
Action Taken (AI summary) The Human Support Group has implemented several changes including revising the care planning process, incorporating falls prevention information into training, developing a falls poster, reviewing care planning matrix, and adding fields to the electronic rota system for recording falls data.
John Smith
Historic (No Identified Response)
2016-0366 18 Oct 2016
Lord Chancellor Wythenshawe Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall and subsequent death.
Nicholas Sullivan
Historic (No Identified Response)
2016-wp25385 22 Aug 2016
Manchester Mental Health and Social Car… North Manchester General Hospital
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important background issues, there was no clear system to trigger urgent triage and safeguarding steps, and no system to safeguard the patient pending a mental health assessment.
Leslie Morrison
Partially Responded
2016-wp25337 28 Jul 2016
Central Manchester University Hospitals… Manchester Mental Health and Social Car… Regard Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Action Planned (AI summary) The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also considering the inclusion of safeguarding at quarterly Audit and Clinical Effectiveness Days.
Stephen Hunt
All Responded
2016-0216 8 Jun 2016
Chief Fire and Rescue Services Home Office
Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.
Noted (AI summary) DSFRS provides responses to the coroner's questions, but does not describe any specific actions taken or planned by their own service. The Ministry of Justice acknowledges the coroner's concerns regarding legal aid funding but states that funding decisions are made independently and there are no plans to change the current scheme.