Manchester City

Concerns 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.

Concerns summary No specific concerns were detailed in the provided text.

Concerns 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.

Concerns 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.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.

Concerns summary Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.

Concerns summary A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.

Concerns summary Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.

Concerns summary Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.

Concerns 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.

Concerns summary Persistent, unaddressed systemic failures at the Trust include poor communication, inadequate supervision, incorrect early warning scores, and delayed action on patient deterioration, compounded by challenges from split-site operations.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.