Manchester City

Concerns summary The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff during a theatre procedure.

Concerns summary Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.

Concerns summary A critical failure in emergency triage assigned a low priority 'code green' to a call concerning the ingestion of multiple potentially fatal tablets.

Concerns summary Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.