Manchester City
Coroner Area
Reports: 66
Earliest: Oct 2013
Latest: 22 Jan 2026
62% response rate (below 63% average).
Norma Holden
Historic (No Identified Response)
2016-0160
25 Apr 2016
University of Manchester NHS Foundation…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.
Milly Zemmel
All Responded
2016-0139
6 Apr 2016
North Manchester General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Action Taken
(AI summary)
The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned Bulletin. Staff will use the SBAR communication tool.
Amelia Calvo
Partially Responded
2016-0192
11 Mar 2016
appropriate Royal Colleges
Department of Health and Social Care
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
RMCH revised the Team Brief used in theatres, implemented an Introductions Board, and confirmed that if the operating surgeon is not present, the patient will not be sent for. Paediatric Anaesthetic Department Mortality and Morbidity discussions will take place as part of Trust-wide Audit and Clinical Effectiveness (ACE) Days from January 2017, with summary notes provided.
Elvis Snelson
Historic (No Identified Response)
2016-0042
21 Jan 2016
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary)
The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its opioid nature, leading to dangerous sedation and respiratory depression.
Craig Bell
Historic (No Identified Response)
2015-0087
9 Mar 2015
MHSC
HMP Manchester
MHSC
+2 more
Suicide (from 2015)
Concerns summary (AI summary)
There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm risk, and a lack of senior clinician attendance at discharge reviews.
Kimberley Lindfield
All Responded
2015-0036
2 Feb 2015
Clinical Commissioning Group for South …
Department of Health and Social Care
Greater Manchester West Mental Health N…
+3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Manchester Mental Health and Social Care Trust (MMHSCT) has agreed to provide UHSM with advice in respect of their development of a self-harm policy and guidance. Regular liaison meetings will be established between UHSM, MMHSCT and GMW. The Department of Health acknowledges the concerns raised and outlines several existing initiatives related to mental health and self-harm prevention, including national indicators, research funding, and the Mental Health Action Plan.
Isa Mushtaq
Historic (No Identified Response)
2014-0423
24 Sep 2014
Department of Health and Social Care
National Institute for Health and Care …
Royal College of Gynaecologists and Obs…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of high-risk pregnancies.
Ashley Ponsonby
All Responded
2014-0386-wp24600
27 Jun 2014
Secretary of State for Health
Other related deaths
Concerns summary (AI summary)
Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a deteriorating patient.
Action Taken
(AI summary)
• Greater Manchester Police agrees that a mental disorder does not absolve individuals of the criminal consequences of their actions.
• It is often appropriate and necessary for legal proceedings to be pursued alongside and in support of an individual who is mentally ill.
• This action can often be necessary to support health workers, so that can carry out their duties as safely as possible.
Joanne Oliver
Historic (No Identified Response)
2014-0210
29 Apr 2014
The Faculty of Intensive Care Medicine
Intensive Care Society
Community health care and emergency services related deaths
Concerns summary (AI summary)
A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and post-transfer care.
Terence Dooley
All Responded
2014-0162
10 Apr 2014
North West Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary)
The call concerning the deceased was given a code green despite the fact that each different tablet could be fatal on its own, let alone together.
Disputed
(AI summary)
NWAS defends its call coding system and response times, stating that the call was coded correctly and all immediately life-threatening calls were responded to within national targets. They dispute there was a lack of communication and that the computer-generated codes were misleading.
Oliver Hiscutt
Historic (No Identified Response)
2014-0152
1 Apr 2014
Department of Health and Social Care
General Medical Council
Health Education England
+2 more
Community health care and emergency services related deaths
Concerns summary (AI summary)
Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.
Stephanie Daniels
All Responded
2013-0353
13 Dec 2013
APEX Nursing Agency
Care Quality Commission
Department of Health and Social Care
+5 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan.
Horace Cottom
Historic (No Identified Response)
2013-0351
3 Dec 2013
Secretary of State for Health
the NHS
HMPS
+3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Michael James Meyler
Partially Responded
2013-0320
2 Dec 2013
HMPS
HMP Manchester
State Custody related deaths
Concerns summary (AI summary)
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.
Action Taken
(AI summary)
HMP Manchester reception staff now record ROSH document existence and consideration of ACCT in NOMIS. Healthcare staff scan paper documents onto SystmOne. Weekly assurance checks of NOMIS entries are conducted by Supervising Officers and Custodial Managers.
Elizabeth Aurora Kerr
Historic (No Identified Response)
2013-0276
18 Oct 2013
All Party Parliamentary Gas Safety Group
Association of Chief Fire Officers
Department for Energy and Climate Change
+6 more
Product related deaths
Concerns summary (AI summary)
The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.
Anthony Bernard Mcormick
Historic (No Identified Response)
2013-0255
8 Oct 2013
Consultant Physician and Gastroenterolo…
East Cheshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.