Manchester City

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 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 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 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 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.

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

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.

Concerns summary The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.

Concerns summary Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.