Manchester City

Concerns summary Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.

Concerns summary Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or authorised containers, lacking staff oversight.

Concerns summary It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.

Concerns summary Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better use of audit tools by NHS Trusts.

Concerns summary Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely recognition and treatment.

Concerns summary National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at risk.

Concerns summary Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.

Concerns summary Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.

Concerns summary Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.

Concerns summary Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.

Concerns summary The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.

Concerns summary National guidelines and the Red Book lack specific directives for Vitamin D supplementation advice for babies by Health Visitors and for at-risk women, particularly those breastfeeding or with increased skin pigmentation.

Concerns summary There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Concerns summary The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.

Concerns summary Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.

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 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 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 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 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 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.