Manchester University NHS Foundation Trust

PFD Addressee
Reports: 35 Earliest: Apr 2014 Latest: 5 Feb 2026

83% 2-year response rate (matches average). 52% of classified responses show concrete action taken.

PFD Reports
35 results
Bruce Caulfield
All Responded
2026-0062 5 Feb 2026 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the Trust.
Action Taken (AI summary) Manchester University NHS Foundation Trust has updated its Adult Early Warning Score and Intentional Ward Rounding policies, with staff reminders and mandatory training rolled out. The Trust has also launched an 'Active Hospitals' programme in several inpatient areas to promote patient physical activity and prevent deconditioning.
Honoria Culshaw (1)
All Responded
2025-0479 24 Sep 2025 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment for infection.
Action Planned (AI summary) Manchester University NHS Foundation Trust will train Cardiology Residents on using the HIVE system to send discharge letters to relevant healthcare providers and create tip sheets and video guides for cardiology teams, which will be shared across the Trust.
Janet Anderson
All Responded
2025-0219 9 May 2025 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.
Action Planned (AI summary) MFT has held discussions with GMMH to improve escalation processes for patients whose discharge is being organised by the CMHT. GMMH is in the process of appointing a new Manager for Community Flow and a clearer escalation pathway has been developed between GMMH and MFT. GMMH and MFT have agreed to internally review Ms. Anderson’s patient journey through a Learning Multi-Disciplinary Team Meeting. GMMH will move to a more proactive approach to discharge and will review all admissions of CMHT patients ensuring discharge planning is considered from admission. Inquiries between the acute trust staff relating to an inpatient and the MHLT will be documented in GMMH electronic patient record and will be included in the Trust wide Standard Operating Procedure for MHLT’s, plan to be in operation across all MHLT’s by 1st September 2025. An escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3 which prescribes actions and timescales at each level to ensure all options have been considered.
Jyoti Rao
All Responded
2024-0513 25 Sep 2024 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.
Action Taken (AI summary) The MRI Transplant team has modified the weekly Wednesday Ward Patient Review meeting to make it an MDT for discussion of complex patients, with the outpatient team now attending to support any issues on discharge. Also, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting.
John Howe
All Responded
2024-0339 25 Jun 2024 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual inaccuracies.
Action Planned (AI summary) MFT has developed a draft "Out of Hours Discharge Avoidance" SOP to manage delayed discharges, which is due to be presented for ratification at the MRI Quality and Safety Committee. They also intend to formally communicate this SOP to external transport providers once ratified across relevant sites. EMAS will continue to contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. The organisation amended inaccuracies in the Serious Incident Review (SIR) and reshared it with relevant safeguarding boards and the Manchester Foundation Trust Safeguarding Team. They have implemented a system to ensure investigations are completed in a timely manner and are reviewing processes for discharges to 'out of area' localities.
Thomas Gibson
Partially Responded
2024-0327 19 Jun 2024 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between specialisms. There's no clear guidance for clinicians or senior review of incongruous test results.
Noted (AI summary) NICE states they will not be creating guidance on ECG interpretation, suggesting other bodies are more appropriate. MFT describes updates to their electronic discharge summary template to include medication updates and concerns.
Benedict Peters
All Responded
2023-0156 16 May 2023 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.
Action Planned (AI summary) The Trust will remind all Physician Associates of the need to discuss patients for discharge with senior medical colleagues and reiterate to all junior medical staff and non-medical clinical practitioners, that it remains good practice to discuss cases with their seniors for learning and development.
Beryl Holt
All Responded
2022-0268 31 Aug 2022 Manchester City
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Manchester University NHS Foundation Trust has implemented actions and recommendations arising from a Root Cause Analysis investigation, including training on the Trust’s new electronic patient record system (HIVE) which issues automated alerts for potential sepsis cases, and periodic audits to ensure appropriate recognition and timely treatment of sepsis.
Lee Winslow
All Responded
2022-0257 17 Aug 2022 Manchester South
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when he continued private practice. A critical lack of multi-disciplinary review, relying on the medical hierarchy, was noted given the gravity and prior similar cases.
Disputed (AI summary) The Trust believes the coroner's concerns were already addressed during the inquest and in prior correspondence. While noting collaborative work among Greater Manchester Medical Directors, it suggests a national-level review would be more appropriate.
Norma Bradbury
Historic (No Identified Response)
2021-0019 27 Jan 2021 Manchester City Area
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Alison Jeanes
All Responded
2020-0200 7 Oct 2020 Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up of haematology advice led to significant care delays.
Noted (AI summary) Manchester University NHS Foundation Trust provides context on policies and procedures regarding neurosurgical referrals, head injury pathways, and anticoagulation management. They express sorrow for the patient's death and state that clinicians are required to follow these standards.
William McKibbin
All Responded
2020-0185 28 Sep 2020 Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.
Noted (AI summary) NHS England notes the Trust's response and states it is promoting the free online Just and Learning Culture training to NHS employers. The Trust acknowledges failings in care and communication and has implemented several changes, including red flag identification, a revised Serious Incident Panel process for 12 months, and a local Serious Incident Panel to review serious incidents requiring further response, and implementation of Patient Safety Incident Response Framework (PSIRF). A mortality review process is also embedded at Trafford General Hospital. The CQC acknowledges the concerns and explains the statutory notification process. While stating that current reporting processes are adequate, it will review existing notifications guidance to determine if it could be clearer about reporting requirements relating to the circumstances of a person’s death. The Trust has updated its falls investigation template to include more detailed guidance around immediate action, including checking and documenting the environment of a fall. The CQC will review its existing notifications guidance in light of the findings from the death.
Charlotte Jacobs
Historic (No Identified Response)
2019-0365 7 Nov 2019 Manchester City
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Mary Jones
Historic (No Identified Response)
2019-0322 30 Sep 2019 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.
David Smith
All Responded
2019-0271 14 Aug 2019 Manchester (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Following acknowledgement that Mr. Smith's care fell below standard, the consent process for transplantation has been strengthened to specifically inform all recipients about CMV infection and its effects. A multidisciplinary team clinic was introduced, and the pharmacy and virology teams generate weekly/daily reports to confirm appropriate dosing regimes and flag CMV positive samples.
Geoffrey Jackson
Historic (No Identified Response)
2019-0071 26 Feb 2019 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Joseph Grantham
Historic (No Identified Response)
2018-0322 18 Oct 2018 Manchester (South)
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.
Angela Jackson
Partially Responded
26 Sep 2018 Manchester (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and potentially delayed emergency treatment.
2 responses from Angela Jackson, Angela Jackson Response2
Mohammed Ahmed
Historic (No Identified Response)
2018-0230 18 Jul 2018 Manchester (West)
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Sheila Ridgway
Historic (No Identified Response)
2018-0229-wp26291 16 Jul 2018 Manchester (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.
Kenneth Longley
Historic (No Identified Response)
2018-0086 22 Mar 2018 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths due to delayed diagnosis and treatment.
Edwin Hooper
All Responded
2018-0016 16 Jan 2018 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.
Action Taken (AI summary) The hospital has implemented a robust escalation and dissemination plan for CT scanner downtime, including senior managers on call, out-of-hours team reminders, and posters in clinical areas. Training on NICE guidelines for hospital-acquired head injuries has been undertaken, with ongoing induction training for new starters.
John Smith
Historic (No Identified Response)
2016-0366 18 Oct 2016 Manchester (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Nicholas Sullivan
Historic (No Identified Response)
2016-wp25385 22 Aug 2016 Manchester City
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important background issues, there was no clear system to trigger urgent triage and safeguarding steps, and no system to safeguard the patient pending a mental health assessment.
Leslie Morrison
Partially Responded
2016-wp25337 28 Jul 2016 Manchester City
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Action Planned (AI summary) The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also considering the inclusion of safeguarding at quarterly Audit and Clinical Effectiveness Days.