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.

Response Status (last 2 years, 6 reports)
Responded 5
AI Classification
Action Taken 52%
Action Planned 28%
Noted 17%
Disputed 3%
Based on 29 classified responses
PFD Reports Received by Quarter
PFD Reports
35 results
Patrick Curran
All Responded
2016-0258 14 Jul 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.
Action Taken (AI summary) The hospital strengthened post-operative clinics by ensuring a consultant is present in the same clinic, along with nurses, and radiology reports X-rays with any concerns.
Peter Rowe
Historic (No Identified Response)
2016-0242 29 Jun 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically from the patient and an uninformed spouse.
Patrick McGagh
All Responded
2016-0171 28 Apr 2016 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.
Action Taken (AI summary) UHSM has undertaken a retrospective audit within the ED of the discharge prescriptions, reiterated to all staff within the ED and CDU the importance of ensuring that patients requiring medication and prescriptions with specific instructions for the GP should be supplied, commenced a regular audit program within the ED to monitor compliance with the policy and documentation and highlighted to the staff within both ED and CDU the importance of comprehensive documentation relating to any discussions had with patient; families and carers regarding treatment and management plans to all clinical staff across the organisation.
Norma Holden
Historic (No Identified Response)
2016-0160 25 Apr 2016 Manchester City
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 Manchester City
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.
David Price
Historic (No Identified Response)
2015-0210 1 Jun 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.
Bryan Whitby
All Responded
2015-0121 25 Mar 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Action Taken (AI summary) Central Manchester reviewed the case and presented it at a directorate meeting. The trust implemented an AKI e-alert system trust-wide and conducted teaching sessions for junior doctors on AKI recognition and management and now have two Critical Care Nurses on site at Trafford at all times. Davyhulme Medical Centre clarified Mr. Whitby's renal function and stated that the NICE guidance on acute kidney injury has been read by all GPs to improve management and awareness of the condition. An electronic alert system to tackle acute kidney injury was introduced locally on 9 March 2015.
Eliza Bashir
Partially Responded
2014-0461 24 Oct 2014 Manchester (North)
Hospital Death (Clinical Procedures and medical management) related deaths Product related deaths
Concerns summary (AI summary) Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better guidance for such incidents.
Action Planned (AI summary) The Department of Health will share information on button battery risks with health visitors, school nurses, and child health leads at Public Health England's regional centers and will contact the National Social Partnership Forum to raise awareness of the issues.
Thomas Maher
All Responded
2014-0252 5 Jun 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Action Taken (AI summary) The hospital has implemented a new process to scan all records for deceased patients and those involved in high-level incidents into the electronic patient records system as a priority. Ward 16 now uses the EPR system.
Samiyo Farah
Partially Responded
2014-0202 30 Apr 2014 Manchester (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Noted (AI summary) The Department of Health acknowledges the concerns raised and highlights existing NICE guidance on self-harm and a government suicide prevention strategy. They note that Trusts develop their own transfer protocols with the private sector and refer to existing guidance from the Royal Pharmaceutical Society on patient transfer.