Manchester University NHS Foundation Trust

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.

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.