NHS Greater Manchester ICB
PFD Addressee
Reports: 31
Earliest: Dec 2021
Latest: 5 Dec 2025
100% 2-year response rate (above 83% average). 32% of classified responses show concrete action taken.
PFD Reports
31 resultsMichael Amesbury
All Responded
2023-0259
19 Jul 2023
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.
Action Planned
(AI summary)
NHS Greater Manchester plans to scale and spread the Patient Pass model of care within the GM ICS, leveraging the installed user base and existing clinical pathways. Deployment at an ICS level would enable complex case transfers and out-patient planning to be managed at a higher and more efficient level.
Bernhard Marek
All Responded
2023-0257
19 Jul 2023
Manchester South
Emergency services related deaths
Concerns summary (AI summary)
The report cites concerns about ambulance service delays due to high demand and resource issues, which are exacerbated by long waits to offload patients at Emergency Departments, impacting frail elderly patients with hip fractures.
Action Taken
(AI summary)
NHS Greater Manchester Integrated Care shared learning from the case with the Greater Manchester System Quality Group and cascaded it to professionals through relevant governance and learning forums. Ambulance performance is reviewed regularly, and they are committed to achieving ARP standards. The DHSC describes national actions to improve urgent and emergency care, including ambulance resources, increasing hospital bed capacity, scaling up virtual wards, and funding for timely discharge. They report improvements in ambulance response times.
Sandra Lomax
All Responded
2023-0051Deceased
10 Feb 2023
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
Action Planned
(AI summary)
Greater Manchester Integrated Care will present learning from the case with the Greater Manchester System Quality Group. Shared learning from this and similar cases will be cascaded to professionals through governance and learning forums. NHS England will share the coroner's report with System Quality Groups and review proposals from The Christie regarding chemo-radiotherapy and stenting services. The Regulation 28 Working Group will discuss all reports received to identify key learnings and emerging trends.
James Tice
All Responded
2022-0275
5 Sep 2022
Manchester North
Community health care and emergency services related deaths
Mental Health related deaths
Suicide
Concerns summary (AI summary)
There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.
Action Planned
(AI summary)
Learning from the case will be presented to the Greater Manchester System Quality Group and cascaded to professionals through governance forums. The Regulation 28 report will be shared with mental health commissioners to ensure a review of older adult inpatient provision.
Violet Howard
All Responded
2022-0273
2 Sep 2022
Manchester North
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.
Noted
(AI summary)
NHS Greater Manchester Integrated Care states that the issue is a gap in acute provision rather than a commissioning gap and is being addressed by the Care Organisation via a SLA. Learning will be shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
Nichola Lomax
Partially Responded
2021-0433
17 Dec 2021
Manchester North
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.
Action Planned
(AI summary)
The Greater Manchester Health and Social Care Partnership (GMHSCP) will present learning from the case at the Greater Manchester Quality Board and cascade it to professionals through governance and learning forums. They commit to establishing clear MARSIPAN pathways and protocols with associated training.