Stockport NHS Foundation Trust

PFD Addressee
Reports: 40 Earliest: Sep 2013 Latest: 25 Feb 2026

100% 2-year response rate (above 83% average). 50% of classified responses show concrete action taken.

Response Status (last 2 years, 7 reports)
Responded 7
AI Classification
Action Taken 50%
Action Planned 31%
Noted 19%
Disputed 0%
Based on 36 classified responses
PFD Reports Received by Quarter
PFD Reports
40 results
Freda Weston
All Responded
2016-0080 23 Feb 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Action Taken (AI summary) Stockport NHS Foundation Trust will supply Patient Information Leaflets with monitored dosage systems, including a generic medicine patient information leaflet. All wards in the Medicine Business Group have access to electronic handover, and printed handover sheets are shredded at the end of each shift. The Trust is recruiting European registered nurses.
Antony Briggs
All Responded
2016-0028 28 Jan 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.
Action Planned (AI summary) The Trust will strengthen communication between secretarial teams at Stepping Hill and Buxton to ensure radiology reports are available at both sites simultaneously. They will develop a standard operating procedure for sending all radiology reports from Buxton to Stepping Hill, regardless of urgency.
Steven Rogers
All Responded
2016-0017 20 Jan 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.
Action Planned (AI summary) The Trust is moving towards a Trust-wide electronic patient record (EPR) which should resolve issues around paper charts. In the meantime, a specialist "Task & Finish Group" is in place to further review the issue and develop an effective interim solution.
Frederick Sutton
Historic (No Identified Response)
27 Aug 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.
Pamela Pattison
Historic (No Identified Response)
2015-0108 23 Mar 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.
Neil Westerman
All Responded
2015-0091 11 Mar 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, especially at night.
Action Taken (AI summary) The Trust addressed the issue of a junior doctor performing the pre-operative assessment with the individual surgeon and discussed the case at a Morbidity & Mortality meeting. They reiterated the requirement for documenting equipment and materials used during surgery and are reviewing junior doctor rotas.
John Matthews
All Responded
2015-0034 29 Jan 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Action Taken (AI summary) The Trust has formally discussed neurological observation needs in sisters' meetings and safety huddles, shared within the ED Quality Newsletter to all ED staff. To avoid a reoccurrence the Trust has instituted a system of checklists whereby a patient cannot leave the ED without all the investigations and treatments being completed.
Rosalind Adshead
Historic (No Identified Response)
2014-0427 9 Sep 2014 Manchester (South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.
Gary Bradshaw
All Responded
2014-0232 15 May 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Noted (AI summary) Stockport NHS Foundation Trust has purchased the Patientrack electronic tracking system which is being piloted and evaluated, with phased rollout planned across the Trust, starting with vital sign input in January 2015. The Department of Health acknowledges the concerns and highlights existing national guidance (NICE, Royal College of Physicians) on early warning scores and the care of acutely ill patients, noting that clinical interpretation is still essential.
Laura Hill
All Responded
2014-0064 17 Feb 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Action Taken (AI summary) Stockport NHS Foundation Trust has instigated an escalation process for locating equipment, to be monitored via the Datix system. The nurses involved were formally counselled, and the case was presented to ward managers at a Surgical Sisters' meeting to disseminate lessons learned.
Russell James Felstead
Historic (No Identified Response)
2014-0016 14 Jan 2014 Manchester (South)
Community health care and emergency services related deaths
Concerns summary (AI summary) Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the patient.
Andrew John Fallon
Historic (No Identified Response)
2014-0005 7 Jan 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Jennifer Rushworth
Historic (No Identified Response)
2013-0264 18 Oct 2013 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.
Alva Jullien
Historic (No Identified Response)
2013-0232 17 Sep 2013 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and a 'nil by mouth' decision was made with insufficient evidence.
Margaret Theresa Corrigan
Historic (No Identified Response)
2013-0233 17 Sep 2013 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.