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
Clear
PFD Reports
25 results
Lesley Krommendijk
All Responded
2026-0109 25 Feb 2026 Manchester South
Community health care and emergency services related deaths
Concerns summary (AI summary) Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
1 response from Stockport NHS Foundation Trust
Richard Worswick
All Responded
2025-0564 7 Nov 2025 Manchester South
Care Home Health related deaths
Concerns summary (AI summary) Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Action Taken (AI summary) The care home has issued refresher guidance to staff on existing policies, emphasizing documentation of hospital communications, and implemented enhanced observations for unstageable pressure ulcers. They've also implemented a sepsis risk assessment for residents with chronic wounds and conduct regular audits of wound care entries. A Trust-wide alert was issued on 20 November 2025 regarding Transfer of Care documentation, ensuring two copies are printed. A Trust-wide audit will take place in February 2026 to check for documentation in patient records and a task and finish group will work on improving the quality of the discharge checklist starting January 2026.
Audrey Newman
All Responded
2025-0443 29 Aug 2025 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic testing.
Action Planned (AI summary) Stockport NHS Foundation Trust is rolling out training on using the IT booking system for theatres to medical staff, formulating a flowchart for escalating lumbar puncture procedures to anaesthetics, and ensuring patients awaiting lumbar punctures are not transferred off the acute medical unit or transferred off the unit on weekends to avoid delays.
Kenneth Edwards
All Responded
2025-0414 7 Aug 2025 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Action Taken (AI summary) Stockport NHS Foundation Trust has reinforced standards for consent, handover, and clinical documentation, continued collaboration with Medica for shared learning, continued engagement in REALM, and maintained a robust incident review and escalation framework for radiology discrepancies.
Neil Clarke
All Responded
2025-0332 2 Jul 2025 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.
Noted (AI summary) NHS England expresses condolences and explains the context of shared decision making and risk assessment, referring to existing national guidance and tools. It states that commenting on the specific clinical decision is outside of NHS England's remit, and refers to the Trust's response regarding handover communications. The Trust has rolled out mandatory consent training and has a focused approach in place to support safe and timely transfers. A daily meeting has been established to identify patients who can be stepped down from ICU care to ward level care. The response acknowledges national guidance from NICE and the British Geriatrics Society and states that Stockport NHS Foundation Trust has taken steps to improve information and training relating to shared decision making and consent. Martha's Rule is being expanded to all acute inpatient sites. Medical examiners have been implemented on a statutory basis.
Ryan Campbell
All Responded
2024-0519 1 Oct 2024 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.
Noted (AI summary) NHS England states that Stockport NHS Foundation Trust plans additional weekend lists to reduce Stress Echocardiogram waiting times and hopes to achieve a 6-week standard by 31st January 2025. NHS England is not developing an MR angiogram service at this stage. Stockport NHS Foundation Trust plans an additional 20 weekend lists for Stress Echo to clear the backlog by 31st January 2025, aiming to achieve a 6-week standard for all patients. The Trust is also reviewing CT Coronary Angiogram service provision as part of its service development programme for next year. DHSC acknowledges the concerns but states that the procurement of diagnostic equipment falls under the responsibility of the trust and NHS England, who are better positioned to respond.
Charles Daniels
All Responded
2024-0575 4 Sep 2024 Cheshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.
Noted (AI summary) The Trust reviewed the concerns regarding record keeping, communication and discharge process. They maintain that the patient's medical presentation at the point of discharge was appropriate, and apologise for the distress caused to the family.
Christine Dickinson
All Responded
2023-0255 18 Jul 2023 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Action Taken (AI summary) The Trust is piloting a new paper-based 'Sepsis Six' assessment, with plans to digitize it, and has purchased additional computers on wheels for nurses to document at the patient's side. They are also participating in an electronic patient record (EPR) programme with the aim to procure and implement a single electronic patient solution to replace the majority of the Trust’s clinical systems.
Kenneth Goodwin
All Responded
2022-0318 14 Oct 2022 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate handover for falls risk patients, slow completion of falls risk assessments on new wards, and inconsistent use of visual fall-risk signs on beds posed a safety concern.
Action Taken (AI summary) Stockport NHS Foundation Trust relaunched its formal patient handover document and the use of maple leaf signs for patients at risk of falls across the Trust on 15 November 2022, adding the latter to agency staff induction checklists.
Alan Hunter
All Responded
2021-0369 25 Oct 2021 Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.
Action Taken (AI summary) The Trust had already begun improvement work related to MUST, nutrition and hydration prior to the inquest, including monthly steering group meetings, training (90.76% compliance), ward audits, and nutrition/hydration information boards. Quality assurance checks and daily safety huddles now include a review of nutrition and hydration concerns and weight completion where appropriate; the Trust also participated in Malnutrition Awareness Week in October 2021.
Lesley Mawby
All Responded
2021-0208 18 Jun 2021 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.
Action Planned (AI summary) The Trust has implemented twice-daily triage by a senior dietitian, prioritising patients, and is updating its enteral feeding policy with specific guidelines for administration. The CCG is satisfied with the Trust's response, and has requested a commissioning led review to ensure service levels can be consistently delivered.
David Kerr
All Responded
2020-0100 22 Apr 2020 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical lack of regular clinical observations for a seriously unwell patient.
Action Taken (AI summary) Stockport NHS Foundation Trust investigated the concerns and implemented several changes, including orthogeriatric reviews within 72 hours, mandatory training regarding nutrition and hydration, and audits of care standards. Consistent individual failings will be addressed and recorded.
Malcolm Shaw
All Responded
2019-0007 10 Jan 2019 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall evidence.
Action Taken (AI summary) The Trust has launched a revised programme of investigation training, including in-depth statement gathering and writing sessions, and implemented a checklist for investigation panel meetings to ensure key requirements are met. They also launched a Safer Mobility Collaborative aimed at reducing inpatient falls.
Glenys Pollitt
All Responded
2017-0228 7 Sep 2017 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning and escalating patient deterioration to consultants.
Action Planned (AI summary) Stockport NHS Trust acknowledges that high-resolution screens should ideally be used for viewing X-rays. They note that a NEWS implementation plan is being developed, independent of the delayed launch of the new electronic patient record (ePR).
John Davies
All Responded
2017-0138 26 Apr 2017 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing Team was unaware of the change, and patient records lacked detail with little communication between the care home and the District Nursing Team.
Action Planned (AI summary) A multi-agency risk assessment has been developed to support residential home managers and will be launched in June 2017 for patients waiting to be transferred to a nursing home. A Consultant Psychiatric Doctor for Older People is planning educational events with District Nursing staff from July 2017.
Maureen Flynn
All Responded
2016-0310 26 Aug 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Action Taken (AI summary) The Trust has completed actions detailed in an updated Patient Safety Investigation report, including an audit of falls risk assessments, enhanced falls sensors, and sharing investigation findings via ward newsletters, with attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair.
Michael Hutchence
All Responded
2016-0228 20 Jun 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.
Noted (AI summary) The Trust provides context regarding patient transfers and staffing levels, but does not describe specific actions taken or planned in response to the coroner's concerns.
Geoffrey Ellis
All Responded
2016-0186 13 May 2016 Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.
Action Planned (AI summary) Stockport NHS Trust is installing an electronic patient record system (EPR) called 'TrakCare' with full roll out expected in 2017. In the meantime they will continue monthly 'live' spot audits of inpatient records to improve written records and communication.
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.
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.
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.