Tameside and Glossop Integrated Care NHS Foundation Trust
PFD Addressee
Reports: 43
Earliest: Jan 2014
Latest: 22 Dec 2025
75% 2-year response rate (below 83% average). 49% of classified responses show concrete action taken.
PFD Reports
43 resultsWinifred Wardle
No Identified Response
2025-0640
22 Dec 2025
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.
Valerie Hampson
All Responded
2025-0306
18 Jun 2025
Manchester South
Community health care and emergency services related deaths
Concerns summary (AI summary)
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.
Noted
(AI summary)
The trust clarifies that no serious incident investigation was undertaken and no follow-up appointment was made in the fracture clinic as no fracture was identified. They describe current protocols for wound management including regular team meetings and monthly masterclass sessions.
Lila Marsland
All Responded
2025-0291
11 Jun 2025
Manchester South
Child Death
Concerns summary (AI summary)
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being lost.
Action Planned
(AI summary)
The Trust has implemented daily audits for PEWS and sepsis, devised individual action plans, and is using the Patient Safety Incident Response Framework (PSIRF) which has greater emphasis on engaging with those affected by incidents. The Department of Health and Social Care outlines existing programmes to improve digital information sharing in the NHS, including investment in Electronic Patient Records and the planned Single Patient Record.
Suzanne Eccles
All Responded
2024-0502
19 Sep 2024
Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.
Action Taken
(AI summary)
The Trust has implemented an alert process on Lorenzo to prompt staff to review the virtual ward position (in place since September 2024), prints off a hard copy of the virtual ward daily for the ED reception team, and created an electronic Virtual Ward Patient Management Board available across the acute organisation. It is working towards implementing GMCR for real-time access to shared care records, and once operational, the Lorenzo alert will be changed to prompt clinicians to review the GMCR record.
Jordan Howarth
All Responded
2024-0236
1 May 2024
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.
Noted
(AI summary)
The Department of Health and Social Care outlines the planned phased implementation of Martha's Rule, giving patients the right to request a rapid review of their case by someone outside their immediate care team, and describes NHS England's broader Managing Deterioration Safety Improvement Programme. The response contains no text and cannot be classified.
Jane Wadsworth
All Responded
2023-0251Deceased
17 Jul 2023
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.
Noted
(AI summary)
NHS England acknowledges the concerns and states that the Tameside and Glossop Integrated Care NHS Foundation Trust is the appropriate organisation to respond. They note the Trust's response addresses the concerns and that they have been implementing improvement work. The Critical Care Unit has amended their daily review chart to provide additional clarity and comprehensive documentation regarding referrals to the Liver Unit. Also clinical induction training includes intravenous (IV) cannulation for all registered staff.
Roger Southwick
All Responded
2023-0158
16 May 2023
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies failures to accurately complete a Falls Risk Assessment and to reassess the risk after family members reported the deceased's compromised mobility; the Trust's Investigation Report also failed to address these issues.
Action Taken
(AI summary)
The Trust already holds daily ward safety huddles to discuss patients at risk of falls, and has a number of existing practices and processes for falls prevention in place. They also held a "Focus on Falls Week" in September 2022 which is now an annual event.
Joan Robinson
Historic (No Identified Response)
2022-0377
25 Nov 2022
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and Hydration Committee suffers from inconsistent support and attendance.
Ernest Bacon
All Responded
2022-0246
6 Aug 2022
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be un-followed. The failure to escalate concerns was unclear.
Noted
(AI summary)
The response acknowledges the concerns raised and references actions taken by Tameside and Glossop Integrated Care NHS Foundation Trust, including a Root Cause Analysis and increased medical rota. It also notes that the CQC received assurance regarding a review of the sepsis pathway and retraining for staff. The Trust is planning to pilot an eNEWS application across its surgical wards to improve the accuracy and speed of data recording and to eliminate errors in early score warning calculation. The Trust's incident trigger lists have been circulated widely throughout the organisation with a reiteration of the importance of incident reporting.
James Curry
All Responded
2022-0239
4 Aug 2022
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. This impacts patient outcomes and mortality.
Noted
(AI summary)
Learning from this case will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums to improve outcomes for the population of Greater Manchester. Response contains no content.
Kathleen Stewart
All Responded
2022-0213
17 Jul 2022
Manchester South
Emergency services related deaths
Concerns summary (AI summary)
A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate this lapse, missing critical opportunities for learning and systemic improvement in acting on abnormal imaging.
Action Taken
(AI summary)
The Trust has an established safety workstream, overseen by the Executive Medical Director. It has updated its policy relating to requesting and acting upon diagnostic results, and it will be updating its Incident Reporting Policy. Mrs Stewart's case will form part of a multidisciplinary learning event being held by the Trust in September 2022.
Derek Holmes
All Responded
2022-0188
22 Jun 2022
Manchester South
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI summary)
The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell functionality and specialist advice delays. The incident's "moderate" harm grading was not revisited despite its contribution to the patient's death.
Action Taken
(AI summary)
NHS Tameside and Glossop Integrated Care acknowledges errors in a root cause analysis and has implemented actions including immediate strategy meetings, training improvements (investigation training, Datix training), and policy/process changes. A new process ensures triage, review, and instruction to clinicians within seven days of an inquest request, with a clinical review and a review of previous investigations also performed.
Irene Esaw
All Responded
2021-0307
Manchester South
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about responsibility between clinical and integrated care teams led to inadequate needs assessments.
Action Planned
(AI summary)
Tameside MBC has developed a comprehensive multi-agency action plan to address concerns regarding mental capacity assessment and multi-agency working, which will be shared in December 2021. A Multiagency Action Plan Group and a Quarterly Multiagency Learning Forum will be established to monitor and support learning.
Roger Ballard
All Responded
2021-0168
24 May 2021
Manchester South
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.
Action Planned
(AI summary)
The trust plans to implement an electronic flagging system to identify when clinicians are not reviewing imaging reports in a timely manner, share the case at Clinician forums and has mandated personal learning and reflection for those involved in the care.
Joseph Brindley
Historic (No Identified Response)
2020-0294
21 Dec 2020
Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.
Sylvia Scully
All Responded
2020-0156
11 Aug 2020
Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor assessment and critical treatment for walk-in patients.
Action Planned
(AI summary)
The RCR has invited its Radiology Informatics Committee to revisit its guidelines to double check that they are clear and unambiguous in their specifications regarding IT equipment standards. The Trust is developing an Abdominal Pain Pathway aiming for CT scans within 2 hours for Emergency Department patients with abdominal pain, expecting it to be in place by the end of October 2020. They have also created an Escalation Handovers Pack for junior doctors, with the Royal College of Emergency Medicine planning to host it on their website.
Gordon Fenton
All Responded
2020-0102
23 Apr 2020
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, hindering optimal integrated care.
Action Planned
(AI summary)
A new joint Standard Operating Procedure (SOP) is being developed between PCFT and TGICFT to improve shared care, with contingency plans including increased communication and guidance. The teams on Summers and Hague Wards are using Digital Health for advice and the inquest's outcome will be presented at a Tameside & Glossop CCG meeting. A new joint Standard Operating Procedure (SOP) is being developed between TGICFT and PCFT regarding shared care for patients with psychiatric and acute medical problems. Once approved, self-directed training will be carried out by all staff and the updated process and outcome of Mr Fenton's inquest will be presented at Divisional Governance Meetings.
Shirley Nightingale
Historic (No Identified Response)
2019-0431
16 Dec 2019
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.
Mellin Beard
All Responded
2019-0157
17 May 2019
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.
Noted
(AI summary)
Tameside and Glossop Integrated Care NHS Trust states that the referral to District Nurses was made by hospital staff, contrary to evidence heard. They outline the Trust's processes for using Bank and Agency staff to fill vacancies and their recruitment/retention efforts.
Michael Flynn
All Responded
2019-0008
10 Jan 2019
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies a lack of EWS monitoring in the post-operative recovery area, failure to adhere to Trust policy regarding monitoring and trigger points for escalation, a lack of doctor review despite deteriorating EWS scores, and incomplete fluid balance charts.
Action Taken
(AI summary)
The Matron for Theatres has confirmed that vital signs are continuously monitored in the recovery area post operatively and documented at set intervals. New signage has been introduced at the bedside to further support staff in recognizing which patients have a fluid balance chart in place; and a trust wide audit of fluid balance chart compliance has been added to the Trust Audit Programme for 2019/2020.
Adrian Jennings
All Responded
2018-0111
19 Apr 2018
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.
Noted
(AI summary)
Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high levels of needs like Mr. Jennings as they consider them covered by existing secondary care services. They will follow up on the other concerns with Pennine Care Foundation Trust through quality and performance monitoring. The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar programme. It also mentions the Healthcare Safety Investigation Branch's investigation into care for patients with mental health problems in emergency departments. NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals (updated Emergency Department module in Lorenzo with mandatory data collection fields).
Margaret Postill
Partially Responded
2017-0382
21 Dec 2017
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation lacking detail on clinical decision-making.
Action Taken
(AI summary)
The home has established an internal falls team, which comprises all the Heads of Department in the home and are subject to audit every three months. Each accidentlincident record has @ 24 hour observation record and an additional clinical walk round.
Matthew Edwards
All Responded
2017-0451
17 Jul 2017
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic scans.
Action Taken
(AI summary)
The Trust has addressed the issue of timely discharge summaries by clearing a backlog with extra resources. Training has been implemented and processes have been revised, and discharge lounges have been relocated and refurbished.
Derrick Brocklehurst
All Responded
2017-0181
5 Jun 2017
Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.
Action Planned
(AI summary)
The council will confirm in writing to all providers their obligations regarding Care Record Books, and the Homecare Commissioning Team will run a weekly report to track recovery of these books. The matter will be discussed at contract performance meetings if providers cannot recover records. The Trust has taken action to improve the timely completion of discharge summaries, including bringing in extra resources to clear a backlog. A new process and supporting documentation has been produced and disseminated to staff within the District Nursing Service, with compliance being monitored by team leaders.
Rachal Murphy
Partially Responded
2016-0401
8 Dec 2016
Manchester (South)
Child Death
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No specific concerns were detailed in the provided text for this report.
Action Taken
(AI summary)
Tameside Early Help Services has undertaken a review of caseloads and allocation of work, leading to a significant reduction in the allocation of cases. In the past six months, any family entered onto a waiting list was allocated a worker within a one-month timeframe, with a manager maintaining contact during that period. The practice has searched for patients on sodium valproate, invited them for LFTs if not checked in the last year, and added alerts to patient notes to schedule annual LFTs. A new staff member has been employed and trained to scan all paperwork received. CAF documents are now given to the duty doctor on the day they arrive.