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.

Response Status (last 2 years, 4 reports)
Responded 3 No Response 1
AI Classification
Action Taken 49%
Action Planned 26%
Noted 26%
Disputed 0%
Based on 47 classified responses
PFD Reports Received by Quarter
PFD Reports
43 results
David Little
All Responded
2016-0237 28 Jun 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel symptoms. Poor inter-departmental communication and treating the least serious diagnosis first were also issues.
Action Taken (AI summary) Tameside Hospital NHS Trust has devised a small bowel obstruction surgical pathway which has been agreed by the surgical, nursing and clinical teams and will be ratified before being signed off at Trust level by the end of September. The Trust has also invited the family to discuss their concerns and involve them with ongoing learning.
Ranjan Mistry
All Responded
2016-0093 4 Mar 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was no, or insufficient, assessment of the deceased's Falls Risk, neurological observation charts were incomplete or lost, and medical staff were not reviewing nursing notes or vice versa; handover sheets were being shredded, preventing further reference.
Action Taken (AI summary) The Trust has initiated one-to-one training and support for staff involved and is undertaking a review of the documentation, which aligns with actions following the Trust's participation in the National Falls Audit and the 'Everyone Matters' programme. The Trust has also initiated a Guidance Document available online for staff involved in concise and local falls investigation.
Wilfred Pearson
All Responded
2016-0088 24 Feb 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Action Taken (AI summary) Tameside Hospital NHS Foundation Trust revised the Status Epilepticus Policy twice since Mr. Pearson's admission, including references to recent guidance in the Lancet Medical Journal. They have also provided MCA/DOLS training sessions and promote DOLS principles through internal communications.
Edith Kirkham
Partially Responded
2016-0068 23 Feb 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records were also unavailable.
Noted (AI summary) Illegible response.
Derek Hare
All Responded
2016-0018 20 Jan 2016 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of a critical abdominal issue.
Action Taken (AI summary) The Trust has provided clarification on the issue of separate sets of notes and the actions taken to address the Senior Coroner's concerns, including reinforcement of the record-keeping policy.
Hilda Haughton
All Responded
2015-0460 29 Oct 2015 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of increased fire-door closing times in hospitals.
Noted (AI summary) The Department of Health issued an Estates and Facilities Safety Alert to the NHS in England regarding the speed of closing fire doors. The alert sets out necessary action to be taken to reduce the risk of similar incidents in the future and covers all self-closing fire doors. The trust states that the incident didn't invoke the Statutory Duty of Candour. The trust states they have been proactive in relation to ensuring Duty of Candour and gives information about training workshops.
Sheila Johnson
All Responded
2015-0238 19 May 2015 Derby and Derbyshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Noted (AI summary) The Department of Health states that officials have made enquiries with the Trust and have been assured that it will respond appropriately. The CQC will follow up any actions identified as a result of the Trust's response and will reinforce the duties of the Trust in relation to its duty of candour. Tameside Hospital has made considerable changes to improve internal investigations and patient discharge processes, including a review of senior nursing and medical staffing and revised procedures for incident investigations. A system for the urgent recall of patients discharged with potentially life-threatening conditions has been addressed by the Patient Flow Manager.
Harold Penny
All Responded
2014-0507 24 Nov 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.
Action Planned (AI summary) The Trust is developing a 'Radiology Requesting and Reporting Policy' and has established a Results Governance Steering Group to improve patient safety related to radiology. The response details responsibilities for radiologists and consultants, including communication of critical findings.
Elsie Mallalieu
All Responded
2014-0501 17 Nov 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Action Taken (AI summary) Tameside Hospital NHS Trust provided training to doctors in the Orthopaedic Department regarding patient transfer protocols and the involvement of senior medical staff. The training also forms part of the induction process for junior doctors, and the Trust's report was shared with the coroner's office previously.
Agnes Hannan
All Responded
2014-0573 27 Oct 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.
Action Taken (AI summary) The hospital replaced its computer system for medical records, is purchasing a scanner for the A&E department to improve record accessibility, and has reviewed and updated its DNACPR policy, emphasizing discussions with patients and families; this includes a DVD available on the intranet and promoted via screensavers.
Alan Peck
Historic (No Identified Response)
2014-0444 14 Oct 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.
Mary Fenton
All Responded
2014-0443 13 Oct 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack of facilities for echocardiograms after hours, shortages of Isoprenaline, and failures in assessing the patient's mental capacity and obtaining consent to treatment.
Noted (AI summary) The Department of Health acknowledges the concerns about shortages of Isoprenaline and outlines the complexity of pharmaceutical supply chains. They note that Isoprenaline injection is unlicensed in the UK, but that the NHS UK Medicines Information service (UKMI) produced a memo summarising the situation and advising on alternative sources of supply. The trust has updated its DNACPR policy, stressed the importance of communication, reminded clinicians of relevant policies, and advised them to seek refresher training; cardiology staff have been instructed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU Ward 31 without the consent of a Consultant Cardiologist or the on-call Cardiologist for pacing out of hours. The Trust has also issued a warning to all medical staff as to their duties to report matters to Her Majesty's Coroner.
Afifa Qaisar
Historic (No Identified Response)
2014-0107 11 Mar 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Nellie Travis
Historic (No Identified Response)
2014-0101 5 Mar 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
Leslie Pates
Partially Responded
2014-0043 30 Jan 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and no pressure-relieving mattress.
Action Taken (AI summary) Tameside Hospital NHS describes several actions taken to improve communication regarding discharge plans, including developing a checklist, ensuring documented evidence of discussions with patients and carers, raising the profile of the ITT team through public awareness campaigns, ensuring a social worker and Clinical Discharge Facilitator are available, and providing training to staff on discharge planning and nursing documentation.
John Malone
Historic (No Identified Response)
2014-0026 21 Jan 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Barbara White
Historic (No Identified Response)
2014-0015 13 Jan 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
James Withers
Historic (No Identified Response)
2014-0004 7 Jan 2014 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.