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.

Responded 3 No Response 1

Action Taken 49%

Action Planned 26%

Noted 26%

Disputed 0%

Based on 47 classified responses

PFD Reports

29 results

Harold Penny

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

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

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.

Mary Fenton

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.