Other related deaths

PFD Category
Reports: 783 Areas: 72 Earliest: Aug 2013 Latest: 14 Apr 2026

76% response rate (above 63% average). 34% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).

PFD Reports
783 results
Jamie Wood
All Responded
2023-0061Deceased 17 Feb 2023 Dorset
Health and Safety Executive
Concerns summary (AI summary) Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a widespread lack of understanding of safe fixing practices among farmers and inspectors.
Action Planned (AI summary) HSE is exploring how to promote key aspects of risk assessment, building maintenance, and work at height with Farm Safety Partnerships (FSPs) and the Agriculture Industry Advisory Committee (AIAC) and updates guidance and briefings to reflect emerging issues; they also plan to offer free webinars on farm safety.
Natalie Young
All Responded
2023-0123 15 Feb 2023 Somerset
Department for Transport
Concerns summary (AI summary) The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially to vulnerable pedestrians.
Action Planned (AI summary) The Department for Transport reminded retailers to advise customers to show consideration for other pavement users and to undertake training in the use of mobility scooters and is supporting the roll-out of a nationwide certified powered wheelchair and mobility scooter assessment and training scheme through Driving Mobility.
Stephen Preston
Historic (No Identified Response)
2023-0060Deceased 14 Feb 2023 West Yorkshire (Western)
Association of Conservative Clubs LTD
Concerns summary (AI summary) Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and safety regulations, and their proximity to stairs poses a significant risk.
Hannah Warren
All Responded
2023-0055Deceased 13 Feb 2023 Swansea Neath Port Talbot
College of Policing Home Office Metropolitan Police Service +1 more
Concerns summary (AI summary) There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.
Noted (AI summary) The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased 8 Feb 2023 Plymouth, Torbay and South Devon
Approved Clubs self-governing schools Chief Constables +5 more
Concerns summary (AI summary) Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.
Disputed (AI summary) North Wales Police will review cases over the last 5 years where applications have been refused or licenses revoked, but where subsequent applications or appeals resulted in a grant, aiming to complete this by 2nd October 2023. They highlight existing processes for quality control and previous review work undertaken. Dorset Police will provide additional training to further enhance the quality of FEO investigations through the national Professionalising Investigations Programme at level 1 over the next 18 months. A presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. Merseyside Police firearms enquiry officers have completed the South Yorkshire Police training package and are enrolled on Mowbray Partners online training. They will also review cases within one month where firearms were seized or surrendered but subsequently returned, and applications refused/licenses revoked but later granted, aiming to complete this by 2nd October 2023. Avon and Somerset Police completed a review and found no cases where approval should not have been granted. They are reviewing their training requirements and will be implementing additional mandatory training for all staff, including PiP Level 1 training. South Wales Police is reviewing approximately 1300 records where certificate holders were subject to a suitability review to determine if certificates were seized, surrendered, revoked or refused and subsequently approved. They are also working with Gwent Police to align processes, conduct peer reviews, and arrange an annual peer assessment of firearms licensing approvals. North Yorkshire Police has established a Gold group to oversee their response and commenced a review of records relating to certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years, aiming for completion by October 2nd. They are developing an Action Plan to manage the response and record decisions. Lancashire Constabulary has commenced a review of all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years, against the March 2023 Home Office Statutory Guidance, expected to be completed by the end of October 2023. They have also introduced process and scrutiny changes, including a dedicated Chief Inspector responsible for Firearms Licensing and training for staff. Greater Manchester Police will review between 70-80 cases at Senior Officer Panel, for the five-year period, where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. The Firearms Licensing Manager and Detective Sergeant will attend a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. The College of Policing is developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. This will underpin the development of a national training course for staff involved in firearms licensing. Surrey Police will review firearms and shotgun licensing prioritizing cases where firearms have been seized or surrendered and then returned; it will review most recent decisions first and applications that have been refused or licences revoked but where subsequent applications/appeals resulted in a grant. An additional resource has been seconded into the department to expedite this review and provide a full report by 2nd October 2023. Norfolk Constabulary will commission external training for Firearms Licensing Unit staff starting in May 2023. They will also conduct a review of certificates seized, refused, revoked, or surrendered and then subsequently approved, prioritizing cases not already subject to renewal, with a dip-sample approach to other cases. Gloucestershire Constabulary will conduct a review of firearms licensing decisions, as per the letter from the NPCC lead, with a target completion date of 2 October 2023. Essex Police is reviewing decisions to return firearms licenses over a five-year period, prioritizing cases where firearms were seized or surrendered and then returned. They have implemented local training for firearms licensing staff, including a lesson plan developed collaboratively with Kent Police, and external auditors will review the team's compliance. Sussex Police's Firearms and Explosives Licencing Unit believes its process for the return of a certificate is suitably stringent and is catered for within a force policy; the team is working with the national NPCC lead and the College of Policing in developing a national curriculum and learning outcomes for Firearms Enquiry Officers, and will be active participants at the two day CPD event hosted by the College of Policing in May 2023. West Mercia Police will review firearms licensing decisions related to returns, refusals, revocations, and surrenders over the past five years, aiming to complete the review by the end of October. A designated team, including a firearms instructor and tactical advisor, will conduct the review. Bedfordshire Cambridgeshire and Hertfordshire Police have instructed a review of firearms seized and returned, certificate holders refused or revoked then successfully reapplied, and holders subject to police intelligence reports over the last five years. New role-specific training is being undertaken by all Firearms Explosives Licencing Unit staff, and an external training package has been purchased. Kent Police will review 134 firearms licensing cases where certificates were returned after seizure/surrender, or granted after refusal/revocation, assessing them against the current Home Office Statutory Guidance. Local firearms licensing training, including refresher courses and mentoring, is provided, with plans to develop a lesson plan with Essex Police by the end of August 2023. Staffordshire Police and West Midlands Police (collaborated service) provided tables that outline certificates seized and returned, revoked, and refused. They have a series of scheduled quality assurance programmes in relation to internal and external audits over decision making. Northamptonshire Police will prioritise reviewing cases where firearms have been seized/surrendered and then returned, and cases where applications were refused/licenses revoked but later granted, completing this by 2nd October 2023. They have secured temporary resources and engaged external companies to audit the unit. The Lord Chief Justice acknowledges the concerns but states that the report does not substantiate the suggestion that judges are not giving appeals the necessary careful and detailed consideration, are applying the incorrect legal test, or are failing to have regard to the statutory guidance. City of London Police acknowledge the findings and learnings from the Keyham Inquest and will review their SOP to ensure procedures for Application / Annual Renewal / Return meet or exceed common national standards, including robust checks across medical, crime recording and Risk Assessment. Risk assessment training and CPD training for all licensing team will be implemented on an annual cycle. Devon and Cornwall Police invested £3 million into the force's Firearms and Explosives Licensing Unit (FELU). In 2023, training is planned, including integrating firearms licensing into practical scenarios for Personal Safety Training and presenting key learning from the incident at CPD events. Durham Constabulary details their history of firearms licensing reform following a 2013 report and states that they are satisfied that their review of decisions to return firearms to licence holders after seizure or surrender was appropriate and subjected to the appropriate level of scrutiny and oversight. Nottinghamshire Police has identified a dedicated resource to review firearms licensing cases where firearms were seized/surrendered and later returned, or where licenses were refused/revoked and later granted. A sample of cases from a 2021 review will be independently re-reviewed, and all reviews will be completed by 2 October 2023. The Metropolitan Police expresses condolences and describes existing processes for reviewing firearms licensing decisions, including reviews conducted in August 2021, and states they are contributing to national discussions on firearms licensing training. They explain the process used to identify cases for review following the Home Secretary's request. Leicestershire Police will review cases from April 2023 for the past 5 years where certificates were seized, refused, revoked or surrendered and then subsequently approved, prioritizing cases where firearms were seized or surrendered. The review will be conducted by individuals independent from the original decision makers and findings will be reported to the strategic lead for Firearms Licensing. Staffordshire Police (and West Midlands Police, as part of a collaborated service) detail existing training for staff, including the National Triage Firearms Classification Course and Police National Decision Model training. They also refer to the review of certificates seized, refused, revoked or surrendered and subsequently approved. The Home Office is allocating £500,000 to the College of Policing to develop accredited training for firearms licensing staff. They will consult on mandating this training and are working to address health information sharing, in consultation with medical bodies. Thames Valley Police will review seized and returned guns over a 5-year period, grants that have been revoked/refused/surrendered, and applications refused/revoked but subsequently granted via appeal. The aim is to complete these stages by 2 October 2023. Devon and Cornwall Police completed a review of 611 license holders identified as meeting the criteria of having certificates seized, refused, revoked or surrendered and then subsequently approved between May 2018 and December 2019. Eleven of these cases identified internal processes that did not meet expected standards, but no ongoing risks were identified. Warwickshire Police states that they have already responded to the Home Secretary's request in 2021 regarding license applications that were refused or revoked but subsequently granted. The force will direct a review of firearms and shotgun licensing, prioritizing cases where firearms were seized or surrendered but then returned. Derbyshire Police has implemented IT system improvements for recording and sharing information, ensuring automatic notifications to the firearms licensing team for incidents involving license holders. They are developing a digital learning package for frontline officers and are exploring an independent scrutiny panel. Dyfed Powys Police will undertake a further review of decision files where firearms have been seized following any incident and subsequently returned to the holder. They welcome and support the recommendation of the Coroner to formalise a training programme to encompass all Firearms roles and responsibilities. Suffolk Constabulary will review cases relating to certificates issued between April 2019 and August 2020. For other periods, they will dip-sample cases, with a wider review if concerns are identified, and highlight prior review work undertaken in Autumn 2021.
Kirsty McKie
All Responded
2023-0043Deceased 4 Feb 2023 Manchester South
Foreign Secretary
Concerns summary (AI summary) There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Action Planned (AI summary) The British Consulate in Bali will place an information banner about methanol poisoning risks in the international arrival area of the local airport from June to December, and the FCDO will engage with the UK Travel Industry and Student Brand Ambassadors to raise awareness.
Andrew Bowles
All Responded
2023-0423 31 Jan 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Sandwell and West Birmingham NHS Trust
Concerns summary (AI summary) A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Action Planned (AI summary) The two Trusts have agreed to allocate access to hospital records for bank staff who regularly work shifts within the Psychiatric Liaison Team to improve information sharing. Issues will be monitored through clinical governance at BSMHFT.
Michael Holmes
Partially Responded
2023-0023Deceased 20 Jan 2023 West Yorkshire (Eastern)
Department for Environment, Food and Ru… Health and Safety Executive J A Mitchell & Sons +1 more
Concerns summary (AI summary) The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk of trampling incidents, exacerbated by a lack of clear regulations for dogs on leads.
Noted (AI summary) Wakefield Council acknowledges the PFD report but states that many of the concerns are national issues. They state that no action is proposed by Wakefield Council in the absence of change to the statutory framework within which it operates and that a Diversion Order application process takes time. The HSE acknowledges the concerns, explains their role as a regulator, and refers to existing guidance for farmers and landowners. They state that posting notices about dogs is outside their remit but will consider including information on re-routing footpaths in a future review of guidance. DEFRA acknowledges the concerns around safety on public rights of way and refers to existing legislation and guidance, particularly the updated Countryside Code. They state they are responsible for setting out the legislative framework and producing guidance and will look at how to make diverting public rights of way more accessible as part of reforms.
Lance Walker
Historic (No Identified Response)
2023-0062Deceased 19 Jan 2023 West London
Department for Education Department of Health and Social Care London Borough of Ealing +2 more
Concerns summary (AI summary) The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training and staffing. Additionally, there is no standard referral form, risking missed vital information for supported housing placements.
Joseph Price
All Responded
2023-0019Deceased 19 Jan 2023 County Durham and Darlington
NHS England
Concerns summary (AI summary) Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.
Action Planned (AI summary) NHS England acknowledges the concerns and is refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history. All reports received are discussed by the Regulation 28 Working Group to ensure that key learnings are shared across the NHS.
Leroy Hamilton
All Responded
2023-0013Deceased 11 Jan 2023 Birmingham and Solihull
Birmingham and Solihull Integrated Care… Birmingham and Solihull Mental Health N… Department of Health and Social Care +2 more
Concerns summary (AI summary) Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.
Action Planned (AI summary) West Midlands Police have taken multiple steps including updating missing person investigation training, providing a toolkit for staff interactions with missing persons, upgrading the missing persons recording system, and developing training in partnership with Birmingham and Solihull Mental Health Foundation Trust. Birmingham and Solihull ICB, with BSMHFT and UHBFT, are jointly reviewing pathways of care for acutely unwell people requiring mental health support, including the need for increased mental health beds and Psychiatric Decision Unit spaces. A consistent system-wide protocol across urgent care services for mental health patients who go missing will be led by the Mental Health Provider Collaborative. The Department of Health is supporting the NHS to reduce waiting times in A&E by adding beds, speeding up discharge, and increasing transparency. West Midlands Police are setting up a working group with key partner agencies to discuss and design a joint missing person protocol.
Floyd Carruthers
All Responded
2023-0006Deceased 5 Jan 2023 Birmingham and Solihull
Minister of State, HM Prison and Probat…
Concerns summary (AI summary) Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious activity.
Action Taken (AI summary) HMP Birmingham issued a notice to staff about safeguarding and the need to take action when prisoners neglect their welfare. Safeguarding is now a standing item at weekly briefings, and trainers will emphasize self-neglect; a HMPPS training program on safeguarding will be available from December 2023. A learning bulletin will remind staff to identify and refer prisoners who appear to be self-neglecting.
Sylvia Price
All Responded
2023-0009Deceased 4 Jan 2023 Suffolk
Minister of State for Disabled People, …
Concerns summary (AI summary) The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence contributing to a death, poses a risk for future accidents.
Action Planned (AI summary) The Department for Levelling Up, Housing and Communities is updating Building Regulations regarding toilet provision and preparing statutory guidance in a new Approved Document. They will hold a period of public consultation to supplement evidence already held by the department.
Emma Powell
All Responded
2022-0416Deceased 28 Dec 2022 North Wales (East and Central)
Prime Minister’s Office Tesco PLC
Concerns summary (AI summary) Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing of life-saving equipment and appropriate leash usage for varying water conditions.
Action Planned (AI summary) Tesco will add a sticker to the front of their paddleboard packaging with safety information and a QR code linking to British Canoeing's website, and will share information with other retailers via the British Retail Consortium's Product Safety Committee. They have made arrangements for stores to receive and affix the stickers to units delivered in 2022. The Department for Business and Trade has referred the report to Hertfordshire Trading Standards, asked the Office for Product Safety and Standards (OPSS) to write to the British Retail Consortium and major retailers, liaise with enforcement partners and manufacturers, and write to the British Standards Institute to consider industry standards relating to paddleboards.
Allah Ismail
All Responded
2022-0411Deceased 22 Dec 2022 Manchester City
British Thoracic Society Healthcare Quality Improvement Partners…
Concerns summary (AI summary) Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better use of audit tools by NHS Trusts.
Action Planned (AI summary) The British Thoracic Society (BTS) has confirmed that HQIP would support an application for inclusion in the Quality Accounts Audit list, relating to a recurrent national audit of emergency oxygen. The BTS suggests that the CAA address the gap in guidance regarding trauma patients in any further revision of its guidance. The Civil Aviation Authority (CAA) has amended its guidance to include new information that is relevant to passenger fitness to fly, which reflects the recommendation in the Report, under the section entitled: ‘Surgical Conditions - Trauma’ and will discuss the content of the Report at the next UK Fitness to Fly Forum meeting on 5th September 2023.
Zef Eisenberg
Historic (No Identified Response)
2022-0403 16 Dec 2022 North Yorkshire and City of York
Regulatory Counsel and Disciplinary Off…
Concerns summary (AI summary) A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about the adequacy of current regulations and strength assessments for harness fitting points in cars.
Akeem Rhoden
All Responded
2022-0414Deceased 13 Dec 2022 South Wales Central
Brecon Beacons National Park Authority,…
Concerns summary (AI summary) Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing to a lack of awareness of potential drowning risks.
Action Planned (AI summary) Natural Resources Wales is commissioning a report from an independent expert concerning visitor safety management including signage in Waterfall Country. Pending the report, semi-permanent signs are being erected at various locations in Waterfall Country. The council acknowledges concerns and will consider signage at the site, undertaking a signage review and implementing necessary actions. The Neath Port Talbot website has been updated to advise individuals of potential risks involved and signs will be erected to advise individuals of unpredictable water flow.
Melsadie Parris
All Responded
2022-0390 2 Dec 2022 Buckinghamshire
Buckingham Council Children’s Services
Concerns summary (AI summary) Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing critical information about the carer's deteriorating mental state.
Noted (AI summary) Buckinghamshire Children's Social Care acknowledges the coroner's concerns regarding a comment made by a carer. They note the coroner's finding that the child was not at risk at the time and state that without new evidence, they would have no legal right to insist on a further visit.
Daniel-John Varndell
Unknown
2022-0388 29 Nov 2022 Hampshire, Portsmouth and Southampton
Concerns summary (AI summary) A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting MAPPA professionals, posing a risk of future deaths.
Celia Marsh
All Responded
2022-0379 21 Nov 2022 Avon
British Hospitality British Retail Consortium British Society for Allergy and Clinica… +5 more
Concerns summary (AI summary) The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and insufficient education for medical staff and high-risk patients. There's also a lack of robust systems to capture anaphylaxis cases.
Noted (AI summary) The UK Health Security Agency states that responsibility for establishing systems related to food policy and anaphylaxis sits outside of their remit, and instead lies with the Food Standards Agency and the Health and Safety Executive. UKHospitality commits to carrying out a consultation with members on managing the risk of vegan dishes for people with hypersensitivity, and reflecting any recommendations in future updates to the Industry Guidance. The Food Standards Agency will focus on a smaller subset of priorities including Precautionary Allergen Labelling (PAL), improving information in the non-prepacked sector, and enabling a step-change in the knowledge, skills, and food safety culture of staff in the 'non-prepacked' sector through training. The Food and Drink Federation highlights existing guidance on allergen labelling, particularly regarding the differences between 'free-from' and vegan claims and will continue to support the work of the FSA. The British Retail Consortium supports members with label decisions but emphasizes company responsibility, noting challenges with 'free-from' and vegan definitions and the potential for unintended consequences with specific dietary statements. The British Society for Allergy and Clinical Immunology will consider holding an educational event on food avoidance in relation to adults with eczema and will address the need for improved recording and analysis of anaphylaxis fatalities. The Department of Health and Social Care acknowledges the recommendation to establish a robust system of capturing and recording cases of food-related anaphylaxis and notes that data regarding all anaphylaxis-related deaths in England and Wales are documented by the Office for National Statistics and the British Society for Allergy and Clinical Immunology also holds a register. The Royal College of Pathologists is updating its autopsy practice guidelines for suspected acute anaphylaxis to include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases.
Susan Skillen
Historic (No Identified Response)
2022-0367 16 Nov 2022 Liverpool and Wirral
NHS England NHS Improvement
Concerns summary (AI summary) Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a review of literature and adverse event reporting.
Awaab Ishak
All Responded
2022-0365 16 Nov 2022 Manchester North
Department of Health and Social Care Ministry of Housing, Communities & Loca…
Concerns summary (AI summary) The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
Noted (AI summary) The Secretary of State requests local authorities prioritize improving housing conditions for private and social tenants, focusing on damp and mould. They request information on the number of properties with damp and mould and how enforcement of housing standards is being prioritized. The Secretary of State calls on social housing providers to treat damp and mould seriously, meet the Decent Homes Standard, and self-refer to the Regulator of Social Housing if in breach of standards. They also highlight the upcoming Social Housing Regulation Bill to hold landlords accountable. The Secretary of State asks legal representatives to direct social housing tenants with concerns about housing to the Social Housing Ombudsman, highlighting recent changes making it easier to access the Ombudsman. The government outlines actions taken to address damp and mould in social housing, including issuing guidance to landlords, suspending funding to Rochdale Boroughwide Housing, and awarding funding to areas with poor privately rented homes. They also highlight the Social Housing Regulation Bill to hold landlords accountable.
Graham Flindle
All Responded
2022-0349 4 Nov 2022 Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary) Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled to identify critical haemoglobin test results amidst high volumes, highlighting a need for better prompts and education.
Action Planned (AI summary) Greater Manchester Integrated Care's Cancer Alliance recirculated a webinar and resources on cancer and anemia to primary care clinicians and is developing clinical decision support tools for GPs to "think cancer" when certain codes are entered. Learning will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
John Fallon
All Responded
2022-0348 4 Nov 2022 Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary) Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Action Planned (AI summary) NHS Greater Manchester Integrated Care will share learning from this case with the Greater Manchester System Quality Group and cascade it to professionals through relevant governance and learning forums. The Team are currently looking into any additional training in relation to obstructed airways that can be undertaken by care home staff.
Lynn Moss
Historic (No Identified Response)
2022-0347 4 Nov 2022 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high demand on EDs, fueled by broader health and social care failures.