Recurring concern

Unreliable operation of the Manchester Triage System

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First reported 30 Mar 2015•Latest report 8 May 2026

Definition

What this concern includes

Includes deficiencies in the Manchester Triage System that affect its safe operation, including inconsistent application, missed triage time targets, and missing or inadequate safety-relevant discriminators or rules.

Not included

  • Excludes generic Emergency Department overcrowding, staffing or ambulance-capacity concerns unless the report directly identifies their effect on operation of the Manchester Triage System.
  • Excludes failures in other triage systems or emergency pathways that do not concern the Manchester Triage System.
  • Excludes an individual clinical diagnostic failure unless it is specifically linked to a deficiency in the Manchester Triage System.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
NHS England2
College of Paramedics1
Greater Manchester Combined Authority1
Hull University Teaching Hospitals NHS Trust1
London Ambulance Service NHS Trust1
National Institute for Health and Care Excellence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East Riding and Hull

    AI-generated summary

    Garth Pretorius · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Garth Pretorius became unwell after a medical procedure and was diagnosed with sepsis at Goole Urgent Treatment Centre. He was directed to Hull Royal Infirmary, where confusion over an impending emergency led to him and other patients being told to leave, delaying appropriate sepsis treatment by approximately 24 hours; this delay contributed to his death. The report also raises concern about two different triage systems being used simultaneously in the Emergency Department, with insufficient resources for universal adoption of the validated Manchester system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use a single validated triage system universally in the Emergency Department

    Wider context from the report

    “Evidence was heard from the Court’s independent expert that it is unacceptable for two different triage systems to be employed simultaneously in the Emergency Department of Hull Royal Infirmary. Professor Fletchager gave evidence that the Manchester system is validated and internationally accepted, but at material times, another system was used and continues to be used. Some practitioners use the Manchester system whilst others use a different system. Evidence was heard that the use of the Manchester system requires training and there do not appear to be sufficient resources still available for it to be adopted universally at Hull Royal Infirmary. ”

    Source location

    Garth Pretorius · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete the expanded Manchester Triage System training, assessment and competency sign-off programme for all triage staff.

    Verbatim wording from the response

    “Implementation of the Manchester Triage System”

    Source location

    Response from Humber Health Partnership
    Page 1 · response
    Published 23 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Address wider emergency-department safety factors, including patient flow, communication, deterioration recognition and timely sepsis management.

    Verbatim wording from the response

    “The Trust has taken, and continues to take, substantive action to ensure the universal, reliable application of the Manchester Triage System, supported by training, governance and audit. In parallel, we are addressing wider systemic factors identified through detailed investigation, including emergency department flow, communication, recognition of deterioration, and the timely management of sepsis.”

    Source location

    Response from Humber Health Partnership
    Page 2 · response
    Published 23 July 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Immediate senior clinical assessment is considered an appropriate alternative to formal Manchester Triage System application in operationally feasible circumstances.

    Verbatim wording from the response

    “Where operationally feasible, the Trust positions senior clinical decision-makers at the front door of the Emergency Department between 08:00 and 00:00.”

    Source location

    Response from Humber Health Partnership
    Page 2 · response
    Published 23 July 2026

    Open published response

  2. Manchester South

    AI-generated summary

    John Turner · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Turner died at Tameside General Hospital on 23 August 2023 from a pulmonary embolism due to a deep vein thrombosis, neither of which had been identified when he attended the Emergency Department three days earlier. The concerns included significant deviation from the Manchester Triage System, a requested D-Dimer test not being undertaken, delayed recording of a senior doctor’s findings, and reduced scope to identify atypical major or life-threatening illness during periods of unremitting demand.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to follow the Manchester Triage System during high demand

    Wider context from the report

    “In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs. In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record, in all likelihood reflecting competing clinical demands on her time. In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced. ”

    Source location

    John Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Zoe Amanda Knight · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Zoe Amanda Knight developed chest pain and other symptoms, was taken to hospital, and deteriorated after a brief seizure while being investigated for ischaemic heart disease and pulmonary embolism. A post-mortem examination concluded that she died from a dissecting aneurysm of the thoracic aorta. The report raised concerns about the overlap of symptoms with other cardiac conditions, delayed recognition of aortic dissection, and the apparent non-implementation of a recommendation to add “aortic pain” as a chest-pain triage discriminator.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to implement an ‘aortic pain’ discriminator for chest-pain triage

    Wider context from the report

    “1. I heard from Dr ████████, a Consultant Cardiologist at Tameside general Hospital that aortic dissection is a well-recognised, but rare condition. It has some characteristic symptoms, but these are by no means definitively diagnostic. 2. There is an overlap of the symptoms of aortic dissection with other cardiac conditions, which can impede or delay the process of diagnosis. Rupture of the aorta following dissection as suffered by Mrs Knight is a catastrophic event. 3. Dr ████████ was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection (Healthcare Safety Investigation I2017/002b – January 2020 Edition) which contained Safety recommendation R/2020/066: “It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.” 4. It does not appear that this recommendation has been implemented. 5. Dr ████████’s evidence was that awareness of aortic dissection was primarily through case-based learning but acknowledged that the recommendation from thee Healthcare Safety Investigation Report above would additionally raise awareness at the triage stage. ”

    Source location

    Zoe Amanda Knight · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Novia Emilia Delima · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Novia Emilia Delima was brought to hospital on 25 July 2016 after blood was seen in her nappies, and she was not seen by a doctor until several hours after triage. She was subsequently diagnosed with sepsis, deteriorated despite treatment, and died later that day from neonatal herpes simplex and E. coli septicaemia. The concerns included delays in emergency assessment, the need for early paediatric input for very young babies, and consultant call-out arrangements that did not require attendance solely because of long waits.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to meet Manchester triage time targets

    Wider context from the report

    “1. The Trust had adopted the Manchester triage system but due to demand on the ED the time identified through the triage system could not be met. The Manchester triage tool is widely used but the inquest heard that often across EDs the targets set by the triage tool are not met; ”

    Source location

    Novia Emilia Delima · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Sabrina Stevenson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain

    Wider context from the report

    “(4) Concern has been raised by Sabrina’s family, with whom I concur, that the Manchester Triage System should reflect the evidence of the consultant Gynaecologist; that any woman of child-bearing age with abdominal pain should be presumed to be pregnant, until proven otherwise by pregnancy testing. ”

    Source location

    Sabrina Stevenson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Raise the Consultant Gynaecologist’s pregnancy-triage recommendation with JRCALC and request its inclusion in the scheduled workstream agenda.

    Verbatim wording from the response

    “1. The College of Paramedics will advise the JRCALC of the recommendation made by the Consultant Gynaecologist and propose that this work is scheduled into the JRCALC workstream. As in our actions for concern (1) we will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 6 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ask JRCALC to explore incorporating formalised triage tools into the next clinical practice guideline iteration.

    Verbatim wording from the response

    “2. The College of Paramedics will take the issue of triage tools, such as the Manchester Triage System and Paramedic Pathfinder to the JRCALC and propose that work is undertaken to explore the inclusion of formalised triage tools into the next iteration of the JRCALC clinical practice guidelines. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 6 · response
    Published 30 March 2015

    Open published response
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Data last updated 7 September 2026