5 Dec 2025 Andrew John Hughes · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Unclear provision for mental health services to deal with emergency situations View source Lack of clear arrangements for signposting and contacting emergency mental health services and clarifying their expected response View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Andrew John Hughes · 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
Andrew John Hughes was found deceased at his home after concerns about his wellbeing and unsuccessful attempts to contact him. The inquest concluded that he died by suicide, with the medical cause recorded as hanging. The principal concern was a lack of clarity about how people raising urgent mental-health concerns could be directed to mental-health services and what emergency response those services could provide.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Unclear provision for mental health services to deal with emergency situations
Wider context from the report “The inquest heard evidence that across Greater Manchester there is a system known as Right Care Right Person (RCRP). This is a system that has been adopted by Greater Manchester along with many other parts of England. The inquest was told that adoption of the system was overseen by the Office of the Deputy Mayor for Greater Manchester.
The aim according to the evidence heard was to identify which agency was most appropriate to respond to concerns raised such as in the case of Mr Hughes. In this case Greater Manchester Police declined to attend and indicated it was a health matter and therefore a matter for the Ambulance Service.
The evidence was that this was an incident that involved concerns around his mental health and the risks that his mental health presented to his wellbeing. It would, the inquest was told have been more appropriate for mental health services to have become involved rather than the ambulance service.
It was however unclear from the evidence how that would have been facilitated. There was no clarity as to what arrangements existed for a concerned family to be signposted by GMP to mental health services or how mental health services could be contacted in such an emergency situation as presented in this case or what response could have been expected. This was because it was unclear what provision there was in Greater Manchester for Mental Health Services to deal with these emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for signposting and contacting emergency mental health services and clarifying their expected response
Wider context from the report “The inquest heard evidence that across Greater Manchester there is a system known as Right Care Right Person (RCRP). This is a system that has been adopted by Greater Manchester along with many other parts of England. The inquest was told that adoption of the system was overseen by the Office of the Deputy Mayor for Greater Manchester.
The aim according to the evidence heard was to identify which agency was most appropriate to respond to concerns raised such as in the case of Mr Hughes. In this case Greater Manchester Police declined to attend and indicated it was a health matter and therefore a matter for the Ambulance Service.
The evidence was that this was an incident that involved concerns around his mental health and the risks that his mental health presented to his wellbeing. It would, the inquest was told have been more appropriate for mental health services to have become involved rather than the ambulance service.
It was however unclear from the evidence how that would have been facilitated. There was no clarity as to what arrangements existed for a concerned family to be signposted by GMP to mental health services or how mental health services could be contacted in such an emergency situation as presented in this case or what response could have been expected. This was because it was unclear what provision there was in Greater Manchester for Mental Health Services to deal with these emergency situations.
” Open source report
30 Sep 2019 Charles Williamson · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Insufficient availability of appropriate neuro-rehabilitation beds in Greater Manchester View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Charles Williamson · 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
Charles Williamson sustained a traumatic brain injury after falling in Portugal and underwent treatment and rehabilitation in several hospitals. He later developed infections and deteriorated; the report raised concern that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester could delay effective rehabilitation and increase the risk of complications leading to death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of appropriate neuro-rehabilitation beds in Greater Manchester
Wider context from the report “The inquest heard that following neurological incidents such as those sustained by Mr Williamson it will often be the case that a key to returning to baseline or closer to baseline is effective and early neuro-rehabilitation. The inquest was told that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester was in some cases preventing early effective neuro-rehabilitation and increasing the risk of complications which could lead to death.
” Open source report
19 Jun 2019 Sophie Louise Lyons · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of an effective, adequately funded and targeted multi-agency approach to car cruising View source Failure to coordinate a pan-Greater Manchester approach to car cruising View source Car cruising involving highly dangerous manoeuvres on public roads View source Ineffective enforcement measures against car cruising View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sophie Louise Lyons · 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
Sophie Louise Lyons was struck by a car during a dangerous manoeuvre at an illegal car cruising event in Trafford Park on 31 May 2018. She died in Salford Royal Hospital on 1 June 2018 from a catastrophic traumatic brain injury. The report identified ineffective measures, poor communication, limited resources and an inadequate multi-agency response to the known risks of car cruising.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective, adequately funded and targeted multi-agency approach to car cruising
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years. The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective. Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers. The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required . In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally. The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate a pan-Greater Manchester approach to car cruising
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years. The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective. Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers. The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required. In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally . The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Car cruising involving highly dangerous manoeuvres on public roads
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years . The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective. Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers . The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required. In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally. The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Ineffective enforcement measures against car cruising
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years. The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective . Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers. The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect .
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required. In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally. The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively.
” Open source report
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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 Agree a coordinated Greater Manchester approach to district councils' use and enforcement of Public Spaces Protection Orders.
Verbatim wording from the response “Consideration was given to the use by the district councils of their powers to make and enforce Public Spaces Protection Orders and it was agreed that a coordinated approach across Greater Manchester was necessary.” Source location 2019-0206-Response-from-Greater-Manchester-combined-authority-and-Transport-for-Greater-Manchester-1
Open published response
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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 District councils, not the Mayor or GMCA, hold the powers to make and enforce Public Spaces Protection Orders.
Verbatim wording from the response “Whilst the Mayor’s functions include holding the Chief Constable to account, the Chief Constable has operational independence and total discretion on decisions concerning the configuration and organisation of policing resources or whether not, to deploy police officers. The powers in relation to Public Spaces Protection Orders are vested solely in the district councils.” Source location 2019-0206-Response-from-Greater-Manchester-combined-authority-and-Transport-for-Greater-Manchester-1
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 The Chief Constable, not the Mayor or GMCA, decides policing resource configuration and whether officers are deployed.
Verbatim wording from the response “Whilst the Mayor’s functions include holding the Chief Constable to account, the Chief Constable has operational independence and total discretion on decisions concerning the configuration and organisation of policing resources or whether not, to deploy police officers. The powers in relation to Public Spaces Protection Orders are vested solely in the district councils.” Source location 2019-0206-Response-from-Greater-Manchester-combined-authority-and-Transport-for-Greater-Manchester-1
Open published response
19 Jun 2019 Mason Logue · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of understanding among community health practitioners about the use and importance of Early Health Assessments View source Lack of a single IT system supporting information sharing across NHS trusts View source Failure of health professionals to understand and use the red book for information sharing View source Lack of shared understanding of information dissemination roles and responsibilities View source Failure of health and social care services to provide integrated care and share health information View source Lack of an overarching supportive care plan on discharge View source Failure to allocate a health professional to oversee and coordinate care for children with multiple specialist needs View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mason Logue · 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
Mason Logue, who had been born prematurely and had a complex medical history, was found unresponsive in his mother’s bed at home on 28 October 2017. The post-mortem examination did not identify a clear cause of death, and the medical cause was recorded as unascertained. Concerns included limited integration and information sharing between services, the absence of an overarching supportive care plan and a single professional coordinating his care, and difficulties arising from differing protocols and the lack of a single IT system across NHS trusts.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding among community health practitioners about the use and importance of Early Health Assessments
Wider context from the report “There was a lack of understanding about the use and importance of Early Health Assessments amongst community health practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a single IT system supporting information sharing across NHS trusts
Wider context from the report “The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult . The red book was not utilised as a tool for sharing information other than by the Health Visitor to record standard information e.g. weight. The purpose and value of the red book was unclear amongst the health professionals. It was clear that clinicians in hospitals rarely utilised it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of health professionals to understand and use the red book for information sharing
Wider context from the report “The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult. The red book was not utilised as a tool for sharing information other than by the Health Visitor to record standard information e.g. weight. The purpose and value of the red book was unclear amongst the health professionals. It was clear that clinicians in hospitals rarely utilised it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding of information dissemination roles and responsibilities
Wider context from the report “During the course of the inquest, it was clear that the understanding of local health professionals about how information would be disseminated in accordance with MOUs and protocols was different from the tertiary centre . This meant that there were different views held between health professionals as to their roles and responsibilities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of health and social care services to provide integrated care and share health information
Wider context from the report “The inquest heard that Mason was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU. His mother had previously been known to Family Services. There was limited evidence available of an integrated approach to care from the Local Authority, Tertiary Centre, Local Hospital and Community Health Professionals. As a result, information about his health was not shared between all health professionals . There was no overarching supportive care plan in place on discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of an overarching supportive care plan on discharge
Wider context from the report “The inquest heard that Mason was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU. His mother had previously been known to Family Services. There was limited evidence available of an integrated approach to care from the Local Authority, Tertiary Centre, Local Hospital and Community Health Professionals. As a result, information about his health was not shared between all health professionals. There was no overarching supportive care plan in place on discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate a health professional to oversee and coordinate care for children with multiple specialist needs
Wider context from the report “Furthermore, no one health professional had an overview of his health needs and ensuring that support was put in place and appointments were coordinated . There was no system for an allocated paediatrician to coordinate care where multiple paediatric specialists were involved.
” Open source report
20 Apr 2018 Novia Emilia Delima · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care View source Failure of emergency department on-call arrangements to trigger consultant attendance after long waits View source Failure to meet Manchester triage time targets View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care
Wider context from the report “2. The inquest heard that very young babies present significant challenges in diagnosis and early clinical input by a clinician experienced in dealing with young children was important. The trust had brought in significant changes to how it dealt with paediatric cases in ED since the death of Novia. This includes early clinical involvement of a paediatric clinician for babies between 0- 6 months due to their recognition of challenges of diagnosis in very young children. The inquest heard that not all trusts, nationally, have systems that ensure very young children are seen by a paediatrician at an early stage particularly in an OOH situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency department on-call arrangements to trigger consultant attendance after long waits
Wider context from the report “3.on the night in question the inquest heard that a consultant was on call for ED but was not called in despite the significant delays in ED. The inquest heard that the ED on call consultant arrangements meant that long wait times would not in themselves trigger on call consultants being asked to attend the hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
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 ;
” Open source report
10 Apr 2018 Andrew Reid · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to provide consistent levels of emergency mental health support and access routes across Greater Manchester View source Unavailability of out-of-hours GP referral routes for emergency mental health care in Trafford View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Andrew Reid · 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
Andrew Reid was found suspended from a ligature at Longford Park on 17 October 2017. The inquest concluded that his death was suicide and recorded the medical cause of death as hanging. Concerns related to differences in mental-health service provision and referral routes for residents of Manchester and Trafford, including the lack of out-of-hours emergency GP referrals in Trafford and the requirement for patients to attend A&E.
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. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent levels of emergency mental health support and access routes across Greater Manchester
Wider context from the report “1. The inquest heard that when Mr Reid went to see his GP she was very concerned about the risk he posed to himself and wanted him to be seen urgently by the Home Based Treatment Team (HBTT). The initial call was to the Manchester team -because the GP practice was within the City Of Manchester-who accept referrals from GPs. The Manchester HBTT are commissioned to provide a 24/7 Urgent Assessment Team that GPs can refer into. However, as Mr Reid was a Trafford resident the referral was not accepted and the GP called the Trafford HBTT. Under the terms of their commissioned service they cannot accept referrals from GPs and contact is via the RAID team in A and E. In this case that meant Mr Reid was told he would have to go to A and E. The inquest was told that the differences in level of provision for those with mental health are based on the decisions made by each commissioning authority. As a result residents of GM with mental health issues have a different level of support and route to access services.
2. In Trafford the outcome of the commissioning is that there are no emergency GP referrals dealt with OOH. They can only be dealt with Monday to Friday by the CMHT. GPs outside these times dealing with emergency mental health issues for Trafford residents have to ask patients to make their way to A and E for assessment. If they are concerned that a patient may not make it to A and E then they have to ask the Police to check with A and E -as happened in the case of Mr Reid
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours GP referral routes for emergency mental health care in Trafford
Wider context from the report “1. The inquest heard that when Mr Reid went to see his GP she was very concerned about the risk he posed to himself and wanted him to be seen urgently by the Home Based Treatment Team (HBTT). The initial call was to the Manchester team -because the GP practice was within the City Of Manchester-who accept referrals from GPs. The Manchester HBTT are commissioned to provide a 24/7 Urgent Assessment Team that GPs can refer into. However, as Mr Reid was a Trafford resident the referral was not accepted and the GP called the Trafford HBTT. Under the terms of their commissioned service they cannot accept referrals from GPs and contact is via the RAID team in A and E. In this case that meant Mr Reid was told he would have to go to A and E. The inquest was told that the differences in level of provision for those with mental health are based on the decisions made by each commissioning authority. As a result residents of GM with mental health issues have a different level of support and route to access services.
2. In Trafford the outcome of the commissioning is that there are no emergency GP referrals dealt with OOH. They can only be dealt with Monday to Friday by the CMHT. GPs outside these times dealing with emergency mental health issues for Trafford residents have to ask patients to make their way to A and E for assessment. If they are concerned that a patient may not make it to A and E then they have to ask the Police to check with A and E -as happened in the case of Mr Reid
” Open source report
14 Mar 2018 Peter STOJILJKOVIC · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of consistent and clear prescribing guidance across local and national lists View source Risk of patients obtaining melatonin from unlicensed internet sources View source Failure to communicate with community GPs before discharge about ongoing melatonin prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter STOJILJKOVIC · 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
Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.
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. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and clear prescribing guidance across local and national lists
Wider context from the report “2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists . It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Risk of patients obtaining melatonin from unlicensed internet sources
Wider context from the report “4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it . This created a risk that he would have to access the drug from unlicensed sources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
Wider context from the report “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community ;
2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources.
5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community.
” Open source report
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to record and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to provide differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of clear officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
Concerns raised 3 Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients View source Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity View source Failure to use incident reporting and risk-register procedures to identify drug supply or consumption View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
ASHLEY CORIN DE WINTER PONSONBY · 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
Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.
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. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients
Wider context from the report “1. It is a matter of concern that any ward could be set up and operated involving the inherent risks of drug misuse by dual diagnosis patients without the staff having any training in recognising and dealing with the physical harm and risks arising from the use of illicit substances . The evidence from the independent psychiatrist was that this was an essential ingredient. Consequently, in rehabilitation wards or those with dual diagnosis patients where there is a risk of continuing drug misuse , the concern which arose was that without this, there was a risk of a future death arising. This has implications locally for the Trust, regionally and on a national basis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity
Wider context from the report “3. There was a concern that a lack of a coherent and mutually understood policy between the Mental Health Trust and the Police as to when they would become involved in illegal activity meant that neither the patients nor the staff had clarity on the position . Just because patients have mental disorder, does not absolve them of all legal responsibilities and indeed understanding and facing possible criminal consequences may be important in their overall clinical management and for the administration of justice. It was suggested that this was being considered by Greater Manchester Police and the local Police and Crime Commissioner, but no policy had yet been finalised . Once again, this has local, regional and national implications, and that the concern is without such policies being formulated and implemented, there is a continuing risk of future deaths which could be prevented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Combined Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to use incident reporting and risk-register procedures to identify drug supply or consumption
Wider context from the report “2. There is a concern that the failure to use the Datix and Trust incident reporting policy, as well as the risk register (or other similar procedures available to other Mental Health Trusts), to identify the problem of drug supply and/or consumption , if unremedied may lead to a future death. It is a concern both locally for the Trust, regionally and nationally, that such procedures should be appropriately used so as to prevent a future death.
” Open source report
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Addressed to Police and Crime Commissioner for Greater Manchester, now represented here by Greater Manchester Combined Authority.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations