Recipient

Greater Manchester Health and Social Care Partnership

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First report 30 Sep 2019•Latest report 4 Nov 2022

Recipient record

Reports, concerns and published responses

Health and care · Health-system partnership. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
32

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Greater Manchester Health and Social Care Partnership linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    John Fallon · 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 Fallon, who had dementia and was resident at Downshaw Lodge Care Home, choked on partially chewed meat while eating lunch without his dentures on 13 March 2022. The concerns included the lack of routine SALT assessments and diet changes when residents eat without dentures, delays in replacing or updating dentures due to limited dental services, and the absence of routinely available suction machines in care homes.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in updating or replacing care home residents' dentures

    Wider context from the report

    “2. Evidence was also heard that the limited availability of dental services to care home residents means that situations where dentures require updating/replacing are not being dealt with promptly which means there is a greater risk of choking on food that has not been adequately chewed; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely carry out SALT assessments when residents transition from eating with dentures to eating without dentures

    Wider context from the report

    “1. The inquest heard evidence that although he needed his dentures to chew in a satisfactory way, SALT assessments are not routinely carried out where an individual goes from eating with dentures to eating without dentures. As a consequence the diet is not routinely altered in a care home setting to reflect the reduced chewing capacity; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely alter care home residents' diets to reflect reduced chewing capacity

    Wider context from the report

    “1. The inquest heard evidence that although he needed his dentures to chew in a satisfactory way, SALT assessments are not routinely carried out where an individual goes from eating with dentures to eating without dentures. As a consequence the diet is not routinely altered in a care home setting to reflect the reduced chewing capacity; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of suction machines in care homes for staff management of choking

    Wider context from the report

    “3. NWAS used a suction machine to clear the airway on their arrival. The inquest heard evidence that these are not routinely in place at care homes and so if a resident is choking food cannot be suctioned out by staff. ”
    Open source report

  2. Manchester South

    AI-generated summary

    Graham Flindle · 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

    Graham Flindle had rectal bleeding and low haemoglobin, was initially treated for haemorrhoids, and was later found to have a malignant tumour. He underwent surgery and subsequently developed breathing complications before dying at Tameside General Hospital on 6 May 2022. Concerns included promoting FIT testing for relevant symptoms and ensuring abnormal, persistently low haemoglobin results prompted timely referral back to secondary care.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Difficulty identifying concerning cases from high volumes of haemoglobin results

    Wider context from the report

    “2. The inquest was told that interpretation of haemoglobin test results and prompt referral back into secondary care if they were abnormal and remained low despite treatment was important to effective and potentially lifesaving treatment. The volume of blood results that GPs were regularly having to consider was significant and made it difficult to always identify cases that were concerning. Prompts in relation to haemoglobin test may be effective in assisting GPs juggling a large volume of results. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of widespread understanding and promotion of FIT testing among community health professionals

    Wider context from the report

    “1. The inquest heard that FIT tests were very effective at identifying bowel cancers at an early stage. GPs and other community health care providers, the inquest heard, have a key role in promoting the use of them where there is rectal bleeding/unexplained weight loss and other symptoms that may be consistent with bowel cancer. Use of FIT tests allows far more effective identification of patients who need to be fast tracked onto the cancer pathway. An understanding of just how effective FIT tests are was not always widely understood and promotion of them amongst all community health professionals was, the inquest was told, crucial in reducing deaths from bowel cancer; ”
    Open source report

  3. Manchester South

    AI-generated summary

    Philip Jones · 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

    Philip Jones developed difficulty swallowing in February 2021, lost significant weight, and was diagnosed with Motor Neurone Disease after hospital admission in September 2021. He developed bronchopneumonia, deteriorated, was discharged home, and died there on 9 October 2021. Concerns included backlogs for neurology appointments, incompatible IT systems affecting information sharing, and delays in communications from consultants to other clinicians and patients.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Significant backlogs in appointments for neurology assessment

    Wider context from the report

    “1. The Inquest heard evidence that there were significant backlogs in appointments to see a neurologist due to a national shortage of clinicians and appointments. In Mr Jones’ case this had not impacted the overall outcome but the Inquest heard evidence that this would not necessarily be the case in all patients. The Inquest heard that pre-pandemic, there was a backlog in existence at 3,500 patients waiting for a neurology appointment. The figure at the time of the Inquest was approx. 7,000; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of IT systems across healthcare organisations to support shared access to complete patient information

    Wider context from the report

    “2. The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult. This impacted the holistic view that clinicians needed of an individual patient. Whilst images could be shared there was no ability for notes for one Trust to be visible to a clinician at another Trust; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in consultants communicating diagnostic and treatment information after appointments or assessments

    Wider context from the report

    “3. The Inquest heard that there were delays in communications from consultants to other clinicians e.g. GPs and patients following appointments/assessments due to a shortage of administrative support for consultants. This meant that important diagnostic/treatment information about patients was not shared expeditiously. ”
    Open source report

  4. Manchester South

    AI-generated summary

    John Edward Kay · 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 Edward Kay had previously undergone larynx removal for stage 4 cancer and had a speech valve, alongside significantly reduced respiratory lung function. He was admitted to Stepping Hill Hospital after a series of aspiration pneumonias and died there on 26 November 2021. Concerns included the failure to share information about caring for his valve with his care home, lack of regular monitoring and replacement, and limited understanding in the community of the specialist nurse service’s role and support.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of understanding of the specialist nurse service role and support

    Wider context from the report

    “2. The role and support available from the specialist nurse service was not understood within the community including by the GP. Greater understanding and awareness of that role would have been helpful in managing Mr Kay and reducing the risk. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange regular valve monitoring and replacement

    Wider context from the report

    “1. The Inquest heard evidence that the management of a patient with a valve such as Mr Kay had is a complex one. It requires regular monitoring and replacement. The evidence was that when he went into a care home that information about how to care for his valve was not shared with the care home. The consequence was that he was not seen or referred for regular replacements of the valve which increased the risk of the valve not functioning correctly and him developing aspiration pneumonia; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share valve-care information with care homes

    Wider context from the report

    “1. The Inquest heard evidence that the management of a patient with a valve such as Mr Kay had is a complex one. It requires regular monitoring and replacement. The evidence was that when he went into a care home that information about how to care for his valve was not shared with the care home. The consequence was that he was not seen or referred for regular replacements of the valve which increased the risk of the valve not functioning correctly and him developing aspiration pneumonia; ”
    Open source report

  5. Manchester South

    AI-generated summary

    James Robert Curry · 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

    James Robert Curry died at Tameside General Hospital on 18 November 2021 from bronchopneumonia after an accidental fall caused a fractured neck of femur. The report identified prolonged waiting in the emergency department, shortages of beds and theatre capacity, lack of orthogeriatric care, and surgery taking place outside the recommended timescale as substantive concerns.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide orthopaedic bed placement for patients requiring hip fracture surgery

    Wider context from the report

    “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide NICE-compliant orthogeriatric care on admission

    Wider context from the report

    “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide hip fracture surgery within NICE-compliant timescales

    Wider context from the report

    “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide timely bed access for elderly patients with hip fracture

    Wider context from the report

    “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”
    Open source report

  6. Manchester South

    AI-generated summary

    Darren Jones · 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

    Darren Jones, who had severe learning disabilities, a long-term catheter and chronic kidney disease, was admitted to Stepping Hill Hospital after unsuccessful catheter changes in the community and Emergency Department. He deteriorated despite treatment for sepsis and died at the hospital on 22 October 2021. The concerns included pressures on community district nursing services, insufficient recognition of his learning difficulties and support needs in hospital, a dispute between Local Authorities affecting respite care and catheter-care training, and the absence of a commissioned LeDeR review.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish responsibility for catheter-care training

    Wider context from the report

    “3. The Inquest heard that there was a dispute between two Local Authorities regarding training in catheter care. This impacted the provision of respite care and his health and wellbeing; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise significant learning difficulties in hospital

    Wider context from the report

    “2. Mr Jones had significant learning difficulties which were not fully recognised at the hospital to ensure that he was provided with support and that an IMCA was put in place to ensure his best interests were met. The Inquest heard evidence that it was important that all clinicians and health care professionals were clear and understood how to effectively support someone with a learning disability to ensure they were given the best and most appropriate care; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient District Nursing Team staffing capacity for caseload demand

    Wider context from the report

    “1. The Inquest heard that delivering care in the community to Mr Jones in relation to his catheter care was impacted by the significant demands on the District Nursing Team due to their staffing levels against their caseload. The evidence was that the District Nursing Teams were under significant pressure which impacted the support and care they could deliver; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to put an IMCA in place to safeguard best interests

    Wider context from the report

    “2. Mr Jones had significant learning difficulties which were not fully recognised at the hospital to ensure that he was provided with support and that an IMCA was put in place to ensure his best interests were met. The Inquest heard evidence that it was important that all clinicians and health care professionals were clear and understood how to effectively support someone with a learning disability to ensure they were given the best and most appropriate care; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to commission a LeDeR review

    Wider context from the report

    “4. No LeDeR appeared to have been commissioned on the evidence before the Inquest. ”
    Open source report

  7. Manchester South

    AI-generated summary

    Rebecca Jayne Flint · 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

    Rebecca Flint was under the care of the Trafford Community Mental Health Team and was found at home on 7 September 2020. The report raised concerns about inconsistent Care Coordinator roles between Trusts and limited Community Mental Health Team resources, including the absence of cover when a Care Coordinator was unavailable.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on individual Care Coordinator capacity for comprehensive mental-health information

    Wider context from the report

    “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust. The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required. I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator. (1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role. (2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of alternative Care Coordinator cover during staff absence

    Wider context from the report

    “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust. The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required. I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator. (1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role. (2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of consistency in Care Coordinator job descriptions and role requirements

    Wider context from the report

    “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust. The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required. I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator. (1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role. (2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role. ”
    Open source report

  8. Manchester South

    AI-generated summary

    Marjorie Walker · 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

    Marjorie Walker was found unresponsive in hospital on 27 May 2020 after receiving prescribed gabapentin, morphine and buprenorphine, with post-mortem toxicology finding gabapentin above the therapeutic level. The report describes concerns about an incorrectly completed DNA CPR form, delays in specialist pain-clinic access, and insufficient recognition and monitoring of kidney function when prescribing gabapentin and other pain medication.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in accessing specialist pain clinics

    Wider context from the report

    “2. Mrs Walker had lived with significant chronic pain for many years. Evidence was heard that she would have benefited from an appointment with a pain clinic for specialist input and the risks around pain medication could have been reduced with specialist input. The inquest heard that there were significant delays in accessing specialist pain clinics due to demand and capacity issues across the NHS; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete and document DNA CPR decisions in accordance with protocols

    Wider context from the report

    “1. The inquest heard evidence that despite the consequences for a patient of a DNA CPR it had not been completed in accordance with protocols. The inquest heard evidence that the importance of well documented and correctly completed paperwork in relation to DNA CPR was important in all cases but particularly in relation to vulnerable members of the community such as Mrs Walker; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of understanding and recognition of kidney-function monitoring alongside prescribing of pain medication

    Wider context from the report

    “3. Mrs Walker was prescribed Gabapentin as part of helping her to manage her chronic pain. The evidence was that the use of pain medication such as Gabapentin carried risk particularly in relation to a patient with underlying kidney issues. The inquest was told that a lack of understanding and recognition of monitoring kidney function including clearance results by health professionals including pharmacists and doctors alongside prescribing created a risk of overdose particularly of vulnerable patients. The inquest was told that the risk would be reduced by greater ease of access to results, more robust checking and education. ”
    Open source report

  9. Manchester South

    AI-generated summary

    Alphonso Alexander Shearer · 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

    Alphonso Alexander Shearer, who had oesophageal cancer and poor swallowing, was discharged with a catheter after treatment for acute urinary retention. He developed symptoms consistent with a urinary tract infection, was prescribed antibiotics he could not swallow, and later collapsed and died while being transferred to an ambulance; post-mortem examination confirmed urosepsis. Concerns included the lack of a system to identify the need for liquid antibiotics, difficulties with the ASK MY GP communication system, and the absence of a face-to-face GP assessment before his deterioration was recognised.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise and flag the most appropriate antibiotic formulation for vulnerable patients

    Wider context from the report

    “1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified as needing them. The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe for avoid delay. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide face-to-face GP assessment when deterioration may be present

    Wider context from the report

    “3. The inquest heard that he had not been seen face to face by a GP and that meant that the full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    ASK MY GP system making communication harder for vulnerable patients and their families

    Wider context from the report

    “2. The inquest heard that the ASK MY GP system had been challenging for those involved with Mr Shearer and had made communication harder. The evidence identified that this was a particular issue for more vulnerable patients and their families. ”
    Open source report

  10. Manchester South

    AI-generated summary

    Matthew McManus · 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

    Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of coordinated support and care with a single point of contact

    Wider context from the report

    “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. ████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and assess complex mental health and social care needs

    Wider context from the report

    “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. ████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of agencies to share information and undertake joint assessment and planning

    Wider context from the report

    “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. ████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess and manage risk to self through a care plan

    Wider context from the report

    “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. ████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf ”
    Open source report

  11. Manchester South

    AI-generated summary

    Fadhia SEGULEH · 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

    Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to enable relevant family input during emergency mental health assessment

    Wider context from the report

    “3. The inquest heard evidence that she had on a previous occasion been taken to A and E due to concerns that she would take her own life/self-harm. Due to Covid she had to go alone to A and E and was assessed alone without input from her family who were aware of the full picture. The experience of attending alone whilst experiencing mental health issues was deeply stressful for her and meant that she had been unsupported by her family at a time of crisis. In addition, the quality of information available was limited as a result of her being there alone. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Telephone-only GP assessments of mental health risk and need

    Wider context from the report

    “2. As a consequence of Covid all of the assessments of her by her GP in relation to her mental health were done via telephone. Prior to Covid it was likely that they would have been done face to face. It was accepted that assessments of mental health risk and understanding of need was far easier to assess face to face. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of coordinated information sharing between professionals involved in mental health care

    Wider context from the report

    “1. The inquest heard evidence that she was being treated by the NHS Mental Health Trust, GP and through private therapy provided by her employer. As a consequence, the professionals treating her did not have a full picture of disclosures made by her and professionals operated in silos. There was no protocol in place for information sharing between those involved and no policy to guide appropriate steps to obtain information. A query raised with the GP would have enabled a clearer picture of the issues to be held by the private provider. Information sharing would have provided a more rounded understanding of risks. The operation in silos meant that the treatment plan put in place by the mental health team including medication was not fully understood by the GP and was altered following a consultation between the GP and Fadhia. Information sharing between agencies would have allowed for a more detailed assessment of risk in the situation. ”
    Open source report

  12. Manchester South

    AI-generated summary

    Norma Rushworth · 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

    Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication difficulties.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to clearly convey community management advice and risks to community health professionals and families

    Wider context from the report

    “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of written documentation to cover communication challenges affecting community care

    Wider context from the report

    “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor deteriorating health early after discharge into the community

    Wider context from the report

    “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited post-discharge support for vulnerable patients in the community

    Wider context from the report

    “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of support for vulnerable patients and their decision making at outpatient appointments

    Wider context from the report

    “1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making. ”
    Open source report

  13. Manchester South

    AI-generated summary

    Martin Gibbons · 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

    Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area

    Wider context from the report

    “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular • A national lack of mental health beds; • The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed. The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a shared definition of high-risk mental health patients between acute and mental health trusts

    Wider context from the report

    “1. During the course of the inquest evidence was heard that the acute and mental health trusts involved had assessed the level of risk he presented differently in part due to there being no shared definition of risk or the factors that triggered a patient being treated as high risk. The inquest heard that across the NHS there is in relation to mental health no shared definition between acute and mental health trusts of what constitutes a high risk patient. The two trusts involved in this inquest had since Mr Gibbon’s death identified that as an issue and work was underway between them to develop and implement a shared definition locally in the absence of any shared national definition. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide detailed and documented shared risk assessments and care plans in acute settings

    Wider context from the report

    “2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting. The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient availability of mental health beds

    Wider context from the report

    “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular • A national lack of mental health beds; • The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed. The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of national or regional guidance for shared care planning

    Wider context from the report

    “2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting. The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach. ”
    Open source report

  14. Manchester South

    AI-generated summary

    Jade Rayner · 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

    Jade Nicole Rayner was a vulnerable adult with complex mental and physical health needs, including seizures, alcohol use and fluctuating capacity. She was found unresponsive at home on 30 March 2020 and had a fatal level of prescribed antidepressants and alcohol in her system. Concerns included the absence of an effective multi-agency strategy, failures in recording and investigating a reported sexual offence, and alcohol misuse support that could not meet the needs of a complex case involving underlying trauma.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record a reported sexual allegation as a crime

    Wider context from the report

    “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code. 2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. 3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of alcohol misuse support programmes able to meet complex trauma-related needs

    Wider context from the report

    “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code. 2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. 3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to offer support set out in the Victims Code

    Wider context from the report

    “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code. 2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. 3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to investigate a reported sexual allegation

    Wider context from the report

    “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code. 2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. 3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a clear multi-agency strategy for supporting complex cases

    Wider context from the report

    “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code. 2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. 3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. ”
    Open source report

  15. Manchester South

    AI-generated summary

    Alan Massam · 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

    Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited understanding of when and how to use s.9 assessments for vulnerable adults

    Wider context from the report

    “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases.in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised. This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear inter-agency information-sharing arrangements for complex care

    Wider context from the report

    “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases.in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised. This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a defined escalation process for refusal of medication and fluids

    Wider context from the report

    “3. The staff at the home were aware of the prescribing of medication including antibiotics. However when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Shortage of suitable adult care beds for complex cases

    Wider context from the report

    “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Continuation of care in a home unable to safely meet complex care needs

    Wider context from the report

    “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidance on ensuring a care home can accept a person back after discharge

    Wider context from the report

    “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidance on acute trust action when attempts to contact a care home are unsuccessful

    Wider context from the report

    “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these. ”
    Open source report

  16. Manchester South

    AI-generated summary

    Alfred Jones · 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

    Alfred Jones was admitted to hospital after an accidental fall at home and sustained further vertebral fractures in a fall on the ward. While awaiting investigation and being medically optimised for discharge, he contracted Covid-19 in hospital and died on 7 September 2020 from bronchopneumonia in combination with Covid-19, with falls and vertebral fractures among the listed contributing conditions. The report raised concerns that shortages of MRI scanner availability and radiology staff prolonged his admission, contributing to the ward fall and Covid-19 infection.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Shortage of qualified radiology staff

    Wider context from the report

    “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient MRI scanner capacity and availability

    Wider context from the report

    “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”
    Open source report

  17. Manchester South

    AI-generated summary

    Carole Mitchell · 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

    Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient local mental health inpatient bed capacity

    Wider context from the report

    “2. Mrs Mitchell on two occasions could not be accommodated locally when an inpatient stay was required. The evidence heard at the inquest was that this was due to limited national mental health bed capacity against the demand within mental health services. The inquest heard evidence that suggested that this impacted on how she could be supported by her family and overall care. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in access to psychology assessment and therapies

    Wider context from the report

    “1. The inquest heard that psychology assessment and therapies can be very beneficial to those with mental health issues in secondary services as well as primary services. The evidence given was that the delay that Mrs Mitchell experienced in accessing that service was reflective of both the regional and national backlog for appointments. The inquest was told that the position had worsened since 2019 and for example someone in Mrs Mitchell’s position today would be more likely to wait 9 months than the 7 months in 2019. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to fully utilise information gathering from family due to misunderstanding of confidentiality

    Wider context from the report

    “3. It was accepted at the inquest that information gathering from family could be beneficial. However, there was a reluctance by health professionals to fully utilise information gathering due to concerns about breaching patient confidentiality. This appeared to stem from a misunderstanding between the concept of information sharing and information gathering and how they inter related with the principle of patient confidentiality. ”
    Open source report

  18. Manchester South

    AI-generated summary

    Anthony Slack · 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

    Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain staff clarity about PPE requirements

    Wider context from the report

    “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited documentation of care home staff observations

    Wider context from the report

    “1. The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff were monitoring him. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share and implement changes to PPE guidance

    Wider context from the report

    “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of risk assessment for admission of new residents

    Wider context from the report

    “3. The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of the entering the home. There was no risk assessment in place relating to admission of new residents. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake observations of sufficient quality

    Wider context from the report

    “2. The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient ambulance availability for timely transport to an acute setting

    Wider context from the report

    “5. The inquest heard that the ambulance was delayed due to shortages of available ambulances. The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and increased capacity. This was not consistent and not on a 24/7 basis. As a result, ambulances were struggling to reach vulnerable and unwell members of the public and transport them to an acute setting. ”
    Open source report

  19. Manchester South

    AI-generated summary

    Alfie Gildea · 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

    Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited police recognition and use of Claire's Law in domestic abuse cases

    Wider context from the report

    “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Unqualified staff making key MARAT decisions

    Wider context from the report

    “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators

    Wider context from the report

    “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different. It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators

    Wider context from the report

    “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Poor information sharing and joint risk recognition across statutory agencies

    Wider context from the report

    “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited police training and capability to identify coercive and controlling behaviour

    Wider context from the report

    “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour. Understanding of how coercive and controlling behaviour in a relationship could be identified was limited. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient health visitor capacity for safeguarding and interagency work

    Wider context from the report

    “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements. As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other 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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible

    Wider context from the report

    “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems. Officers giving evidence did not understand how such information could be accessed or 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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Reduced specialist support and oversight for low and medium risk domestic abuse cases

    Wider context from the report

    “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA 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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share complete relevant information between police and CPS

    Wider context from the report

    “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of CPS decision makers to follow guidance and document prosecution assessments

    Wider context from the report

    “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited health visitor understanding of coercive and controlling behaviour

    Wider context from the report

    “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs

    Wider context from the report

    “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed. There was no evidence of a clear and effective system of notification on the Trafford Division of GMP. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share perpetrator risk information with alleged victims

    Wider context from the report

    “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to place domestic abuse suspects on protective bail conditions during further investigation

    Wider context from the report

    “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required. Instead they were placed under investigation. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide safe opportunities for domestic abuse disclosure

    Wider context from the report

    “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to pursue further enquiries supporting victimless domestic abuse prosecutions

    Wider context from the report

    “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely document police and CPS case discussions

    Wider context from the report

    “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use the MARAC framework when appropriate

    Wider context from the report

    “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Limited police training in domestic abuse risk evaluation and scoring

    Wider context from the report

    “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient resourcing of the MARAT frontline service

    Wider context from the report

    “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct required health visiting conversations face to face

    Wider context from the report

    “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
    Open source report

  20. Manchester South

    AI-generated summary

    Joan Margaret Sanderson · 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

    Joan Margaret Sanderson died at Tameside General Hospital on 15 June 2020 after an accidental fall, surgery for a left hip fracture, and a subsequent MRSA infection. The principal concern was that an MRSA swab was not routinely collected on admission for orthopaedic patients from care homes or with a previous positive MRSA result, which could have enabled earlier identification of infection.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely swab orthopaedic surgery patients from care homes or with previous positive MRSA results on hospital admission

    Wider context from the report

    “The inquest heard evidence from the Trust that following her death they had carried out a RCA to understand what learning could be taken from Mrs Sanderson’s death. A key piece of learning was identified, as patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result should have a routine swab sent for MRSA on admission to hospital. In this case a swab was not collected as that was not standard at that time. Surgery would not be held up awaiting the outcome but it would have allowed earlier identification of MRSA which could impact the outcome in another case where emergency surgery is required and there is an infection post operatively. Patients admitted for elective surgery have a MRSA swab collected 12 weeks prior and receive decolonisation treatment for a positive MRSA result prior to surgery. The inquest was told this change had been rolled out in the trust and was seen as wider learning that could prevent future deaths within the NHS. ”
    Open source report

  21. Manchester South

    AI-generated summary

    Joseph Michael Cheetham · 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

    Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in hospital.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of acute hospital bed capacity

    Wider context from the report

    “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible, and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department. Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide suitable waiting conditions in A and E

    Wider context from the report

    “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible, and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department. Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in putting care packages in place for medically optimised patients

    Wider context from the report

    “2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place. One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place. To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge. ”
    Open source report

  22. Manchester South

    AI-generated summary

    Reginald Collins · 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

    Reginald Collins fell and fractured his neck of femur, underwent surgery, and remained in hospital after becoming medically optimised because a suitable placement was unavailable. He developed aspiration pneumonia and died on 22 October 2019; concerns included delays in discharge and the lack of suitable complex EMI beds locally and nationally.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of suitable complex EMI bed capacity

    Wider context from the report

    “1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him. 2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not. 3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally. 4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in discharge via Adult Social Care

    Wider context from the report

    “1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him. 2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not. 3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally. 4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust. ”
    Open source report

  23. Manchester South

    AI-generated summary

    Samuel Garner · 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

    Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of appropriate Emergency Department space for treating vulnerable patients

    Wider context from the report

    “2. As a result of the lack of appropriate space Mr Garner for an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED. This included whilst he was being given antibiotics intravenously - he scored on the sepsis pathway on arrival. He was also moved in and out of bays depending on varying prioritisation of need. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of surgical bed capacity delaying transfer from the Emergency Department

    Wider context from the report

    “4. It was identified at an early stage that he would need a surgical bed and his care would be optimised in such a setting. There was a significant delay in moving him from the Emergency Department to a surgical ward due to lack of bed capacity within the Trust. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in performing clinically required chest drainage due to competing staff demands

    Wider context from the report

    “3. He waited a number of hours for his chest to be drained (after it was identified that was what was required) due to competing demands on clinical staff. He was in significant distress whilst waiting. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain sufficient Emergency Department capacity during recurring periods of high demand

    Wider context from the report

    “1. The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department. This had been typical of the picture in both the preceding and following weeks due to winter pressures/demands. ”
    Open source report

  24. Manchester South

    AI-generated summary

    John Cheetham · 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 Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of sufficient emergency department and inpatient bed capacity

    Wider context from the report

    “2. The evidence given to the inquest was that the Trust and all other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity. The capacity issues on that day were not one off but had been on going throughout December and continued through the winter months. As a result the ED was regularly overcrowded and elderly, vulnerable patients were regularly waiting for very long periods of time in unsuitable conditions in the ED. 3. The prolonged wait Mr Cheetham had was a result of lack of bed capacity. The inquest was told that this was due to delayed discharges of elderly in-patients back into the community because of challenges faced by adult social care. On the day that Mr Cheetham was waiting for a bed there were over 20 other patients in a similar position waiting for an in-patient bed. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate staffing by nurses trained to work in the emergency department

    Wider context from the report

    “4. The inquest was also told that a shortage of nurses nationally trained to work in ED had meant that the unit was short staffed on the night he fell and suffered a catastrophic injury. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prioritise timely risk assessments for elderly patients at risk of falls

    Wider context from the report

    “5. In his case a risk assessment was not carried out at the earliest opportunity. The inquest heard that when an ED is facing the demands caused by capacity issues risk assessments are not always prioritised increasing the risks faced by elderly patients at risk of falls. ”
    Open source report

  25. Manchester South

    AI-generated summary

    Wendy Margaret Wilkes · 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

    Wendy Margaret Wilkes was found at her home on 6 August 2019, with toxicology showing a fatal level of ethanol and concomitant use of gabapentin, zopiclone, diazepam and amitriptyline. Concerns were raised about the absence of a clear system for alert notes and follow-up reviews, and about whether prescribers were aware of her high alcohol use and assessed the risks of mixing alcohol with her medication.

    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of alert notes for prescribed medication

    Wider context from the report

    “The inquest heard that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure prescribers are aware of high alcohol use

    Wider context from the report

    “The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication. ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of follow-up review appointments for prescribed medication

    Wider context from the report

    “The inquest heard that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication; ”
    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 Health and Social Care Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess the risk of mixing alcohol with prescribed medication

    Wider context from the report

    “The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 59%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026