6 Feb 2026 Michaela FINCH · Prevention of Future Deaths report Manchester West
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Concerns raised 11 Failure to recognise mental health deterioration and consider appropriate escalation View source Risk of self-harm or attempted self-harm after mental health assessment and discharge View source Failure to document and identify co-occurring mental health and alcohol dependency disorders View source Unavailability of escalated interim home-based or community mental health care View source Failure to evaluate alcohol misuse as a possible consequence of mental health deterioration View source Insufficient mental health treatment and care for patients referred to addiction services View source Failure to communicate family concerns to assessing clinicians View source Unsafe discharge practices View source Deficiencies in diagnostic accuracy View source Inadequate patient follow-up View source Deficiencies in clinical risk assessment and management View source See 8 more concerns
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michaela FINCH · 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
Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise mental health deterioration and consider appropriate escalation
Wider context from the report “3. Neither the treating mental health clinician who last assessed the deceased before her death, nor the author of Rapid Review of Care Report identified the missed opportunities to appreciate the full extent of the deceased’s mental health deterioration, nor the potential differential ‘co-occurring’ diagnosis , nor a meaningful consideration of a referral to the Home Based Treatment Team .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Risk of self-harm or attempted self-harm after mental health assessment and discharge
Wider context from the report “7. The evidence established confirmation of a significant incidence of patients suffering from self-harm or attempted self-harm in the immediate or short term following purported assessment and discharge after interface with the Mental Health Team based at the Royal Albert Edward Infirmary – including self-discharges because of the challenging environment with the Accident & Emergency Department .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to document and identify co-occurring mental health and alcohol dependency disorders
Wider context from the report “1. The deceased had a well established diagnosis of mixed anxiety and depressive disorder and profound alcohol dependency syndrome - in evidence, it was established that there was no recent documented mental health diagnosis , and that it was possible that the deceased ought to have been considered as suffering from “co-occurring disorder” (formerly ‘dual diagnosis’) and so eligible for a more active treatment and care escalation pathway, including a care co-ordinator.
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Unavailability of escalated interim home-based or community mental health care
Wider context from the report “6. Both her last treating mental health practitioner and the author of the Rapid Review stated that there are funding issues that affect their ability to deploy escalated interim home based/community care for patients who do not qualify for voluntary/involuntary in patient assessment, or Home Based Treatment Team referral – there was stated to be no mental health equivalence of ‘hospital at home’ afforded to patients with a physical health condition .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to evaluate alcohol misuse as a possible consequence of mental health deterioration
Wider context from the report “5. The evidence established a potential lack of professional curiosity and confirmation bias as to the aetiology of the deceased’s relapse profile - her recourse to alcohol misuse not being evaluated to be a consequence of mental health deterioration .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health treatment and care for patients referred to addiction services
Wider context from the report “2. An experienced recovery worker gave evidence to the effect that addiction services in Wigan receive a significant number of referrals of service users who are suffering from ongoing mental health issues that may require a care programme approach because they are suffering from possible co-occurring disorders and that the mental health element of treatment and care is insufficient to meet the needs of the patient - the perception being that a referral to addictions services is being used as an interim means to deal with a cohort of service users and even as in this case - complex needs .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate family concerns to assessing clinicians
Wider context from the report “4. The evidence established that at least two family members had brought to the attention of a member of the Mental Health Team their profound concerns, their recent lived experiences with the deceased that underpinned these concerns, their views that the deceased was paranoid, at greater risk to herself - but none of these concerns were brought to the specific attention of the assessing clinician - the communication between the Mental Health Team and family members being sub-optimal .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Unsafe discharge practices
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in diagnostic accuracy
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Inadequate patient follow-up
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in clinical risk assessment and management
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” Open source report
21 Aug 2024 Beverley Stanisauskis · Prevention of Future Deaths report Manchester North
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Concerns raised 3 Lack of recognition of learning disability as a factor in patient engagement View source Failure to attempt communication with the patient View source Lack of involvement from the learning disability team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Beverley Stanisauskis · 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
Beverley Stanisauskis was admitted to hospital with significant blood loss from gastrointestinal bleeding and likely pneumonia, and died on 18 January 2024 despite treatment. She had a learning disability, lived alone, and had not been seen by her GP practice for 10 years. The principal concern was that primary care did not recognise that her learning disability may have contributed to her lack of engagement, and did not involve the learning disability team or make attempts to communicate with her through a doctor.
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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of learning disability as a factor in patient engagement
Wider context from the report “1. There was a lack of recognition in the primary care setting that the patient’s known learning disability may have been a factor in their lack of engagement . No attempts were made to speak to or for a doctor to the patient and there was a lack of involvement from the learning disability team.
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt communication with the patient
Wider context from the report “1. There was a lack of recognition in the primary care setting that the patient’s known learning disability may have been a factor in their lack of engagement. No attempts were made to speak to or for a doctor to the patient and there was a lack of involvement from the learning disability team.
” 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 Integrated Care Partnership; that does not assign responsibility.
PFD Monitor interpretation Lack of involvement from the learning disability team
Wider context from the report “1. There was a lack of recognition in the primary care setting that the patient’s known learning disability may have been a factor in their lack of engagement. No attempts were made to speak to or for a doctor to the patient and there was a lack of involvement from the learning disability team .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations