Recipient

Green Surgery Manchester

First report 15 Oct 2014•Latest report 15 Oct 2014

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Green Surgery Manchester linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Oct2014
Manchester (North)
Concerns raised7
1. Lack of communication between GMP and MEDACS about the existence of an escalation protocol
2. Lack of resources for mental health response
3. Failure to adhere to or use escalation and call grading protocols
1. Failure and reluctance to correspond with patients’ GPs and other healthcare professionals after consultation
2. Clinical decision-making by a non-medically qualified Practice Manager
3. Failure of clinicians to retain responsibility for patients’ safety and wellbeing in the community
4. Delays in GMP responses
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Lucasz Lewandowski · 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

Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Lack of communication between GMP and MEDACS about the existence of an escalation protocol
Wider context from the report
“2. Lack of communication between GMP and MEDACS regarding the existence of their escalation protocol resulting in the delayed attendance of an FME. ”
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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Lack of resources for mental health response
Wider context from the report
“3. The use of S.136 of the Mental Health Act due to lack of resources – albeit on logical, pragmatic grounds. ”
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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Failure to adhere to or use escalation and call grading protocols
Wider context from the report
“1. The timeliness of GMP’s response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols. ”
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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Failure and reluctance to correspond with patients’ GPs and other healthcare professionals after consultation
Wider context from the report
“4. The psychiatric practice’s failure and reluctance to correspond with a patient’s GPs and/or other healthcare professionals following consultation, jeopardising continuity of 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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Clinical decision-making by a non-medically qualified Practice Manager
Wider context from the report
“5. Clinical decision-making by a non-medically qualified Practice Manager. ”
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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Failure of clinicians to retain responsibility for patients’ safety and wellbeing in the community
Wider context from the report
“6. The view of the physician - that responsibility for maintaining a patient’s safety and wellbeing within the community rests entirely with the family and/or patient rather than the clinician. ”
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 Green Surgery Manchester; that does not assign responsibility.
PFD Monitor interpretation
Delays in GMP responses
Wider context from the report
“1. The timeliness of GMP’s response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised7

Lack of communication between GMP and MEDACS about the existence of an escalation protocol

Lack of resources for mental health response

Failure to adhere to or use escalation and call grading protocols

Failure and reluctance to correspond with patients’ GPs and other healthcare professionals after consultation

Clinical decision-making by a non-medically qualified Practice Manager

Failure of clinicians to retain responsibility for patients’ safety and wellbeing in the community

Delays in GMP responses