25 Jun 2024 John Howe · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to communicate changes in discharge timings to the ambulance service View source Failure to discharge patients within the required timing when they are unable to manage independently at home View source Failure to ensure factual accuracy in Serious Incident Review reports View source Delays in completing Serious Incident Reviews View source See 1 more concern
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AI-generated summary
John Howe · 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 Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.
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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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate changes in discharge timings to the ambulance service
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings .
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to discharge patients within the required timing when they are unable to manage independently at home
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening . In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure factual accuracy in Serious Incident Review reports
Wider context from the report “(2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies , giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in completing Serious Incident Reviews
Wider context from the report “(2) Completion of the Serious Incident Review was delayed , and the report contained factual inaccuracies, giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement processes preventing investigations from depending on a single person.
Verbatim wording from the response “I recognise the delay in completing the initial SIR due to myself not being in work, and as such we have set up a system, as a service, to ensure all investigations are completed in a timely manner going forward. In reviewing the systems it is essential we are not dependent on a single person within the service and, as such, we have put in place processes to ensure that this does not happen again.” Source location Response from MCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a service-wide system to ensure investigations are completed in a timely manner.
Verbatim wording from the response “I recognise the delay in completing the initial SIR due to myself not being in work, and as such we have set up a system, as a service, to ensure all investigations are completed in a timely manner going forward. In reviewing the systems it is essential we are not dependent on a single person within the service and, as such, we have put in place processes to ensure that this does not happen again.” Source location Response from MCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share consultation agencies’ information for review and accuracy checking before finalising Serious Incident Reviews.
Verbatim wording from the response “We are also reviewing our processes where a person is discharged from a Manchester hospital into an ‘out of area’ locality and if a safeguarding concern takes place on discharge. This will include ensuring engaging with partners in carrying out the SIR and sharing with them the outcomes and recommendations to those organisations. We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report.” Source location Response from MCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Correct inaccuracies in the Serious Incident Review and reshare the amended report with relevant safeguarding teams.
Verbatim wording from the response “I am extremely saddened by the events of the Mr John Howe’s death and, following your report, we have amended the inaccuracies in the report and reshared the Serious Incident Review (SIR) with Derbyshire Safeguarding Adults Board. I have also rehashed the amended SIR with Manchester Foundation Trust Safeguarding Team.” Source location Response from MCC
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27 Nov 2023 Benn Curran-Nicholls · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Risk of deaths arising in similar circumstances 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
Benn Curran-Nicholls · 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
Benn Curran-Nicholls ate yew tree berries and leaves during a walk in Fletcher Moss Park, collapsed later that day, and died in hospital in the early hours of 19 September 2022. The report identified a risk of similar deaths and stated that informing the public about the risk could reduce it.
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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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Risk of deaths arising in similar circumstances
Wider context from the report “There is a risk of a death arising in similar circumstances , and informing the public will clearly reduce the risk of those deaths. Perhaps particularly so for a child whose carer would be so informed.
” Open source report
19 Feb 2019 Janice Andrea Keelan · Prevention of Future Deaths report Manchester City
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Concerns raised 8 Failure to conduct internal review of processes and prioritisation criteria View source Unclear operation of the case prioritisation process View source Failure to provide realistic risk management for bath use by people with mental health conditions View source Failure to account for impaired cognition and probable lack of mental capacity in care and welfare decisions View source Failure to contact the mental health team for assistance when safety work is delayed View source Failure to obtain authority to obtain relevant information from the mental health team View source Failure to urgently prioritise cases involving an apparent risk of death View source Risk of fatal events and scalding injuries during bath use View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Janice Andrea Keelan · 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
Janice Andrea Keelan, who had chronic and complex health conditions and was at risk of falling asleep or having a seizure in the bath, died by drowning on 14 November 2017. A referral for a walk-in shower was not approved until ten days after her death. Concerns included inadequate consideration of her impaired cognition and mental capacity, failure to prioritise the urgent risk, and insufficient action to involve mental health services to reduce the risk of death.
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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct internal review of processes and prioritisation criteria
Wider context from the report “3. It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case, or the need to address changes to the prioritisation criteria .
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Unclear operation of the case prioritisation process
Wider context from the report “2. It was understood that there was some form of prioritisation process for dealing with these sort of cases, although it was not entirely clear at the inquest hearing how this actually worked, specifically and in detail in practice . The process in this case clearly required urgent prioritisation because of the obvious and apparent risk of death, which MCC were told about at the outset.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide realistic risk management for bath use by people with mental health conditions
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic . Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to account for impaired cognition and probable lack of mental capacity in care and welfare decisions
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare . The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the mental health team for assistance when safety work is delayed
Wider context from the report “4. The death was potentially avoidable. If for practical reasons the work simply could not have been done prior to 14 November 2017, contact could have been made with the mental health team seeking assistance and advising them of the position so that they could take steps to intervene in order to minimise the risk of a fatality . Sadly, the deceased died just as her daughter feared she might and that is why the application had been made in the first place
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain authority to obtain relevant information from the mental health team
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to urgently prioritise cases involving an apparent risk of death
Wider context from the report “2. It was understood that there was some form of prioritisation process for dealing with these sort of cases, although it was not entirely clear at the inquest hearing how this actually worked, specifically and in detail in practice. The process in this case clearly required urgent prioritisation because of the obvious and apparent risk of death , which MCC were told about at the outset .
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal events and scalding injuries during bath use
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal . Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath . She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath . This added to the risks to the deceased.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review MSIL prioritisation criteria to improve communication and align resource allocation with need.
Verbatim wording from the response “Manchester’s Service for Independent Living (MSIL)’s prioritisation criteria has been reviewed with the fundamental principal of improved communication within the service. What this means is that the service will allocate resources in line with need. In addition, all those on waiting list we will review on a regular basis, identifying those who are at risk and intervening in a timely manner.” Source location 2019-0057-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review mental capacity awareness training to clarify complex decision-making.
Verbatim wording from the response “Action:” Source location 2019-0057-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review agency escalation processes jointly with GMMH.
Verbatim wording from the response “There are agency escalation processes in place for high risk cases but further work is required to ensure adherence.” Source location 2019-0057-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a safeguarding referral for consideration of whether a Safeguarding Adults Review is required.
Verbatim wording from the response “Action:” Source location 2019-0057-Response-by-Manchester-City-Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an overview, assessment and prioritisation process for the MSIL waiting list, including regular review and reprioritisation.
Verbatim wording from the response “It is essential that we have a continuous overview of our citizens’ wellbeing, if people relapse, become unwell or have adverse life events, such as carer breakdown, the service needs to be able to intervene immediately. The waiting list will now be managed i.e. citizens will be contacted on a regular basis and be continually reprioritised if necessary.” Source location 2019-0057-Response-by-Manchester-City-Council
Open published response
11 Sep 2017 Mr Brian MacLean · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure of Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working View source Failure to identify people potentially at risk of fire in their premises View source Lack of a GPHA process to automatically consider fire risks and prevention View source Lack of automatic water suppression systems for blocks of flats and individuals at high risk View source Failure to refer people at risk of fire to GMFRS View source Failure of GPHA to make referrals to GMFRS for safe and well visits View source Lack of appropriate smoke alarms and assistive technology View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Brian MacLean · 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
Mr Brian MacLean died on 19 March 2016 from smoke inhalation contributed to by alcohol toxicity after a fire started while he was smoking on his sofa. The report raised concerns about insufficiently proactive social services involvement, failure to identify and refer him as being at risk of fire, and the absence of automatic processes for fire-risk assessment, referrals, sprinklers and other preventive measures.
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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working
Wider context from the report “1. That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased . This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS .
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify people potentially at risk of fire in their premises
Wider context from the report “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a GPHA process to automatically consider fire risks and prevention
Wider context from the report “3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic water suppression systems for blocks of flats and individuals at high risk
Wider context from the report “4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk . In addition appropriate smoke alarms and other assistive technology could have been installed.
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to refer people at risk of fire to GMFRS
Wider context from the report “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS .
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of GPHA to make referrals to GMFRS for safe and well visits
Wider context from the report “3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits .
” 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 Manchester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate smoke alarms and assistive technology
Wider context from the report “4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed .
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review contacts closed or classified as non-urgent by the two officers.
Verbatim wording from the response “1. All contacts which have been closed or viewed as non-urgent by Officers A and B have been reviewed.” Source location 2017-0233-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake regular audits of Contact Centre work through the Quality Assurance Team.
Verbatim wording from the response “4. The Quality Assurance Team are to undertake regular audits of the work undertaken by the Contact Centre.” Source location 2017-0233-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue raising adult social care staff awareness of Greater Manchester Fire and Rescue Service offerings through partnership meetings and consideration of extended partnership working.
Verbatim wording from the response “6. MCC has considered the recommendations of the GMFRS report and will continue with the work currently underway to raise the awareness of the services offered by GMFRS among adult social care staff. There are regular meeting between the Community Safety Officer from GMFRS and MCC to ensure that all options for extending partnership working are considered.” Source location 2017-0233-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit 20% of Contact Centre contacts classified as No Further Action between July and September 2017.
Verbatim wording from the response “2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact Centre between July 2017 and September 2017 is being undertaken” Source location 2017-0233-Response-by-Manchester-City-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore increasing social work supervision and oversight of Contact Centre officers.
Verbatim wording from the response “5. MCC is currently exploring increasing social work supervision and oversight of the Contact Centre officers” Source location 2017-0233-Response-by-Manchester-City-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations