5 Dec 2025 Andrew John Hughes · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Unclear provision for mental health services to deal with emergency situations View source Lack of clear arrangements for signposting and contacting emergency mental health services and clarifying their expected response View source
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AI-generated summary
Andrew John Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew John Hughes was found deceased at his home after concerns about his wellbeing and unsuccessful attempts to contact him. The inquest concluded that he died by suicide, with the medical cause recorded as hanging. The principal concern was a lack of clarity about how people raising urgent mental-health concerns could be directed to mental-health services and what emergency response those services could provide.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear provision for mental health services to deal with emergency situations
Wider context from the report “The inquest heard evidence that across Greater Manchester there is a system known as Right Care Right Person (RCRP). This is a system that has been adopted by Greater Manchester along with many other parts of England. The inquest was told that adoption of the system was overseen by the Office of the Deputy Mayor for Greater Manchester.
The aim according to the evidence heard was to identify which agency was most appropriate to respond to concerns raised such as in the case of Mr Hughes. In this case Greater Manchester Police declined to attend and indicated it was a health matter and therefore a matter for the Ambulance Service.
The evidence was that this was an incident that involved concerns around his mental health and the risks that his mental health presented to his wellbeing. It would, the inquest was told have been more appropriate for mental health services to have become involved rather than the ambulance service.
It was however unclear from the evidence how that would have been facilitated. There was no clarity as to what arrangements existed for a concerned family to be signposted by GMP to mental health services or how mental health services could be contacted in such an emergency situation as presented in this case or what response could have been expected. This was because it was unclear what provision there was in Greater Manchester for Mental Health Services to deal with these emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for signposting and contacting emergency mental health services and clarifying their expected response
Wider context from the report “The inquest heard evidence that across Greater Manchester there is a system known as Right Care Right Person (RCRP). This is a system that has been adopted by Greater Manchester along with many other parts of England. The inquest was told that adoption of the system was overseen by the Office of the Deputy Mayor for Greater Manchester.
The aim according to the evidence heard was to identify which agency was most appropriate to respond to concerns raised such as in the case of Mr Hughes. In this case Greater Manchester Police declined to attend and indicated it was a health matter and therefore a matter for the Ambulance Service.
The evidence was that this was an incident that involved concerns around his mental health and the risks that his mental health presented to his wellbeing. It would, the inquest was told have been more appropriate for mental health services to have become involved rather than the ambulance service.
It was however unclear from the evidence how that would have been facilitated. There was no clarity as to what arrangements existed for a concerned family to be signposted by GMP to mental health services or how mental health services could be contacted in such an emergency situation as presented in this case or what response could have been expected. This was because it was unclear what provision there was in Greater Manchester for Mental Health Services to deal with these emergency situations.
” Open source report
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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 Continue working with system partners, including emergency services, to improve urgent and emergency care across Greater Manchester.
Verbatim wording from the response “We will ensure that the learning from this Prevention of Future Deaths report is shared through our existing system governance and across sectors and continue our work with our system partners, including the emergency services, to provide the best urgent and emergency care for the people of Greater Manchester.” Source location Response from Greater Manchester Integrated Care
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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 Operate an agreed process for GMP call handlers to transfer or signpost people with mental-health welfare concerns to NHS 111 option 2.
Verbatim wording from the response “It is not known whether signposting to mental health services, on the day in question, would have been able to prevent Andrew’s death as this did not take place. However, I can confirm that we do have an agreed process, developed in partnership with Greater Manchester Police (GMP) for police call handlers to transfer and signpost people for whom there is a mental health concern for welfare. This is via NHS 111 option 2 which in GM is staffed by trained mental health professionals who provide triage and assessment over the phone for people experiencing mental health crisis. We have established a dedicated mental health team based in Northwest Ambulance Service (NWAS) Emergency Operations Centre that provides 24/7 support and tactical advice to ambulance and ambulance teams ‘at scene’. It is not clear from your report whether GMP contacted the team for tactical advice in this incident.” Source location Response from Greater Manchester Integrated Care
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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 Provide commissioned mental-health crisis spaces in every Greater Manchester borough with drop-in access.
Verbatim wording from the response “In addition to this, we have commissioned mental health crisis spaces in each borough in Greater Manchester that provide ‘drop-in’ access for people, and we are currently expanding our 24/7 crisis resolution and home-based treatment services across GM to better support people at home or in their place of residence when in crisis.” Source location Response from Greater Manchester Integrated Care
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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 Provide 24/7 mental-health tactical advice to ambulance services through a dedicated team based in the NWAS Emergency Operations Centre.
Verbatim wording from the response “It is not known whether signposting to mental health services, on the day in question, would have been able to prevent Andrew’s death as this did not take place. However, I can confirm that we do have an agreed process, developed in partnership with Greater Manchester Police (GMP) for police call handlers to transfer and signpost people for whom there is a mental health concern for welfare. This is via NHS 111 option 2 which in GM is staffed by trained mental health professionals who provide triage and assessment over the phone for people experiencing mental health crisis. We have established a dedicated mental health team based in Northwest Ambulance Service (NWAS) Emergency Operations Centre that provides 24/7 support and tactical advice to ambulance and ambulance teams ‘at scene’. It is not clear from your report whether GMP contacted the team for tactical advice in this incident.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Expand 24/7 crisis resolution and home-based treatment services across Greater Manchester to support people in crisis at home or their place of residence.
Verbatim wording from the response “In addition to this, we have commissioned mental health crisis spaces in each borough in Greater Manchester that provide ‘drop-in’ access for people, and we are currently expanding our 24/7 crisis resolution and home-based treatment services across GM to better support people at home or in their place of residence when in crisis.” Source location Response from Greater Manchester Integrated Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 999 services, rather than commissioned mental health services, are responsible for emergency responses requiring immediate intervention.
Verbatim wording from the response “We have reviewed the circumstances of the death included in your report and understand that immediately prior to Andrew’s death, mental health services were not contacted. It is our understanding from your report that 999 services were contacted as Andrew required an emergency response. Mental health services commissioning by NHS in Greater Manchester would not provide a 999-emergency response, nor would they have the means to contact someone who is not responding to phone calls or be able to force entry to a property when there is a concern for an individual’s safety.” Source location Response from Greater Manchester Integrated Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental health services provide crisis, not emergency, responses; the concern incorrectly treats them as responsible for 999 emergencies.
Verbatim wording from the response “In your report you state that ‘it was unclear what provision there was in Greater Manchester for mental health services to deal with these emergency situations’. It should be stressed that mental health services are commissioned by NHS GM to deliver a crisis mental health response, and not an emergency response, which is provided by 999 services. Based on the circumstances of the death, this report of concern required an emergency response and as mental health services were not contacted immediately prior to Andrew’s death, they could not have known about the immediate risk to life.” Source location Response from Greater Manchester Integrated Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioned mental health services cannot provide 999 emergency responses, contact nonresponsive individuals, or force entry to protect someone at risk.
Verbatim wording from the response “We have reviewed the circumstances of the death included in your report and understand that immediately prior to Andrew’s death, mental health services were not contacted. It is our understanding from your report that 999 services were contacted as Andrew required an emergency response. Mental health services commissioning by NHS in Greater Manchester would not provide a 999-emergency response, nor would they have the means to contact someone who is not responding to phone calls or be able to force entry to a property when there is a concern for an individual’s safety.” Source location Response from Greater Manchester Integrated Care
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14 Nov 2025 Margaret Crooks · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Lack of clarity about the level of overnight expert stroke support View source Failure to provide timely stroke consultant input for thrombolysis complications View source
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AI-generated summary
Margaret Crooks · 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
Margaret Crooks attended Stepping Hill Hospital after being diagnosed with a stroke and received intravenous thrombolysis. She developed a large bleed attributed to the thrombolysis, and died at Salford Royal Hospital on 20 February 2025. The report identified confusion about the level of overnight specialist stroke support and concern that time-critical treatment advice was not provided promptly or with stroke consultant input.
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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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the level of overnight expert stroke support
Wider context from the report “The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand.
During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill . This creates a risk that expert and complex advice is not given as quickly as necessary . The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical.
In Mrs Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs Crooks was at Stepping Hill appears to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant. In Mrs Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely stroke consultant input for thrombolysis complications
Wider context from the report “The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand.
During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill. This creates a risk that expert and complex advice is not given as quickly as necessary. The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical .
In Mrs Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs Crooks was at Stepping Hill appears to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant . In Mrs Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome .
” 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 Obtain formal network governance approval for the amended standard operating procedure wording.
Verbatim wording from the response “On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.” Source location Response from Greater Manchester Integrated Care
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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 the standard operating procedure governing out-of-hours specialist stroke advice.
Verbatim wording from the response “• Reviewed the current Standard Operating Procedure (SOP) between CSCs and the other Greater Manchester stroke centres that details the protocol to be followed in terms of provision of hyper acute advice out of hours.” Source location Response from Greater Manchester Integrated Care
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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 Agree amended wording defining specialist stroke advice in the standard operating procedure.
Verbatim wording from the response “On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.” Source location Response from Greater Manchester Integrated Care
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8 Aug 2025 Jessica Lynda Smithson · Prevention of Future Deaths report Manchester North
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Concerns raised 6 Unavailability of arrangements for locating people at immediate risk across all charity crisis text services View source Failure of crisis text services to use Greater Manchester mental health pathways for early referral View source Failure to provide crisis text services across all ICBs View source Lack of standard policies and procedures for responding to immediate suicide risk View source Failure of charity crisis text services to link with local NHS Trusts and pathways View source Lack of a commissioned crisis text mental health support service in Greater Manchester View source See 3 more concerns
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AI-generated summary
Jessica Lynda Smithson · 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
Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.
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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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of arrangements for locating people at immediate risk across all charity crisis text services
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life.
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities .
In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of crisis text services to use Greater Manchester mental health pathways for early referral
Wider context from the report “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service. Whilst GM residents can message national services, often the location of an individual texter will not be known.
The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk.
In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide crisis text services across all ICBs
Wider context from the report “(a) The NHSE indicated in their April 2024 Crisis Text Support Guidance and Specification document that they will oversee the rollout of these services which was expected to be rolled out by the end of March 2025. This has now been extended to March 2026.As of to date the evidence indicates only 10 have set up such a service with another 11 in the process of doing so . Some ICBs have indicated that they have no plans to do so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of standard policies and procedures for responding to immediate suicide risk
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide . The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life .
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life , for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.
In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of charity crisis text services to link with local NHS Trusts and pathways
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life.
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.
In addition, as they are not linked into local NHS Trusts , they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a commissioned crisis text mental health support service in Greater Manchester
Wider context from the report “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service . Whilst GM residents can message national services, often the location of an individual texter will not be known .
The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk .
In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis.
” 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 a phased, locally delivered crisis-text service integrated with the Greater Manchester 111 mental-health crisis line.
Verbatim wording from the response “NHS GM alongside the mental health trusts have considered options for the provision of crisis text services and are currently considering our preferred model through our Greater Manchester Mental Health Clinical Effectiveness Group (CEG) as our established clinical governance route. Our preferred model is for a text service to be incorporated into the Greater Manchester 111 Mental Health crisis line service so that texts are handled by Greater Manchester Mental Health First Responders based within the team.” Source location Response from Greater Manchester Integrated Care
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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 crisis-service capacity and demand to enable implementation of a Greater Manchester crisis-text service.
Verbatim wording from the response “These services are planned to be mobilised in Quarter 3 of 2025/26 and we will commence a review of capacity and demand which will enable implementation of the crisis text service. We are exploring options available to us to implement this in a phased approach with consideration given to approaches elsewhere in the country such as in Northampton.” Source location Response from Greater Manchester Integrated Care
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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 the interface between the crisis-text service and Greater Manchester Police during service scoping and mobilisation.
Verbatim wording from the response “For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text messaging service for anyone who is struggling to cope) previously and took the decision to discontinue after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service user feedback online. This was also done in the context that the universal offer commissioned by NHSE was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and Greater Manchester Police should be considered within any commissioning arrangements between NHSE and the provider.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSE and its provider should address the crisis text service's interface with Greater Manchester Police through their commissioning arrangements.
Verbatim wording from the response “For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text messaging service for anyone who is struggling to cope) previously and took the decision to discontinue after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service user feedback online. This was also done in the context that the universal offer commissioned by NHSE was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and Greater Manchester Police should be considered within any commissioning arrangements between NHSE and the provider.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate local implementation is deferred until crisis-service recruitment, service mergers and capacity-and-demand work are completed.
Verbatim wording from the response “These services are planned to be mobilised in Quarter 3 of 2025/26 and we will commence a review of capacity and demand which will enable implementation of the crisis text service. We are exploring options available to us to implement this in a phased approach with consideration given to approaches elsewhere in the country such as in Northampton.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing NHSE universal crisis text service was considered sufficient to discontinue local commissioning at that time.
Verbatim wording from the response “For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text messaging service for anyone who is struggling to cope) previously and took the decision to discontinue after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service user feedback online. This was also done in the context that the universal offer commissioned by NHSE was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and Greater Manchester Police should be considered within any commissioning arrangements between NHSE and the provider.” Source location Response from Greater Manchester Integrated Care
Open published response
10 Jul 2025 Doreen Swann · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Lack of suitable social care placements causing delayed hospital discharges View source
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AI-generated summary
Doreen Swann · 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
Doreen Swann was a patient at Tameside General Hospital whose discharge had been delayed while she awaited a suitable social care placement. She was a high falls risk, fell while unobserved with the bed rails up, suffered a traumatic brain injury and died. The concerns included delayed discharges due to shortages of suitable social care placements, the challenges of managing high falls risk patients in an acute setting, and impacts on hospital bed availability and the Emergency Department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable social care placements causing delayed hospital discharges
Wider context from the report “1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement . The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.
2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.
3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed .
4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department .
” 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 Maintain weekly multidisciplinary oversight of length of stay and delayed transfers to review hospital appropriateness and support discharge.
Verbatim wording from the response “In terms of oversight of discharge planning and patients with NCTR, the Trust’s Chief Operating Officer chairs a weekly meeting to review Length of Stay and Delayed Transfers of Care. Membership includes local stakeholders and the Director of Adult Services to review each patient and ensure appropriateness of care within a hospital setting and aim to support discharge.” Source location Response from Greater Manchester Integrated Care
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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 the Tameside patient-flow and discharge improvement programme, including front-door process mapping and monthly monitoring of delivery targets.
Verbatim wording from the response “As part of a system led improvement programme, there is a continued focus on patient flow and discharge in Tameside covered by the Trust Deputy Chief Operating Officer, Trust Deputy Chief Nurse, and Director of Adult Services for the Local Authority. Progress against the delivery targets within this improvement programme is monitored through a monthly programme group which was established in April 24 and has delivered a significant reduction in patients with a No Criteria to Reside (NCTR) status over recent months. This means that patients who are medically fit for discharge are being discharged to the right place much quicker. This includes process-mapping to support front-door processes to enable deflection to other services.” Source location Response from Greater Manchester Integrated Care
Open published response
10 Jun 2025 Andrew James CONNOLLY · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of a mechanism for family input into mental health clinical assessments View source Lack of guidance for using telephone appointments instead of face-to-face appointments in general practice View source
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
Andrew James CONNOLLY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew James Connolly died after being struck by a train having entered the track at a railway station on 26 November 2024. Concerns included telephone GP appointments despite his mental health not improving, no opportunity for family input into his clinical assessment, and a lack of guidance or mechanism for these arrangements; the inquest heard that his risk was not recognised.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for family input into mental health clinical assessments
Wider context from the report “The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health . The evidence given by his family at the inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide this information.
The consequence of these two factors was that his risk was not recognised.
On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for using telephone appointments instead of face-to-face appointments in general practice
Wider context from the report “The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health. The evidence given by his family at the inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide this information.
The consequence of these two factors was that his risk was not recognised.
On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations.
” 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 Produce and distribute a briefing for Greater Manchester GPs on appointment-mode appropriateness, contextual mental-health risk, family involvement, confidentiality, and Zero Suicide Alliance guidance.
Verbatim wording from the response “Having reflected on the contents of your report, I do think it is important for our GP practices to ensure that the best options for appointments are provided for patients recognising both their preferences but also an individual’s clinical assessment of their condition and needs. In response to this report, I will ensure that NHS GM produces an advice briefing for our GPs and practices to be distributed through our primary care networks, that:” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
×
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 the need for a Greater Manchester decision-making tree or flowchart to guide practitioners on sharing information with families, using Zero Suicide Alliance guidance.
Verbatim wording from the response “- Reviews the need for a decision-making tree / tool to guide practitioners across our GM system using the Zero Suicide Alliance guidance and condensing it into a “decision making tree” flowchart.” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual GPs decide whether family involvement or other information is needed, balancing professional assessment, confidentiality, consent and safeguarding duties.
Verbatim wording from the response “GPs along with all health professionals are bound by the duty of confidentiality between them and their patients, and this is always balanced with their duty of care and responsibilities to safeguard the health and welfare of their patients. Whilst due consideration will always be given to consent, confidentiality and whether there is an agreement in place for family involvement, it will be the individual GP who makes an assessment in their professional opinion in any given consultation that will inform any decision to provide care and treatment and whether other information or opinions are required. A GP will always consider past history, knowledge of previous risks, any treatment and interventions as well as partner agencies that may already be involved. This is balance of professional responsibility and, in some circumstances, this can be difficult” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone and online consultations remain appropriate for many patients, depending on their clinical circumstances; face-to-face appointments are not universally required.
Verbatim wording from the response “GPs in Greater Manchester provide a range of appointment options to meet patient need. This does involve both face to face appointments as well as telephone and online consultations, all of which can meet patient need depending on the circumstances.” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
6 Jun 2025 Esme Vera Louise Atkinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Lack of audit of the cardiac component of abnormality scans View source Insufficient training of community midwives, health visitors and GPs for early suspicion of heart defects View source Failure to ask all appropriate questions during the 6-8 week GP check View source Failure to store cardiac images from abnormality scans View source Failure to recognise the increased heart-defect risk associated with maternal diabetes when assessing presenting symptoms View source Insufficient sharing of information about feeding and weight loss concerns View source Failure to track infant weight centiles in the early stages View source Insufficient understanding of how to listen for heart defects during the 6-8 week GP check View source Failure of routine echocardiogram protocols to account for relevant genetic heart-defect history View source Lack of routine echocardiograms for babies born to mothers with diabetes View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Esme Vera Louise Atkinson · 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
Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of the cardiac component of abnormality scans
Wider context from the report “6. Esme had the usual abnormality scan which the inquest was told did not detect the defect on her heart. The inquest was told that the cardiac part of the abnormality scan was not audited in England under national guidance and the cardiac images were not stored. This meant they were not available for subsequent examination.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of community midwives, health visitors and GPs for early suspicion of heart defects
Wider context from the report “1. The inquest heard evidence that health visitors /midwives and GPs play a key role in the early identification of a heart defect such as Esme’s at an early stage. Such a defect will rarely be apparent at the 72 hour check on the evidence given at the inquest but symptoms will manifest subsequently. Such symptoms can be subtle and the inquest was told that for there to be early suspicion, of a heart defect, training for community midwives/health visitors and GPs needed to be improved and good quality information sharing was also essential. This should include concerns around feeding and weight loss.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ask all appropriate questions during the 6-8 week GP check
Wider context from the report “2. The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking all of the right questions and a good understanding of how to listen for such a heart defect.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to store cardiac images from abnormality scans
Wider context from the report “6. Esme had the usual abnormality scan which the inquest was told did not detect the defect on her heart. The inquest was told that the cardiac part of the abnormality scan was not audited in England under national guidance and the cardiac images were not stored . This meant they were not available for subsequent examination .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the increased heart-defect risk associated with maternal diabetes when assessing presenting symptoms
Wider context from the report “3. The inquest was told that it was important that it was understood by health professionals involved in the care of a baby that the mother being diabetic increased the risk of a defect significantly and should increase the care taken in relation to presenting symptoms .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient sharing of information about feeding and weight loss concerns
Wider context from the report “1. The inquest heard evidence that health visitors /midwives and GPs play a key role in the early identification of a heart defect such as Esme’s at an early stage. Such a defect will rarely be apparent at the 72 hour check on the evidence given at the inquest but symptoms will manifest subsequently. Such symptoms can be subtle and the inquest was told that for there to be early suspicion, of a heart defect, training for community midwives/health visitors and GPs needed to be improved and good quality information sharing was also essential . This should include concerns around feeding and weight loss .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to track infant weight centiles in the early stages
Wider context from the report “7. The evidence of the paediatricians at the inquest was that tracking weight on the centile chart even from an early point assisted in understanding if there was a significant issue in relation to feeding triggering professional curiosity. However the evidence from the Health Visitor appeared to suggest that centile tracking was not seen as useful before 1 month and the red book was not used to look at weight centile tracking in the early stages .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of how to listen for heart defects during the 6-8 week GP check
Wider context from the report “2. The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking all of the right questions and a good understanding of how to listen for such a heart defect .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of routine echocardiogram protocols to account for relevant genetic heart-defect history
Wider context from the report “5. In Esme’s case although her mum’s identical twin had a heart defect this did not in the North West, trigger the protocol for a routine echocardiogram . A heart defect in her mother would have. It was unclear why this was excluded given the genetic link .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of routine echocardiograms for babies born to mothers with diabetes
Wider context from the report “4. There was no routine echocardiogram of a baby born of a mother with diabetes nationally although their risk of a defect was significantly higher than other babies and such a test would detect a baby with a ventricular septal defect at an early stage
” 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 Develop a briefing with clinical leadership and distribute it through the primary care newsletter to reinforce GPs’ role in early heart-defect identification.
Verbatim wording from the response “NHS GM is committed to learning from Prevention of Future Death reports. In response to this report, I will initiate the following actions:” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Include specific heart-defect content in all student midwives’ NIPE training.
Verbatim wording from the response “All of the above guide staff to escalate with any concerns around heart defects. Additionally, the specialist NIPE training does detail specific training around heart defects, and is now included in all student midwives training, historically this was seen as specialist training completed by some midwives.” Source location Response from Greater Manchester Integrated Care
Open published response
9 May 2025 Janet Alison Anderson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of coordinated discharge planning and joint working between trusts View source Failure of documentation to capture key discussions and decisions View source Unavailability of acute hospital beds for patients needing acute care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Review support-accommodation barriers in Bury and share the resulting learning system-wide.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025. View source
Action
Match patients actively to schemes within the new local provider framework.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025. View source
Action
Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
Status unclearThe respondent did not make the status of this action clear when they made their response on 20 May 2025. View source
Action
Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
Stated completedThe respondent said that this action was complete when they made their response on 20 May 2025. View source
Action
Fund and recruit additional patient-flow capacity and gatekeeping roles covering admissions, weekends and out-of-hours periods.
Stated completedThe respondent said that this action was complete when they made their response on 20 May 2025. View source
Action
Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025. View source
Action
Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
Stated plannedThe respondent said that this action was planned when they made their response on 20 May 2025. View source
Action
Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Stated completedThe respondent said that this action was complete when they made their response on 20 May 2025. View source
Action
Pursue system-wide reductions in clinically ready-for-discharge bed days and mental-health acute inpatient length of stay by March 2026.
Stated plannedThe respondent said that this action was planned when they made their response on 20 May 2025. View source
Action
Review community-based alternatives to admission across Greater Manchester.
Status unclearThe respondent did not make the status of this action clear when they made their response on 20 May 2025. View source
Action
Realign community support resources toward housing and forensic step-down.
Status unclearThe respondent did not make the status of this action clear when they made their response on 20 May 2025. View source
Action
Embed the Home First model across localities.
Stated completedThe respondent said that this action was complete when they made their response on 20 May 2025. View source
Action
Implement locality improvement plans addressing accommodation, complex-needs, step-up, step-down, escalation, urgent-care integration and cross-border discharge barriers.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025. View source See 10 more actions
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AI-generated summary
Janet Alison Anderson · 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
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of coordinated discharge planning and joint working between trusts
Wider context from the report “1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline.
She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge .
The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of documentation to capture key discussions and decisions
Wider context from the report “2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication . As a consequence, trust staff were not fully sighted on earlier decisions and her 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute hospital beds for patients needing acute care
Wider context from the report “3. The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting .
” Open source report
×
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 support-accommodation barriers in Bury and share the resulting learning system-wide.
Verbatim wording from the response “• Bespoke work in Bury to review support accommodation barriers – learning to shared system wide” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Match patients actively to schemes within the new local provider framework.
Verbatim wording from the response “• Active matching of patients to the new local provider framework schemes” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
Verbatim wording from the response “• Additional Voluntary Community and Social Enterprise (VCSE) capacity in Manchester locality to support prevention of avoidable admissions and ensure timely discharge following inpatient admissions” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
Verbatim wording from the response “• Improved CRFD escalation through a newly implemented senior system MADE forum” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Fund and recruit additional patient-flow capacity and gatekeeping roles covering admissions, weekends and out-of-hours periods.
Verbatim wording from the response “• Additional patient flow capacity and gatekeeping roles have been funded and recruited to ensure robust admissions and additional focus on weekends and out of hours.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
Verbatim wording from the response “As well as the actions and improvements listed above, an escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3. This escalation process could be applied to the case of a patient who is CRFD in a medical bed but waiting for a package of care through a MH provider. The process, which is currently being piloted, provides a system aligned to 4 levels of escalation, levels 1-4. Any case where a mental health patient is CRFD with an unidentified barrier to discharge can be escalated.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
Verbatim wording from the response “In addition, a series of extraordinary MADE events have taken place, reviewing every CRFD case and identifying both individual and system-level blockers. One of the key actions agreed is the development of a consistent, end-to-end brokerage and funding pathway. This will define clear responsibilities, time standards at each stage, and introduce a formal protocol for cases that depend on external provider responses. In these cases, delays will be logged and monitored but not attributed to statutory agencies.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Verbatim wording from the response “GMMH have worked closely with NHS GM and Manchester commissioners to understand internal causes of delay, identify resource priorities, and explore immediate opportunities within existing services to reduce flow pressures. This work includes:” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Pursue system-wide reductions in clinically ready-for-discharge bed days and mental-health acute inpatient length of stay by March 2026.
Verbatim wording from the response “As a Greater Manchester (GM) system, we have committed to reducing the number of Clinically Ready for Discharge (CRFD) bed days by 25% and reducing the Length of Stay (LoS) for Mental Health Adult acute, older adults Psychiatric Intensive Care Unit (PICU) inpatients wards by end March 2026. A trajectory has been set and is monitored through a single source data set to ensure alignment and a comprehensive dashboard for monitoring is available system wide.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 community-based alternatives to admission across Greater Manchester.
Verbatim wording from the response “• Review across GM of community-based alternatives to admission” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Realign community support resources toward housing and forensic step-down.
Verbatim wording from the response “• Realignment of community support resources with a focus on housing and forensic step-down” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Embed the Home First model across localities.
Verbatim wording from the response “• Home First model to be embedded in localities” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 locality improvement plans addressing accommodation, complex-needs, step-up, step-down, escalation, urgent-care integration and cross-border discharge barriers.
Verbatim wording from the response “To support the reduction, NHS GM localities have committed to and submitted Improvement Plans. These show that barriers to discharge remain, particularly in relation to accommodation pathways and individuals with complex needs. Localities are addressing these barriers through focused actions around step-up/step-down provision, targeted escalation approaches for complex patients, urgent and emergency care integration schemes, and coordinated planning for cross-border discharges. Manchester locality remains the locality with the highest number of Out of Area Placements (OAPs), Long Stay Patients (LSP’s), and CRFD cases. However, significant work has been undertaken and, as an example of progress to date, we have seen a 38% reduction in the Manchester locality, giving us confidence that our plans and actions are having an impact.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Verbatim wording from the response “I note that your report has been shared with Manchester University Hospitals NHS Foundation Trust (MFT) and Greater Manchester Mental Health NHS Foundation Trust (GMMH) and trust they will respond to the issues specifically relating to Ms. Anderson’s care. I have responded to the issues you raise in light of the work undertaken by NHS GM as commissioner responsible for health and social care..” Source location Response from Greater Manchester Integrated Care
Open published response
30 Apr 2025 Louise Danielle ROSENDALE · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Limited review of long-term opiate prescribing View source Lack of long-term detailed planning and oversight of patients prescribed opiates View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Danielle ROSENDALE · 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
Louise Danielle Rosendale was prescribed long-term opiates for pain following previous surgery and was found unresponsive on 24 September 2024. She died from multiple drug toxicity and pneumonia; concerns included limited review of her long-term opiate prescribing and a lack of detailed planning or oversight for such patients within the practice.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited review of long-term opiate prescribing
Wider context from the report “THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her . The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of long-term detailed planning and oversight of patients prescribed opiates
Wider context from the report “THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her. The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice
” 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 Work with Manchester University colleagues to investigate and implement the SMASH dashboard opioid indicator for identifying and reviewing patients after hospital discharge.
Verbatim wording from the response “• Working with colleagues from Manchester University to investigate and implement use of the new Safety Medication (SMASH) dashboard indicator which identifies patients prescribed opioids within 30 days of discharge from hospital. The aim of the indicator is to facilitate identification and review of patients to prevent harm from long term opioid use.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Collaborate with other localities and secondary-care pain clinics to explore multidisciplinary review of complex primary-care patients receiving high-dose opioids.
Verbatim wording from the response “• Collaborate with colleagues from other GM localities and secondary care pain clinics to explore the potential for multidisciplinary team review of complex patients on high dose opioids in primary care.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Work with GP practices to increase use of the SMASH dashboard, including its opioid indicator.
Verbatim wording from the response “• Work with GP practices to increase use of the safety medication (SMASH) dashboard, including the new opioid indicator.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 patients flagged by the SMASH opioid indicator, identify primary-care review-process improvements and feed potential secondary-care improvements to the Opioid Safety Group.
Verbatim wording from the response “• Review by a pharmacy technician and pharmacist from the team of patients flagged by the SMASH opioid indicator and identify improvements that can be made to primary care review processes as well as feeding back, via the trust Opioid Safety Group, potential improvements to secondary care processes.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Use regular meetings with PCN clinical pharmacists to promote identification and prioritisation of opioid patients for structured medication review and signpost review resources.
Verbatim wording from the response “• Discussion at regular meetings held with PCN clinical pharmacists to highlight the need to identify and prioritise patients prescribed opioids for structured medication reviews and ensuring they are aware of resources available to facilitate review, including the Greater Manchester Pain Management Resources Hub.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Work with other Greater Manchester localities to produce and implement standards for primary-care review of patients discharged on opioids.
Verbatim wording from the response “• Work with colleagues in other GM localities to produce and implement standards for primary care review of patients discharged on opioids.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Produce and disseminate primary-care communications highlighting chronic-pain opioid risks, review expectations and available resources.
Verbatim wording from the response “• Collaboration with a colleague from another locality to produce a communication for primary care to highlight the risks of opioids used in chronic pain, encourage review of these patients and signpost to resources available on the Greater Manchester Pain Management Resources Hub.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Provide GP practices with opioid-prescribing data, including high-dose prescribing, and signpost resources supporting patient review.
Verbatim wording from the response “• Provide data to GP Practices regarding their opioid prescribing, including high dose opioids, and ensure they are aware of resources available to facilitate review of patients.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Increase awareness and accessibility of local services supporting opioid-patient review, including pain-clinic referral pathways and non-pharmacological pain-management support.
Verbatim wording from the response “• Increase awareness, and ensure information is readily accessible to GP practice clinicians, regarding local services available to support the review of patients on opioids, including pain clinic referral pathways and non-pharmacological support for pain management.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Structured medication reviews for opioid patients are limited by PCN clinical pharmacist capacity under the DES contract.
Verbatim wording from the response “Since October 2020, there has been a requirement, as part of the PCN Direct Enhanced Service (DES) contract, for GP practices to proactively identify and prioritise for structured medication review (SMR) patients using one or more potentially addictive medications from the following groups: opioids; gabapentinoids; benzodiazepines; and Z-drugs. However, the PCN DES also states that the number of SMRs that a PCN is required to offer will be determined and limited by their clinical pharmacist capacity.” Source location Response from Greater Manchester Integrated Care
Open published response
10 Apr 2025 Robert Leighton SMITH · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Insufficient commissioned capacity for timely mental health therapy support View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Leighton SMITH · 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
Robert Leighton Smith was found unresponsive at home on 25 October 2024 while prescribed high levels of painkillers; toxicology found above-therapeutic levels of his prescribed medication, and the inquest concluded accidental death. He had been assessed as likely to benefit from Interpersonal Psychotherapy but had not started it because of a significant waiting list, with average waits of 12 months attributed to demand exceeding commissioned 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient commissioned capacity for timely mental health therapy support
Wider context from the report “The inquest was told that Mr Leighton –Smith had been assessed as someone who would gain a real benefit from IPT. However he had not started it at the time of his death due to a significant waiting list . This was caused by the demand for the service being far higher than the capacity . The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months . This was due to the ongoing demand against commissioned capacity.
The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level . The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring . The Trust GMMH indicated they provided the services they were commissioned to provide but unless the additional services were commissioned they could not increase their provision and waiting lists would remain high .
” Open source report
×
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 Commission Kooth and Qwell online platforms to provide free, anonymous, clinically supervised mental-health support.
Verbatim wording from the response “• Digital Support commissioned from Kooth and Qwell: We have commissioned online mental health platforms Kooth (for children and young people) and Qwell (for adults), offering free, anonymous, and clinically supervised mental health support. These services expand access to therapeutic support, particularly for those awaiting more intensive interventions.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
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 Explore targeted recruitment, training and retention measures to increase the psychological-therapy workforce.
Verbatim wording from the response “In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
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 and evolve commissioning practices to better align psychological-therapy provision with population needs.
Verbatim wording from the response “In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
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 Use benchmarking to map psychological-therapy provision gaps and inform long-term commissioning plans.
Verbatim wording from the response “In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioned psychological therapy capacity cannot currently meet all identified need because of longstanding underinvestment and financial constraints.
Verbatim wording from the response “Recent benchmarking has demonstrated that our commissioned services currently have the capacity to deliver psychological interventions to approximately 14.6% of individuals who require support outside of early intervention services. This figure reflects longstanding systemic underinvestment and financial challenge resulting in capacity limitations within mental health care.” Source location Response from Greater Manchester Integrated Care Board
Open published response
4 Apr 2025 Hailey Anne Thompson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to allocate medication enquiries to clinicians with appropriate competencies View source Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor View source Failure to record clinical task communications on the medical records system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hailey Anne Thompson · 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
Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate medication enquiries to clinicians with appropriate competencies
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist , which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock .
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice ,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery .
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to .
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical task communications on the medical records system
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist . On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” Open source report
×
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 Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
Verbatim wording from the response “NHS GM recognises the importance of staff training in all our primary care practices to ensure that patients are navigated correctly and in a timely way as appropriate for the symptoms they are presenting with, including providing appropriate and timely treatment. NHS GM will” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Share a GDPR record-keeping reminder through the NHS Greater Manchester Primary Care Newsletter.
Verbatim wording from the response “I have reviewed the response from SSP Health to this part of your report and think there is some learning for primary care providers around ensuring efficient and effective access to the right clinician to treat them and the requirement to ensure accurate, detailed and timely record keeping.
To this aim, I will ensure that:” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Develop and share a learning document on safe, effective referrals to treating clinicians with Greater Manchester practices.
Verbatim wording from the response “I have reviewed the response from SSP Health to this part of your report and think there is some learning for primary care providers around ensuring efficient and effective access to the right clinician to treat them and the requirement to ensure accurate, detailed and timely record keeping.
To this aim, I will ensure that:” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
Verbatim wording from the response “NHS GM recognises the importance of staff training in all our primary care practices to ensure that patients are navigated correctly and in a timely way as appropriate for the symptoms they are presenting with, including providing appropriate and timely treatment. NHS GM will” Source location Response from Greater Manchester Integrated Care
Open published response
Concerns raised 3 Failure to utilise hospital passports View source Failure to provide adequate information about care needs in referrals to specialist services View source Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Anthony Fernandez · 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
Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to utilise hospital passports
Wider context from the report “1. The hospital passport was not utilised .
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate information about care needs in referrals to specialist services
Wider context from the report “1. The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions
Wider context from the report “1. The hospital passport was not utilised.
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual .
” Open source report
×
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 Remind staff to check for and seek Hospital Passports at every presentation, regardless of whether records or systems identify one.
Verbatim wording from the response “• As a health and care system, we recognise the importance of Hospital Passports. Staff have been reminded to immediately aware of and seek out whether a Hospital Passport is held, regardless of whether or not one is noted on the patient records, Trust or community systems or is available at any given presentation to services for care.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
16 Oct 2024 Paul Michael Clark · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to monitor patients with former opioid addiction prescribed opioid painkillers View source Failure to consider the risks of prescribing opioids to patients with former opioid addiction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Michael Clark · 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
Paul Michael Clark was found unresponsive at home on 12 May 2024 and died from drug toxicity; the inquest concluded that the death was accidental. The principal concern was that opioid painkillers were prescribed despite his documented previous heroin addiction, without evidence that the risks of reintroducing opioids were considered or monitored, and he subsequently became addicted and took increasing amounts, including non-prescribed opioids.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients with former opioid addiction prescribed opioid painkillers
Wider context from the report “The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored . It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the risks of prescribing opioids to patients with former opioid addiction
Wider context from the report “The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored. It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing .
” Open source report
×
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 Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
Verbatim wording from the response “The Regulation 28 report and our response will also be shared, in January 2025, for system learning with the GM cross-sector medicines safety group - the IPMO Medicines Safety Group. This group reports to the Greater Manchester Medicines Management Group (GMMG) and is co-chaired by NHS GM and Manchester University NHS Foundation Trust (MFT). The intention is to reflect on any learning from the Regulation 28 report and create a 7-minute briefing to be produced, disseminated to clinical staff and used for shared learning.” Source location Response from GMIC
Open published response
×
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 Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
Verbatim wording from the response “In order to support our wider GP population, a Masterclass presentation on the subject of opioid prescribing was delivered to Stockport GPs and clinicians on 12 September 2024. The session title was ‘Pain Transformation, IMPS and Opioid Stewardship’. A total of 62 clinicians attended the session which was delivered by Dr Thomas Walton, Consultant in Anaesthesia and Pain Management.” Source location Response from GMIC
Open published response
24 Sep 2024 George Neville Coulthard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Delays in identifying suitable care home placements View source Limited access to tissue viability and district nursing information and support for wound care in the community View source Lack of effective communication about the required care pathway between discharging and community teams View source Failure of management teams to clarify the required level and type of care View source Unavailability of acute beds causing delays in allocating beds to patients requiring admission View source Failure to ensure internal care documentation reflects the correct care position View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Neville Coulthard · 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
George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying suitable care home placements
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home . This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission. The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited access to tissue viability and district nursing information and support for wound care in the community
Wider context from the report “4. The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited . Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However the demands across GM on TVN and DN services made this difficult to achieve .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication about the required care pathway between discharging and community teams
Wider context from the report “2. The lack of effective communication between the discharging team and the community teams meant that it was not understood if Mr Coulthard was on End of Life Care or for rehabilitation . The staff at the first home treated him as an end of life patient / palliative care patient as a consequence even though the paperwork suggested he may be a discharge to assess patient. As a consequence he was moved to another care home for rehabilitation although the evidence was that there was little purpose in the transfer.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of management teams to clarify the required level and type of care
Wider context from the report “3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute beds causing delays in allocating beds to patients requiring admission
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home. This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission . The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure internal care documentation reflects the correct care position
Wider context from the report “3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position .
” Open source report
×
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 Continue reviewing discharge processes, alternatives to hospital admission, and patient-flow pathways across Greater Manchester hospitals.
Verbatim wording from the response “You refer to such delays occurring on a regular basis and often exacerbated by the festive period. The winter period generally is extremely busy with high numbers of patients entering the hospital and needing to be admitted for care and treatment. Whilst every effort is made to appropriately manage the flow of patients to free up beds, there are occasions when delays in discharge do impact on patient flow. This is regrettably not a scenario that is specific to the festive period as such challenges occur throughout the year, but particularly through the winter months. As a system we consistently review discharge processes, alternatives to hospital admission, and patient flow pathways. This is with a view to improving the patient experience and flow through all GM hospitals so that patients can receive the right care at the right time and in the right place.” Source location Response from GMIC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Demand across Greater Manchester tissue viability and district nursing services made improved community wound-care access difficult to achieve.
Verbatim wording from the response “The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited. Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However, the demands across GM on TVN and DN services made this difficult to achieve.” Source location Response from GMIC
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge referral contained nothing implying that the patient was at the end of life.
Verbatim wording from the response “The D2A referral form received on Wednesday, 27 December 2023, from Wythenshawe hospital, provided the following information (this was also further discussed with the discharging organisation):” Source location Response from GMIC
Open published response
11 Sep 2024 Nisren Abdul-Karim · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Insufficient detail in neurology notes to communicate advice and clinical contact View source Failure to store neurology notes in the patient record in an accessible location View source Absence of a face-to-face neurology service at some sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nisren Abdul-Karim · 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
Nisren Abdul-Karim had underlying health conditions and developed hallucinations before being admitted to Wythenshawe Hospital, where she sustained a fractured hip in an unsupervised fall. She was transferred to Trafford General Hospital for rehabilitation, continued to deteriorate, and died there on 5 January 2024. The principal concern was that neurology notes recorded on patient pass were difficult to access and contained limited detail, resulting in disjointed neurology care and an unclear overview, particularly at sites without face-to-face neurology services.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in neurology notes to communicate advice and clinical contact
Wider context from the report “The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed.
In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology . As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to store neurology notes in the patient record in an accessible location
Wider context from the report “The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass . This meant accessing the notes required recognising that patient pass needed to be accessed .
In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a face-to-face neurology service at some sites
Wider context from the report “The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed.
In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Rochdale does not require inpatient neurology ward reviews because it is non-acute and has no demand; 24/7 on-call neurology advice remains available.
Verbatim wording from the response “The neurology team provide ward reviews to all GM hospital sites. This is with the exception of Rochdale. As Rochdale is not an acute site, there has never been the demand for neurology inpatient reviews. Any site can always access Neurology opinion via the on-call service 24/7, and advice will be provided. Requests for ward reviews come through Patient Pass. There is currently variation in process in terms of on-going documentation after that initial request via the system. In some cases, on-going clinical advice is continued on Patient Pass (akin to how this works for on-going neurosurgical or spinal advice through the same system). This requires local hospital-based clinicians to access Patient Pass to see the documentation. In other cases, on-going clinical advice is written in the local hospital site’s notes, on whatever system exists on that site for this.” Source location Response from GMIC
Open published response
12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to identify absence of NHS community services when formulating the ongoing plan View source Failure to open the four standard care plans during inpatient stay View source Failure to commence and complete a safety plan during admission and before discharge View source Failure to engage the local Home Based Treatment Team before discharge View source Lack of ability to access relevant parts of medical records View source Failure of consultant-to-consultant communication across NHS and private care View source Failure to investigate nursing staff and determine whether care failures reflect individual or system failure View source Failure to consult treating consultants across Priory locations View source Failure to make a 48-hour post-discharge follow-up call View source Failure to consider regulatory referral of individuals View source Failure to undertake an internal review for learning from the admission View source Failure to discuss the reasons for rapid relapse with the patient View source Failure to provide crisis information at discharge View source Failure to complete the discharge clinical entry and risk assessment View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr David Thompson · 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 David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to identify absence of NHS community services when formulating the ongoing plan
Wider context from the report “2. At the time of his appointment in January 2024 Mr Thompson was not under any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to open the four standard care plans during inpatient stay
Wider context from the report “6. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to commence and complete a safety plan during admission and before discharge
Wider context from the report “1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to engage the local Home Based Treatment Team before discharge
Wider context from the report “2. There was no engagement prior to discharge with the local 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of ability to access relevant parts of medical records
Wider context from the report “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information . Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of consultant-to-consultant communication across NHS and private care
Wider context from the report “1. There was a complete absence of any Consultant – Consultant discussions or communication , given this patient was receiving care from both the NHS and privately .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate nursing staff and determine whether care failures reflect individual or system failure
Wider context from the report “7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out . There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure . Nor was consideration given to whether any individuals should be reported to their regulatory body.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consult treating consultants across Priory locations
Wider context from the report “3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make a 48-hour post-discharge follow-up call
Wider context from the report “4. There was no 48 hour follow up call to Mr Thompson following his discharge , as per Priory 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider regulatory referral of individuals
Wider context from the report “7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an internal review for learning from the admission
Wider context from the report “3. No internal review was undertaken of Mr Thompsons admission within the Priory Altrincham to consider whether there was any learning
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss the reasons for rapid relapse with the patient
Wider context from the report “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide crisis information at discharge
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the discharge clinical entry and risk assessment
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
” Open source report
×
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 sending-provider oversight of out-of-area patients, including ward-round attendance, appropriate visits, and engagement in discharge and care planning.
Verbatim wording from the response “GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.” Source location Response from Greater Manchester NHS
Open published response
×
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 Define consistent practical care-coordination oversight actions for acute placements, rehabilitation beds, non-contracted beds and trust beds across the system.
Verbatim wording from the response “Greater Manchester is working on ensuring these processes are consistent across the system and” Source location Response from Greater Manchester NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.
Verbatim wording from the response “GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.” Source location Response from Greater Manchester NHS
Open published response
2 Jul 2024 James Neil COCKBURN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in patients waiting to see a cardiologist View source Shortage of suitably qualified professionals to carry out essential cardiac tests View source Failure of separate trust IT systems to transmit test information into the other trust’s patient records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Neil COCKBURN · 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 Neil Cockburn had severe aortic stenosis and was awaiting assessment for suitability for open heart surgery when he suffered a myocardial infarction and died at home on 26 May 2023. The report identified delays in cardiology appointments and essential tests, together with communication delays between NHS trusts caused by separate IT systems, as substantive concerns affecting treatment planning and decision-making.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in patients waiting to see a cardiologist
Wider context from the report “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services . This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist . As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.
The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out.
In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitably qualified professionals to carry out essential cardiac tests
Wider context from the report “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.
The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out .
In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of separate trust IT systems to transmit test information into the other trust’s patient records
Wider context from the report “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.
The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out.
In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT . Their IT systems are completely separate and cannot transmit information into the others patient records easily . This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal .
” Open source report
×
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 Continue improving interoperability between primary, secondary, tertiary and wider care information technology systems.
Verbatim wording from the response “Inter-operability of different information technology systems to enable efficient and effective communication across primary care, secondary care, tertiary care and wider system partners is a challenge. This is both at a Greater Manchester level and wider. We continue to work towards improving this as a system.” Source location Response from GMIC
Open published response
×
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 Challenge digital transformation leaders to examine interfaces between secondary and tertiary care systems and improve provider collaboration.
Verbatim wording from the response “We acknowledge that there is still further work to do in relation to this and we will be challenging the leaders who support our digital transformation programmes to look in more detail at improving the interface between secondary and tertiary care systems and our providers in these sectors as to how they work together to enable this.” Source location Response from GMIC
Open published response
20 Jun 2024 Lee-Ann Sarah INCE · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to share information effectively between agencies supporting victims of domestic abuse View source Failure to recognise the additional vulnerability arising from physical health and dependence on a perpetrator for care View source Failure to listen to the voice of the child in domestic abuse cases View source Failure to recognise coercive and controlling relationship behaviours and their impact on victims’ mental health View source See 1 more concern
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
Lee-Ann Sarah INCE · 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
Lee-Ann Sarah Ince was a victim of domestic abuse in a coercive and controlling relationship and was found unresponsive attached to a ligature on 9 May 2023. The inquest identified concerns that agencies did not fully recognise coercive control, the impact of “love bombing” on her mental health, information shared by her children, or her physical-health-related vulnerability and dependence on the perpetrator.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share information effectively between agencies supporting victims of domestic abuse
Wider context from the report “Her children had expressed their concerns to their school. The school had been proactive in sharing those concerns but there was little evidence that other agencies were then listening to “the voice of the child”. This meant that agencies who had direct contact with her did not have a full grasp of the situation or her vulnerability. The inquest was told that if information is not effectively shared and the voice of the child is lost there is an increased risk to the victim.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the additional vulnerability arising from physical health and dependence on a perpetrator for care
Wider context from the report “A feature of her vulnerability was her physical health and how dependent she was, as a consequence, on the perpetrator to help care for her. The additional vulnerability and impact of this was not recognised by agencies involved in supporting her . The inquest was told that where vulnerability is not properly understood the risk presented to a victim of domestic abuse increases.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to listen to the voice of the child in domestic abuse cases
Wider context from the report “Her children had expressed their concerns to their school. The school had been proactive in sharing those concerns but there was little evidence that other agencies were then listening to “the voice of the child” . This meant that agencies who had direct contact with her did not have a full grasp of the situation or her vulnerability. The inquest was told that if information is not effectively shared and the voice of the child is lost there is an increased risk to the victim.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise coercive and controlling relationship behaviours and their impact on victims’ mental health
Wider context from the report “The inquest heard evidence that agencies involved in supporting her in the months leading up to her death had a limited understanding of how behaviours could be twisted in a coercive and controlling relationship to make it appear as if the victim was part of the problem . In this situation it was clear that Lee-Ann was the victim of so called “love bombing” which meant that she was barraged with messages from the perpetrator. The impact of that on a victim’s mental health was not recognised .
” Open source report
15 May 2024 Mr Benjamin Sulzbacher · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Unclear eligibility for NHS discharge service referral for private paying inpatients View source Lack of understanding of NHS community discharge services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Benjamin Sulzbacher · 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 Benjamin Sulzbacher had experienced deteriorating mental health and was admitted to a private hospital after attempting to tie a ligature at home. After discharge, no referral was made to the NHS Home Based Treatment Team, and he died after tying a ligature on 27 September 2023. Concerns included uncertainty among services about NHS discharge support for private inpatients and a lack of understanding at the Priory about the community services available.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear eligibility for NHS discharge service referral for private paying inpatients
Wider context from the report “1. It was unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS . The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. Importantly the face to face contact enables a better understanding of how a patient is actually presenting when considering their mental health.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of NHS community discharge services
Wider context from the report “1. There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge . The court heard that the Home Based Treatment Team was understood to simply be a “Crisis team” which was incorrect .
” Open source report
×
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 Raise the case during quality assurance visits to providers, highlighting NHS referral access for privately funded patients and robust discharge planning.
Verbatim wording from the response “We will be raising this case at our quality assurance visits to providers over the coming weeks, highlighting how private providers can refer all patients (both NHS and privately funded) into NHS services and the importance of robust discharge planning. We will also be sharing this learning at the Greater Manchester System Quality Group in July and at the Greater Manchester Mental Health Programme Board.” Source location Benjamin Sulzbacher - Prevention of Future Deaths Report and Responses Bundle
Open published response
×
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 Maintain an out-of-area placement team to bridge private hospitals and local NHS mental health services.
Verbatim wording from the response “Locally, Pennine Care NHS Foundation Trust (PCFT) now have an out of area placement team who help bridge the gap between the private hospitals and PCFT.” Source location Benjamin Sulzbacher - Prevention of Future Deaths Report and Responses Bundle
Open published response
3 May 2024 Michael Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to account for actual category 3 ambulance response times when accepting call categorisation View source Lack of specific sepsis trigger questions on the ambulance pathway View source Delays in category 3 ambulance responses View source Failure of suspected sepsis indications to trigger a faster ambulance response View source See 1 more concern
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
Michael Clarke · 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
Michael Clarke, who had multiple underlying health conditions including end stage renal failure, developed suspected urosepsis after a cystoscopy and died in hospital on 30 July 2023. The report raised concerns about delays in category 3 ambulance responses, the categorisation of a call where sepsis was suspected, and the absence of specific sepsis trigger questions on the ambulance pathway.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to account for actual category 3 ambulance response times when accepting call categorisation
Wider context from the report “2. The inquest was told that the initial call to NWAS was made by the out of hours nurse. She made it clear that she felt the ambulance response needed to be within 1 hour. As this was in theory the response time consistent with a category 3 response, she accepted the categorisation. This acceptance did not appear to take into account that on that evening a category 3 call was not going to result in an ambulance within 1 hour .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of specific sepsis trigger questions on the ambulance pathway
Wider context from the report “3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway . The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in category 3 ambulance responses
Wider context from the report “1. The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour . The inquest was told that this was not unusual and was still an ongoing issue . The evidence was that this was not unique to NWAS but the general picture in England. The inquest was told that there had been improvements in category 1 and 2 response times but to achieve this category 3 calls continued to have these significant delays .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of suspected sepsis indications to trigger a faster ambulance response
Wider context from the report “3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway. The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority .
” Open source report
19 Apr 2024 Dr Richard George Hardman · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a mechanism for multidisciplinary medical coordination under a single practitioner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dr Richard George Hardman · 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
Dr Richard George Hardman had complex swallowing and respiratory problems associated with prior radiotherapy and Parkinson’s disease. He was admitted to hospital on 7 August 2023 with aspiration pneumonia, and the inquest concluded that he died from aspiration pneumonia arising from natural disease and recognised effects of necessary medical treatment. The principal concern was the absence of a mechanism for coordinating care across different medical disciplines and hospital sites under the leadership of a single practitioner.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for multidisciplinary medical coordination under a single practitioner
Wider context from the report “The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient.
” Open source report
14 Mar 2024 Tobias Ryse Mannering-Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of resources for stable housing solutions for vulnerable young people View source Lack of overall ownership for coordinated multi-agency support View source Lack of resources for sustained support of vulnerable young people experiencing homelessness View source Delays in access to mental health support View source Failure of public service contact arrangements for people without a stable address View source Failure to recognise sexual exploitation and vulnerability among homeless LGBTQIA young people View source Failure to use regular MDTs to share and understand multi-agency information View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tobias Ryse Mannering-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
Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for stable housing solutions for vulnerable young people
Wider context from the report “2. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources for either sustained support and stable housing solutions . The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of overall ownership for coordinated multi-agency support
Wider context from the report “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for sustained support of vulnerable young people experiencing homelessness
Wider context from the report “2. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources for either sustained support and stable housing solutions. The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in access to mental health support
Wider context from the report “1. The inquest was told that Tobias had sought and had been referred for mental health support however due to the high demand and long waiting lists he was still on a waiting list at the time of his death . The evidence before the inquest was that long delays were still an issue and were not restricted to Tameside but were part of a national picture of delays and long waiting lists for those seeking help with their mental health .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of public service contact arrangements for people without a stable address
Wider context from the report “3. Evidence was also heard that a person who has to rely on a homeless shelter can then become uncontactable to public service providers as they have no address for contact which means they then have even less chance of accessing support .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise sexual exploitation and vulnerability among homeless LGBTQIA young people
Wider context from the report “4. The inquest was told that young adults who are homeless are often sexually exploited and that those who identify as LGBTQIA can be particularly vulnerable and that the underlying vulnerability and risk was not always appreciated by those dealing with young homeless people and that it could be mistaken by agencies as a lifestyle choice rather than what it actually was, i.e., exploitation by an older adult .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use regular MDTs to share and understand multi-agency information
Wider context from the report “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support.
” Open source report
×
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 Continue recruiting to fill vacancies in the 3.5 therapy pathway.
Verbatim wording from the response “Within Tameside there has been improvement with waiting lists in recent months in the Neighbourhood Mental Health Team following successful recruitment to Senior Mental Health Practitioner posts. The Living Well team is now fully staffed for both Coaches and Senior Mental Health Practitioners, however the vacancies remain in the 3.5 therapy pathway with continued efforts in recruitment. To mitigate the risk if any individual is presenting with an increase in risks these are passed through a duty system for a review of the risks and there will be an intervention by a Duty worker that day where identified. The 3.5 pathway waiting times remain on the Pennine Care Foundation Trust (PCFT) Risk Register which is reviewed regularly and has scrutiny by the Senior Leadership Team within that system.” Source location Response from Greater Mnachester Integrated Care
Open published response
×
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 accommodation available in Tameside to identify new opportunities and increase options for people facing street homelessness.
Verbatim wording from the response “We are reviewing the accommodation available within Tameside to identify new opportunities to increase provision available which will provide additional options to be considered for any person facing street homelessness.” Source location Response from Greater Mnachester Integrated Care
Open published response
×
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 the Mental Health Workforce Strategy to identify workforce, skill-mix and service-configuration requirements and deliver workforce supply across Greater Manchester.
Verbatim wording from the response “Increasing access to mental health services in the community is a key priority for NHS GM, supported by the Community Mental Health Transformation Workstream. Work to support this includes but is not limited to:” Source location Response from Greater Mnachester Integrated Care
Open published response
×
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 Work with the adult safeguarding board to embed tiered risk assessment in team practice and train staff to recognise sexuality-based discrimination as potential abuse.
Verbatim wording from the response “We are also working with the adult safeguarding board to embed the tiered risk assessment process for adults into the teams working practices alongside training around how discrimination due to sexuality should be recognised as potential abuse and therefore a safeguarding issue.” Source location Response from Greater Mnachester Integrated Care
Open published response
×
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 Maintain increased Neighbourhood Mental Health Team capacity through successful recruitment to Senior Mental Health Practitioner posts.
Verbatim wording from the response “Within Tameside there has been improvement with waiting lists in recent months in the Neighbourhood Mental Health Team following successful recruitment to Senior Mental Health Practitioner posts. The Living Well team is now fully staffed for both Coaches and Senior Mental Health Practitioners, however the vacancies remain in the 3.5 therapy pathway with continued efforts in recruitment. To mitigate the risk if any individual is presenting with an increase in risks these are passed through a duty system for a review of the risks and there will be an intervention by a Duty worker that day where identified. The 3.5 pathway waiting times remain on the Pennine Care Foundation Trust (PCFT) Risk Register which is reviewed regularly and has scrutiny by the Senior Leadership Team within that system.” Source location Response from Greater Mnachester Integrated Care
Open published response
×
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 the Living Well waiting list to assess needs and divert people to other services where appropriate.
Verbatim wording from the response “In addition, The Living Well team are undertaking a review of the Waiting List to assess the current needs and diversion to other services if appropriate.” Source location Response from Greater Mnachester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing systems ensure people with multiple disadvantages known to services have an appropriately experienced lead professional coordinating their support.
Verbatim wording from the response “As an immediate measure, to address concerns relating to the multi-agency co-ordination of support to vulnerable young adults in Tameside, TASPB asked agencies to audit their ████████ young adults already known to services. This was with a view to ensuring that an appropriately experienced lead professional has or is given responsibility for coordinating services to the young person and is supporting their engagement. In response to this request, TASPB are assured systems are in place across organisations to ensure people who experience multi-disadvantage that are known to services do have a lead professional allocated. This will support people who are known to services and rely on services from the homeless shelter.” Source location Response from Greater Mnachester Integrated Care
Open published response
13 Mar 2024 Alan William Rowland Smith · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to provide sufficient detail in referrals for risk assessment and prioritisation View source Lack of understanding of the need for prompt referral to vascular services View source Delays in referral for District Nursing input View source Poor communication and fragmented input across trusts View source Lack of understanding of the need for prompt referral to District Nursing services View source Failure to follow secondary care advice for two-week-wait dermatology referral View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan William Rowland Smith · 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 William Rowland Smith developed severe leg swelling associated with venous insufficiency and probable venous thrombosis, followed by an infected leg and rapid deterioration. He died at Stepping Hill Hospital on 17 September 2023. The concerns included delayed recognition of the severity of his condition, late referral to vascular and district nursing services, poor communication across services, and failure to follow advice about a dermatology referral.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient detail in referrals for risk assessment and prioritisation
Wider context from the report “2. Where such referrals were made it was essential that sufficient detail be provided to ensure that the degree of risk could be accurately assessed and effective prioritisation could take 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the need for prompt referral to vascular services
Wider context from the report “1. The inquest heard evidence that a prompt referral to vascular services was important in cases such as these, where GPs would have limited expertise in managing the risks and offering effective treatments. The need for early referral was not, the inquest was told, widely understood.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in referral for District Nursing input
Wider context from the report “3. The inquest was told that as well as referral to vascular services it was important that GPs understood that District Nurses were a resource that should be utilised with prompt referrals. This could be challenging as the District Nursing Service was under huge pressure due to demand. However, they were well used to recognising high risk patients and clearer referrals for GPs around when to refer would ensure that their expertise would be available at an early stage . Management of any case such as Mr Smith’s would of necessity involve the District Nursing Team as compression bandaging was the most effective treatment to prevent a critical situation such as Mr Smith’s arising and the District Nurses were best placed to provide this. In Mr Smith’s case the referral for District Nursing input was not until a very late stage even though the GP had identified at an early appointment that compression would be of benefit.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor communication and fragmented input across trusts
Wider context from the report “4. The evidence before the inquest was that there were multiple specialisms across multiple GM Trusts with different IT systems involved in Mr Smith’s care. As a consequence communication was poor with a limited understanding of his overall condition and fragmented input . The inquest was told that a framework that promoted a structure for a multi-disciplinary team approach across trusts in GM would avoid many of the challenges around information sharing across trusts.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the need for prompt referral to District Nursing services
Wider context from the report “3. The inquest was told that as well as referral to vascular services it was important that GPs understood that District Nurses were a resource that should be utilised with prompt referrals . This could be challenging as the District Nursing Service was under huge pressure due to demand. However, they were well used to recognising high risk patients and clearer referrals for GPs around when to refer would ensure that their expertise would be available at an early stage. Management of any case such as Mr Smith’s would of necessity involve the District Nursing Team as compression bandaging was the most effective treatment to prevent a critical situation such as Mr Smith’s arising and the District Nurses were best placed to provide this. In Mr Smith’s case the referral for District Nursing input was not until a very late stage even though the GP had identified at an early appointment that compression would be of benefit.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to follow secondary care advice for two-week-wait dermatology referral
Wider context from the report “5. In Mr Smith’s case there had been advice from secondary care to his GP that he should be referred on the 2 Week wait path for dermatology. That advice was not taken by his GP who felt such a referral was not necessary. It was unclear what if any protocol was in place across GM when such advice was given but not followed.
” 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 Provide additional training on how to access and use the GM Care Record.
Verbatim wording from the response “Whilst data tells us that the system is being accessed and patient information being appropriately shared via the GM Care Record, it is acknowledged that not all health care professionals are accessing the benefits of this system. With this in mind, there is a programme of work currently underway with a plan to update the web page and re-launch the GM Care Record in early June 2024. The re-launch aims to raise awareness further and I can confirm that eLearning has been updated in addition to which additional training will be provided on how to access and use the system.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Deliver a Masterclass on timely vascular and District Nursing referrals, including required referral information and examples of good referrals.
Verbatim wording from the response “In light of the findings in this case, a Masterclass learning event will be delivered in September 2024 to include advice and guidance in relation to the circumstances in which to refer and the information required within a referral to ensure timely triage and progression to care under the vascular surgery team as appropriate.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Update the GM Care Record webpage and relaunch the system to raise awareness of its information-sharing capabilities.
Verbatim wording from the response “There is a ‘joint’ care record that exists across Greater Manchester (the GM Care Record) which holds information from various organisations including GP Practices, Acute Trusts, Adult Social Care (Local Authority) and Mental Health Trusts. Most clinicians have access to this system and to provide an indication of how often it is used, in February 2024, 708 individual acute trust staff accessed records 12,715 times, viewing 8,243 patients.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Update GM Care Record eLearning to support access to and use of the system.
Verbatim wording from the response “Whilst data tells us that the system is being accessed and patient information being appropriately shared via the GM Care Record, it is acknowledged that not all health care professionals are accessing the benefits of this system. With this in mind, there is a programme of work currently underway with a plan to update the web page and re-launch the GM Care Record in early June 2024. The re-launch aims to raise awareness further and I can confirm that eLearning has been updated in addition to which additional training will be provided on how to access and use the system.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Awaiting the imminent scan before processing the dermatology referral was considered clinically appropriate and in the patient’s interest.
Verbatim wording from the response “In regard to a GP making a decision not to follow the advice of a secondary care colleague, the GP would always be responsible for their clinical decision making. It would be unusual to ignore advice from a colleague without clinical justification. In this case, my understanding is that Mr Smith was scheduled to imminently attend for a scan and the GP decision was therefore to await scan findings prior to progressing the request to process this referral. From a clinical perspective this would be appropriate and in the interest of the patient.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GPs remain responsible for their clinical decisions when deciding whether to follow secondary-care referral advice.
Verbatim wording from the response “In regard to a GP making a decision not to follow the advice of a secondary care colleague, the GP would always be responsible for their clinical decision making. It would be unusual to ignore advice from a colleague without clinical justification. In this case, my understanding is that Mr Smith was scheduled to imminently attend for a scan and the GP decision was therefore to await scan findings prior to progressing the request to process this referral. From a clinical perspective this would be appropriate and in the interest of the patient.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice considers that Mr Smith’s leg-swelling management, compression hosiery and District Nursing referral were clinically appropriate.
Verbatim wording from the response “Following the inquest and the issuing of the Regulation 28 in this case, the GP partners have undertaken a full review of Mr Smith’s journey of care, focusing on the timing of referrals into specialist services including referrals to the vascular surgery team. The practice maintain that the management of Mr Smith’s leg swelling was appropriate.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GPs can refer uncertain leg-swelling cases to vascular services for specialist triage and advice.
Verbatim wording from the response “In circumstances where a GP has a query in relation to a leg swelling and whether to refer into vascular surgery, the process is for a referral to be completed so that the vascular team can then triage and determine if the patient is appropriate for them and / or to advise on the way forward.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation District Nursing referrals are triaged and prioritised by clinical need, with enquiries from GPs welcomed and visits arranged where indicated.
Verbatim wording from the response “Regardless of the level of demand on the District Nursing (DN) Team, all referrals are triaged and prioritised appropriately so that patients are seen in order of clinical need. The service confirm that they welcome enquiries from their GP colleagues and where an enquiry indicates the potential need for a DN visit this is arranged.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist referrals are expected to contain relevant information and are returned with requirements when insufficient for prompt triage.
Verbatim wording from the response “It is expected that any referral into any specialist service will be complete to include all relative information to enable the team reviewing / triaging the referral to do so in a timely manner. In circumstances where a referral is processed but the team are unable to promptly triage due to insufficient information, the referral is rejected with details of the information or action required in order to progress.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation When secondary care considers an urgent two-week-wait referral necessary, the secondary-care clinician should complete it.
Verbatim wording from the response “The standard protocol for onward referrals from secondary care (Stepping Hill Hospital) is that if a secondary care provider considers that an urgent referral onto a two week wait care pathway is required, then the referral should be completed by the secondary care clinician. This is because of the additional time involved in sending a recommendation into primary care and the referral then being completed.” Source location Response from Greater Manchester Integrated Care
Open published response
14 Feb 2024 Alfie Anthony Kevin Nicholls · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Insufficient school nurse service capacity for identifying health issues and supporting professionals View source Failure to use EHCPs holistically to integrate health and education information View source Unavailability of regular dietitian input for children with eating disorders View source Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry View source Failure to establish effective cross-sector strategies for identifying and managing ARFID View source Lack of understanding of ARFID-related medical risk in acute medical settings View source Lack of professional awareness of ARFID and how to approach it View source Failure to consider the health impact of poor and restricted eating in children with autism View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 15
Action
Develop and make a seven-minute ARFID briefing available across all Partnership agencies.
Stated plannedThe respondent said that this action was planned when they made their response on 22 February 2024. View source
Action
Implement revised paediatric medical guidance for nutritional screening and medical management.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2024. View source
Action
Share learning from Alfie’s death across NHS Greater Manchester professional networks and relevant services.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2024. View source
Action
Deliver ARFID awareness and training sessions to health, education, social care and school nursing staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024. View source
Action
Lead implementation of the Education, Health and Care Plan flag in EMIS for health visitors and school nurses.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024. View source
Action
Roll out a restricted-eating dietetic referral pathway with parental support tools, professional training and screening through food diaries.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024. View source
Action
Lead assurance work to improve health information quality in Education, Health and Care Plans.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024. View source
Action
Increase school nursing provision through the Stockport school nursing transformation, including identified coverage for Alfie’s school and three others.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2024. View source
Action
Introduce a nutritional element into assessments and plans within Stockport neurodiversity pathways.
Stated plannedThe respondent said that this action was planned when they made their response on 22 February 2024. View source
Action
Support development of a multi-agency Education, Health and Care Plan audit process through health links with the Local Authority team.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024. View source
Action
Maintain monthly multidisciplinary links between paediatricians and CEDS to discuss concerns and refer children to appropriate ARFID support.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2024. View source
Action
Review children known to paediatricians to ensure dietetic referrals, appropriate blood tests and access to food supplements.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2024. View source
Action
Complete a dedicated ARFID away day for Stockport school nurses to develop nutritional assessment skills and introduce the new dietetic pathway.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024. View source
Action
Map current ARFID-related provision across Health, Education and Social Care.
Stated plannedThe respondent said that this action was planned when they made their response on 22 February 2024. View source
Action
Make Royal College of Child Psychiatrists ARFID guidance available to all Stockport paediatricians.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2024. View source See 12 more actions
×
AI-generated summary
Alfie Anthony Kevin 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
Alfie Anthony Kevin Nicholls, a child with autism and a severely restricted diet, collapsed at home on 17 December 2021 and died at Stepping Hill Hospital despite attempts to resuscitate him. A post-mortem examination found significant malnutrition, and the report identified concerns about poor communication between professionals and the family, limited recognition and understanding of ARFID and medical risk, and insufficient coordinated support and resources.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient school nurse service capacity for identifying health issues and supporting professionals
Wider context from the report “5. The Inquest heard that the school nurse service could play a vital role in identifying health issues and supporting other professionals . This key role was significantly impacted by the high demand on the service and the very high caseloads school nurses working with complex children were being asked to carry 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use EHCPs holistically to integrate health and education information
Wider context from the report “4. Whilst there was an Education, Health and Care Plan (EHCP) in place for Alfie there was little evidence that EHCPs were being used as a holistic tool to understand the inter relationship between health and education . There was evidence that those writing EHCPs needed to consider a child more holistically for the EHCP to cover all the aspects that it was meant to cover and not just to focus on education .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of regular dietitian input for children with eating disorders
Wider context from the report “6. The role of a dietitian in supporting children with eating disorders could be fundamental in maximising the nutritional value of what they consumed. Demands on the service and a limited understanding of how they could work to support children with disorders such as ARFID (nationally) meant that there was rarely regular input from dieticians .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry
Wider context from the report “7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges . In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective cross-sector strategies for identifying and managing ARFID
Wider context from the report “2. Evidence before the Inquest was that in addition to there being increased awareness amongst professionals there needed to be strategies within and across Health, Education and Social care to ensure effective strategies were put in place and those with ARFID or at risk of developing ARFID were identified and managed effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of ARFID-related medical risk in acute medical settings
Wider context from the report “7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges. In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late .
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of professional awareness of ARFID and how to approach it
Wider context from the report “1. The inquest heard evidence that Avoidant Restrictive Food Intake Disorder (ARFID) was not widely understood by those involved with children and adults who may be impacted by it . That included a lack of awareness of what it was and how to approach it amongst Health, Education and Social Work professionals . The inquest was told that until awareness of it improved then similar situations to that of Alfie could go unrecognised with similar consequences.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the health impact of poor and restricted eating in children with autism
Wider context from the report “3. A feature of the evidence before the Inquest was a normalisation of poor and restricted eating by children with autism . This meant that the impact on their overall health and wellbeing was not considered . Children with autism were measured against each other in relation to their eating with phrases such as “we have children with poorer diets …” being used.
” 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 Develop and make a seven-minute ARFID briefing available across all Partnership agencies.
Verbatim wording from the response “(5) The SSCP Learning Event Action Plan includes the development of a 7-minute briefing that will be easily available across the Partnership to all agencies.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 revised paediatric medical guidance for nutritional screening and medical management.
Verbatim wording from the response “• Revised medical guidance for paediatricians has been put in place regarding nutritional screening & medical management.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Share learning from Alfie’s death across NHS Greater Manchester professional networks and relevant services.
Verbatim wording from the response “As a system we are committed to learning from the sad death of Alfie and I can confirm that information / learning has been shared across NHS Greater Manchester ICB via the following:-” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Deliver ARFID awareness and training sessions to health, education, social care and school nursing staff.
Verbatim wording from the response “A variety of training sessions have been delivered in Stockport during 2023 which includes:” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Lead implementation of the Education, Health and Care Plan flag in EMIS for health visitors and school nurses.
Verbatim wording from the response “The DCO is also leading work to ensure the use of the EHCP ‘flag’ within EMIS, the record keeping system for health visitors and school nursing.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Roll out a restricted-eating dietetic referral pathway with parental support tools, professional training and screening through food diaries.
Verbatim wording from the response “• A new dietetic referral pathway for restricted eating which includes a tool to support parents who are concerned. Training of School Nurses and Health Visitors has commenced and will be a rolling program throughout the year to screen when parents raise concerns with 3-day food diaries as part of that pathway.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Lead assurance work to improve health information quality in Education, Health and Care Plans.
Verbatim wording from the response “Stockport Designated Clinical Officer [DCO] SEND has been leading on assurance work to improve the quality of EHCP particularly looking at the health information which is included within them.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Increase school nursing provision through the Stockport school nursing transformation, including identified coverage for Alfie’s school and three others.
Verbatim wording from the response “In Stockport the 0-19 yr service is commissioned by Public Health. Stockport reflects the national picture of very high caseloads for school nurses working with complex children. In 2022 a school nursing transformation was undertaken which included an increase to provision resulting in an identified school nurse covering Alfie’s school plus 3 other schools.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Introduce a nutritional element into assessments and plans within Stockport neurodiversity pathways.
Verbatim wording from the response “There are also plans in place to introduce a nutritional element to assessments and plans within Stockport neurodiversity pathways.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Support development of a multi-agency Education, Health and Care Plan audit process through health links with the Local Authority team.
Verbatim wording from the response “There are now 2 health links with the Local Authority EHCP team who are supporting the development of a EHCP multi-agency audit process. The DCO also meets with the health links monthly.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Maintain monthly multidisciplinary links between paediatricians and CEDS to discuss concerns and refer children to appropriate ARFID support.
Verbatim wording from the response “Paediatricians and the CEDS continue to link through the monthly multi-disciplinary meetings where they can discuss children, they are worried about, and refer to the CEDS ARFID pathway if appropriate. Although the CEDS ARFID pathway is for children over the age of 8 at the MDT there is the opportunity to discuss children under the age of 8 and CEDS advise on the management.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 children known to paediatricians to ensure dietetic referrals, appropriate blood tests and access to food supplements.
Verbatim wording from the response “Following Alfie’s death, Stockport NHS Foundation Trust has undertaken a review of all children known to paediatricians to ensure all had a referral to dietetics, appropriate blood tests and access to food supplements.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Complete a dedicated ARFID away day for Stockport school nurses to develop nutritional assessment skills and introduce the new dietetic pathway.
Verbatim wording from the response “Stockport School nurses are having an away day this week solely dedicated to ARFID which will support their skills in nutritional assessment and introduce them to the new dietetic pathway.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Map current ARFID-related provision across Health, Education and Social Care.
Verbatim wording from the response “Evidence before the Inquest was that in addition to there being increased awareness amongst professionals there needed to be strategies within and across Health, Education and Social care to ensure effective strategies were put in place and those with ARFID or at risk of developing ARFID were identified and managed effectively.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Make Royal College of Child Psychiatrists ARFID guidance available to all Stockport paediatricians.
Verbatim wording from the response “An action from the SSCP Learning Event was that all Stockport paediatricians be made aware of the recent Royal College of Child Psychiatrists published guidance in relation to ARFID which was completed in February 2024.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Schools are responsible for leading EHCP annual reviews and seeking updated advice before caseworkers amend plans.
Verbatim wording from the response “Schools are responsible for leading the EHCP annual review, so will lead on seeking updating advice and ensuring this element of the plan is reviewed in the meeting. If as an outcome of the EHCP annual review the plan needs to be amended, they the school will provide all the information gathered to the EHCP caseworker to update the plan document.” Source location Response from Greater Manchester Integrated Care
Open published response
2 Feb 2024 Susan Wendy Bracegirdle · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to obtain input from key people involved in care during safeguarding reviews View source Failure to share pressure-ulcer care plans with the care team View source Lack of a communication strategy supporting joint working and family involvement in pressure-ulcer care View source Failure to upload updated images for Tissue Viability review of deteriorating pressure ulcers View source Failure to provide the GP with sufficient information about pressure-ulcer deterioration View source Failure to share and discuss internal pressure-ulcer reviews with the family View source See 3 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
Susan Wendy Bracegirdle · 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
Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain input from key people involved in care during safeguarding reviews
Wider context from the report “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future . It was unclear why such an approach had been 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share pressure-ulcer care plans with the care team
Wider context from the report “1. The inquest heard evidence that because Mrs Bracegirdle was in a care home setting the District Nurses were responsible for management of her pressure ulcers. The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. As a consequence, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a communication strategy supporting joint working and family involvement in pressure-ulcer care
Wider context from the report “2. There was no communication strategy in place as a consequence of an approach that did not promote team /joint working . The inquest heard that as a consequence the family were unsighted on the condition of Mrs Bracegirdle until shortly before her admission to hospital . This meant that the family could not support the work to reduce the risk of the pressure ulcers deteriorating further and were not able to be a proactive about the care she was receiving increasing the risk of her pressure ulcers deteriorating
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to upload updated images for Tissue Viability review of deteriorating pressure ulcers
Wider context from the report “6. The Tissue Viability team had been asked by the District Nurses for input. This was provided remotely via access to photos taken by the District Nursing Team. Whilst it was clear that remote review could be effective it was not in this case because the review was based on an older image and an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded . This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the GP with sufficient information about pressure-ulcer deterioration
Wider context from the report “3. The GP was asked to provide input. Due to a lack of information sharing the GP who dealt with Mrs Bracegirdle does not seem to have appreciated the extent of the issue and as a consequence there was no face-to-face examination and antibiotics were not started.
” 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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share and discuss internal pressure-ulcer reviews with the family
Wider context from the report “5. An earlier internal review by the District Nursing team when Mrs Bracegirdle’s pressure ulcer became a category 3 was not shared or discussed with the family and they were unsighted on the issue .
” 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 Photograph and upload every wound to the patient’s electronic record weekly.
Verbatim wording from the response “All wounds are to be photographed and uploaded on to the patient’s electronic record system once per week by the District Nursing Team.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Ensure a Being Open discussion occurs with patients or families after all rapid reviews deemed to involve no lapses in care, with compliance monitored monthly.
Verbatim wording from the response “However, the Trust acknowledge that a ‘Being Open’ conversation should have taken place with Mrs Bracegirdle’s next of kin to discuss the pressure ulcer damage and the outcome of the rapid review of the incident. Going forward the Trust will ensure that a ‘Being Open’ discussion does take place with patients or families for all raid reviews (which are deemed no lapses in care), and this will be monitored through the monthly Quality Assurance Meetings.” Source location Response from Greater Manchester Integrated Care
Open published response
×
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 Discuss with the nursing team the importance of following up concerns and actions directly with GPs rather than relying on care-home staff.
Verbatim wording from the response “During the Trust review of the pressure ulcer review, an area of learning was identified in relation to communication with the GP and an action was taken: This was to discuss with the nursing team the importance of following up any concerns or actions with the GP and not to rely on carers to ensure this is done. Since this rapid review, there have been no further incidents in relation to contact with GP practices.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Complete the Safeguarding Adult Review, including a multi-agency practitioner learning event and production of the review report.
Verbatim wording from the response “I can confirm that following initial review of Ms Bracegirdle’s case it was confirmed that the circumstances of the case met the criteria for a Safeguarding Adult Review (SAR) as set out in Section 44 of The Care Act 2014.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Develop an information leaflet explaining how families can contact District Nursing for pressure-area-care advice.
Verbatim wording from the response “In undertaking this review there was evidence of verbal communication with the care home staff and written notes within the communication book at the care home. However, an information leaflet will be developed to promote communication.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The registered GP had access to current District Nursing information through the shared electronic record, contrary to the concern that information was unavailable.
Verbatim wording from the response “Members of the District Nursing Team input their clinical notes onto the Emis clinical system; these notes are visible to a patient’s GP as they use the same clinical system. This does ensure that the registered GP does have access to full details of all District Nurse visits and treatments. This would include confirmation of referral to Tissue Viability Service and access to any wound photographs which may have been taken as these are uploaded into Emis.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The care home provider is responsible for keeping family members updated about residents’ health, including pressure ulcer management and nursing advice.
Verbatim wording from the response “The care home provider would be expected to keep family members updated in relation to all aspects of a resident’s health and wellbeing as a matter of course, using the information from the communications book, and from direct conversations with the attending district nurses. In the event of further questions from the family then it would be expected for the care home staff to liaise with the attending team to obtain information to address those questions. This would include information about pressure ulcer management and any advice from community colleagues (District Nursing Team) or the TVN Team.” Source location Response from Greater Manchester Integrated Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The review panel found no District Nursing care lapses that directly contributed to the acquired pressure ulcers.
Verbatim wording from the response “The Division of Integrated Care at Stockport NHS Foundation Trust, carried out two rapid reviews in relation to Mrs Bracegirdle’s pressure ulcers, one in October 2022 and one in December 2022. These were presented to the Serious Incident Review Group (SIRG), chaired by the Deputy Director of Governance and panel members. The panel agreed that there were no lapses in care by the District Nursing Team which directly contributed to the” Source location Response from Greater Manchester Integrated Care
Open published response
29 Jan 2024 Terence Briney · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to consider and investigate treatable conditions in elderly patients when deterioration is attributed to ageing 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
Terence Briney · 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
Terence Briney's health deteriorated from July 2022, including weight loss, lethargy and worsening oesophageal function. He was admitted to hospital in March 2023 and died on 17 March after an acute respiratory event caused by aspirating saliva; the principal concern was that symptoms in older people may be attributed to ageing rather than investigated for potentially treatable conditions.
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 NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and investigate treatable conditions in elderly patients when deterioration is attributed to ageing
Wider context from the report “The inquest heard evidence that symptoms raised by Mr Briney and his family were attributed to old age rather than a possible neurological disease. The evidence before the inquest was that there were situations where clinicians would attribute a deterioration to the aging process rather than consider the whole picture and investigate if there was a treatable condition . This presented a risk that treatable conditions in the elderly could be missed .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations