31 Aug 2022 Name not published · Prevention of Future Deaths report Manchester City
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Concerns raised 8 Failure to undertake periodic audits of sepsis recognition and treatment View source Failure to appropriately recognise sepsis View source Failure of new, locum and agency staff to act in accordance with sepsis protocols and policies View source Failure to keep sepsis protocols and policies up to date View source Failure to ensure clinical and nursing staff are familiar with sepsis protocols and policies View source Failure to make new, locum and agency staff aware of sepsis protocols and policies View source Inadequate training and updates for clinical and nursing staff on sepsis View source Delays in commencing appropriate sepsis treatment View source See 5 more concerns
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
Name not published · 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
A 78-year-old woman developed severe sepsis and necrotising fasciitis following dental treatment. She was not triaged or assessed promptly at hospital, suffered a cardiac arrest, underwent emergency surgery, and died on 6 July 2019. The concerns included the currency and implementation of sepsis protocols, staff training and awareness, and timely recognition and treatment of sepsis.
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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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake periodic audits of sepsis recognition and treatment
Wider context from the report “4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately recognise sepsis
Wider context from the report “4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of new, locum and agency staff to act in accordance with sepsis protocols and policies
Wider context from the report “3. That new or locum clinicians as well as agency nursing staff are made aware of the sepsis policies and protocols and act in accordance with them .
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to keep sepsis protocols and policies up to date
Wider context from the report “1. That MFT ensure that all their sepsis protocols and policies are up to date .
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinical and nursing staff are familiar with sepsis protocols and policies
Wider context from the report “2. That all appropriate clinical and nursing staff are familiar with them and have necessary training and updates as required.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to make new, locum and agency staff aware of sepsis protocols and policies
Wider context from the report “3. That new or locum clinicians as well as agency nursing staff are made aware of the sepsis policies and protocols and act in accordance with them.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and updates for clinical and nursing staff on sepsis
Wider context from the report “2. That all appropriate clinical and nursing staff are familiar with them and have necessary training and updates as required .
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing appropriate sepsis treatment
Wider context from the report “4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner .
” Open source report
22 Aug 2016 Nicholas Patrick SULLIVAN · Prevention of Future Deaths report Manchester City
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Concerns raised 3 Absence of a clear system to safeguard patients pending mental health assessment View source Lack of a reception checklist for identifying and recording mental health and self-harm or suicidal ideation information View source Absence of a clear system for triggering urgent triage and safeguarding steps 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
Nicholas Patrick SULLIVAN · 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
Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.
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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear system to safeguard patients pending mental health assessment
Wider context from the report “5.2 There was no clear system to trigger urgent triage and safeguarding steps prior to that.
5.3 There was no clear system following triage and mental health assessment referral, to safeguard the patient pending that assessment .
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a reception checklist for identifying and recording mental health and self-harm or suicidal ideation information
Wider context from the report “5.1 Whilst recognising that Emergency Departments can by busy, reception staff did not work to a short bullet point pro-forma checklist which identifies issues of mental disorder/conditions and check and record important background issues, such as self-harming behaviour or suicidal ideation . This information is vital to record and should trigger urgent triage/mental health assessment.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear system for triggering urgent triage and safeguarding steps
Wider context from the report “5.2 There was no clear system to trigger urgent triage and safeguarding steps prior to that .
5.3 There was no clear system following triage and mental health assessment referral, to safeguard the patient pending that assessment.
” Open source report
6 Apr 2016 Milly ZEMMEL · Prevention of Future Deaths report Manchester City
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Concerns raised 6 Failure to initiate appropriate one-to-one supervision and observations View source Inadequate internal investigation of failures in basic medical care View source Failure to hand over important clinical information to the next shift View source Failure to assess and correctly apply the falls risk policy View source Failure to escalate required clinical review after a fall View source Failure to check patient records for up-to-date information at shift change View source See 3 more concerns
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
Milly ZEMMEL · 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
Milly ZEMMEL, who was blind and aged 89, was admitted to hospital after becoming unwell and later suffered falls, including an unwitnessed fall on 1 March 2015 while experiencing acute confusion. She fractured her left femur, was not considered fit for surgery, and died on 3 March 2015. The principal concerns were failures in falls-risk assessment, escalation and handover after an earlier fall, appropriate supervision and observations, and the adequacy of the hospital’s internal investigation.
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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate appropriate one-to-one supervision and observations
Wider context from the report “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate internal investigation of failures in basic medical care
Wider context from the report “1. The Trust’s own internal investigative procedures were demonstrably inadequate because the internal hospital investigation did not fully and properly identify the gross failure to provide the deceased with the basic medical care which her condition obviously required on the morning of 1 March 2015. The full particulars only became apparent when evidence was heard at the inquest and the records were checked. The gravity of the failings in care had not been properly identified .
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over important clinical information to the next shift
Wider context from the report “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift . Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death.
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and correctly apply the falls risk policy
Wider context from the report “2. There have been failures to assess and correctly apply the then existing falls risk 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate required clinical review after a fall
Wider context from the report “3. There was a failure to escalate the requirement for a clinical review following her fall on 21 February 2015 and nor was this identified at handovers on several occasions .
” 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 North Manchester General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to check patient records for up-to-date information at shift change
Wider context from the report “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was . Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations