Recipient

Walsall Manor Hospital

First report 17 Nov 2015•Latest report 16 Sep 2021

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Walsall Manor Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 Sep2021
Black Country
Concerns raised3
1. Poor procedures for identifying residents' DNAR status
2. Lack of clarity among care staff about the role and referral circumstances of the enhanced care and quality team
3. Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents
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

Mrs Tripta Bhanote · 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

Mrs Tripta Bhanote, who was 86 and living in a residential care home, was found on the floor on several occasions in May 2020 and her condition then declined rapidly before she died. Concerns included unclear procedures for escalating acute illness to emergency services, uncertainty about referral to the enhanced care and quality team, and poor procedures for identifying residents’ DNAR status.

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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Poor procedures for identifying residents' DNAR status
Wider context from the report
“3. There was evidence of poor procedures in place in identifying the DNAR status of residents. ”
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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity among care staff about the role and referral circumstances of the enhanced care and quality team
Wider context from the report
“2. There was lack of clarity and understanding by care staff of the role of the enhanced care and quality team and circumstances for referral to 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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents
Wider context from the report
“1. Evidence emerged during the inquest that there was a lack of clarity and understanding by care staff in the requirements for escalation to emergency services when a patient/resident becomes acutely unwell. ”
Open source report
11 Mar2019
Black Country
Concerns raised2
1. Inadequate audit process for monitoring non-suspicious samples by dip-sampling
2. Lack of a protocol or policy for managing the anticoagulation/prophylaxis regime for community patients with identifiable risk factors for complications
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

Ms Jennifer McKoy · 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

Ms Jennifer McKoy underwent laparoscopic cholecystectomy in August 2018 and later developed disseminated gallbladder adenocarcinoma, with a retrospective review finding that carcinoma had been present in the original histology but was not identified. She died on 17 May 2019 after developing pulmonary venous thrombo-embolism, deep phlebo-thrombosis and disseminated gallbladder adenocarcinoma. Concerns included inadequate audit of non-suspicious samples and limited evidence of a protocol for managing anticoagulation or prophylaxis for community patients with identifiable risk factors for complications.

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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate audit process for monitoring non-suspicious samples by dip-sampling
Wider context from the report
“Evidence emerged during the inquest that there was an inadequate audit process in place for monitoring non-suspicious samples by way of dip-sampling. ”
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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of a protocol or policy for managing the anticoagulation/prophylaxis regime for community patients with identifiable risk factors for complications
Wider context from the report
“There was limited evidence of any protocol or policy in place for managing the anticoagulation/prophylaxis regime for community patients who have identifiable risk factors for developing complications. ”
Open source report
16 Aug2017
Black Country
Concerns raised2
1. Failure by radiologists to assess scans for findings requiring further investigation
2. Failure to note fractures on X-rays during admission
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

Dorothy Webb · 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

Dorothy Webb’s health declined amid falls, suspected neurological events, hyponatraemia and subsequently identified small cell carcinoma of the right lung with liver metastases. She died shortly after aspirating vomited blood and gastric contents following episodes of coffee-ground vomiting. The report identified a missed opportunity to assess a CT scan showing a mass and a failure to note a fracture on an earlier x-ray.

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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure by radiologists to assess scans for findings requiring further investigation
Wider context from the report
“1. Evidence emerged during the inquest that there was a missed opportunity and failure by the Radiologist to assess the scan which would have resulted in further investigation of the “mass” that was identified. Although this may not, on the balance of probability prevented the outcome, it may well have resulted in further medical investigation and treatment. ”
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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to note fractures on X-rays during admission
Wider context from the report
“2. There was also a failure to note a fracture from the x-ray during the admission in February 2017 and consequently the patient and family were unaware of its existence until the re-admission in April 2017. ”
Open source report
17 Nov2015
Black Country
Concerns raised2
1. Failure to communicate DNAR decisions to the patient’s family
2. Failure of nursing and medical staff to communicate DNAR decisions
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

Mr Frank Mellers · 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 Frank Mellers fell at home on 4 September 2015, fractured his left hip, and was admitted to hospital for surgery. He suffered a cardiac arrest on 17 September 2015 and died that day from congestive cardiac failure, with ischaemic heart disease and the post-operative fracture repair recorded as contributing factors. The concerns included poor communication with his family about his DNAR status and poor communication between nursing and medical staff, including CPR being commenced despite a DNAR being in place.

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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate DNAR decisions to the patient’s family
Wider context from the report
“(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions. (2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place. (3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. ”
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 Walsall Manor Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing and medical staff to communicate DNAR decisions
Wider context from the report
“(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions. (2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place. (3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Poor procedures for identifying residents' DNAR status

Lack of clarity among care staff about the role and referral circumstances of the enhanced care and quality team

Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents

Concerns raised2

Inadequate audit process for monitoring non-suspicious samples by dip-sampling

Lack of a protocol or policy for managing the anticoagulation/prophylaxis regime for community patients with identifiable risk factors for complications

Concerns raised2

Failure by radiologists to assess scans for findings requiring further investigation

Failure to note fractures on X-rays during admission

Concerns raised2

Failure to communicate DNAR decisions to the patient’s family

Failure of nursing and medical staff to communicate DNAR decisions