PFD report

Mark Anthony Fernandez · Prevention of Future Deaths report

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Issued 4 Mar 2025•Manchester North

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns: 3
Recipients: 3
Responses found: 4
Stated actions: 31

Recipients and published responses

NHS Greater Manchester Integrated Care Board

Response foundNorthern Care Alliance NHS Foundation TrustResponse found Oldham Borough CouncilResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

I opened an investigation into the death of Mark Anthony Fernandez on the 30th October 2024 and the final Inquest hearing took place on the 17th February 2025 before HM Joanne Kearsley.

A conclusion of natural causes was returned.

Circumstances of the death

Mr Fernandez was born with cerebral palsy and complex medical needs. He had been in the care of Oldham Social Services since he was a child. He was not able to speak and registered blind.

Since 2008 he had been residing at a supported living home with full time carers. His care package was provided by Comfort Call. His carers had a wealth of knowledge and understanding as to how Mark communicated, what he liked and disliked, his feeding regime and all aspects of his care and health needs. They also facilitated weekly visits with a close family member who received similar care.

During the day on the 1st February Mr Fernandez had attended the specialist sarcoma service at Manchester Foundation Trust ("MFT") following a referral from Rochdale Infirmary. Limited information had been provided as to his level of disability and as such the court heard that a very limited examination was conducted whilst he remained clothed and in his chair. If MFT had been aware they indicated they would have had the opportunity to obtain a hoist and would have requested bloods before attendance. They indicated they had now changed their practices.

On the 1st February 2025 Mr Fernandez was admitted to Royal Oldham hospital at 8pm in the evening with suspected meningitis (a rash had become evident). His carers forwarded his hospital passport and also sent further copies to the hospital following his admission to a ward. Investigations highlighted he had recurring infections and despite treatment, including the insertion of a PEG, he remained in hospital until his death on the 18th April 2024. On the 12th April 2024 following a best interests meeting he was placed on end of life care.

The carers and social services involvement in Mark’s life was overlooked and their views and knowledge of Mark was not taken into account in the best interest decision-making process. The court heard that in 2020 the carers had successfully presented evidence against the introduction of a DNAR, at a best interests meeting.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

Failure to utilise hospital passports
Part of recurring concern: Unreliable use of hospital passports to support safe care
Failure to provide adequate information about care needs in referrals to specialist services
Part of recurring concern: Insufficient detail in referrals for safe risk assessment and prioritisation
Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions
Part of recurring concern: Failure to obtain relevant collateral information from family and social supports Part of recurring concern: Unreliable best-interests decision-making processes

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 14

Action
Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
Stated by Oldham Borough CouncilStated planned
Action
Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.
Stated by Oldham Council ASCStated planned
Action
Implement Patient Care Alert procedures to verify contact details, contact care providers, obtain Hospital Passports, and record unresolved information for nursing follow-up.
Stated by Northern Care Alliance NHS Foundation TrustStated completed

Action
Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
Stated by Northern Care Alliance NHS Foundation TrustStated in progress
Action
Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
Stated by Northern Care Alliance NHS Foundation TrustStated in progress
Action
Complete the multidisciplinary review of the Enhanced Patient Observation policy to address learning disability needs and active Hospital Passport use.
Stated by Northern Care Alliance NHS Foundation TrustStated in progress
Action
Add a Hospital Passport prompt and learning disability indicator to the patient-status-at-a-glance board.
Stated by Northern Care Alliance NHS Foundation TrustStated planned
Action
Use and further develop the Enhanced Patient Observation audit tool and targeted training to improve person-centred observation practice and quality assurance.
Stated by Northern Care Alliance NHS Foundation TrustStated completed
Action
Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.
Stated by Northern Care Alliance NHS Foundation TrustStated planned
Action
Disseminate the Share Learning Take 5 education on learning disability care, diagnostic overshadowing, communication, Hospital Passports and carer involvement.
Stated by Northern Care Alliance NHS Foundation TrustStated completed
Action
Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
Stated by Northern Care Alliance NHS Foundation TrustStated completed
Action
Red-flag patients with learning disabilities or Hospital Passports in daily safety huddles and assign senior nurse oversight of vulnerable patients.
Stated by Northern Care Alliance NHS Foundation TrustStated completed
Action
Continue quarterly Senior Nurse Walkabout reviews of learning disability identification, safety-huddle flags, Hospital Passport availability and currency.
Stated by Northern Care Alliance NHS Foundation TrustStated planned
Action
Remind staff to check for and seek Hospital Passports at every presentation, regardless of whether records or systems identify one.
Stated by NHS Greater Manchester Integrated Care BoardStated completed

Respondent positions 1

Position
The initial absence of the Hospital Passport did not impact the patient’s care, although its immediate availability remains important.
Stated by Northern Care Alliance NHS Foundation TrustDisputes the concern

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 17

1
Train duty workers to cover the Learning Disabilities and Autism hospital-discharge tracking role when the named worker is unavailable.
Stated by Oldham Council ASCStated planned
2
Add learning and guidance documents to the Adult Social Care SharePoint site for ongoing practitioner use.
Stated by Oldham Council ASCStated planned
3
Add the learning to mental-capacity-act theory-to-practice training.
Stated by Oldham Council ASCStated planned
4
Assign responsibility for hospital-discharge work to a named worker within the Learning Disabilities and Autism Team.
Stated by Oldham Council ASCStated planned
5
Establish proactive hospital-admission tracking and multiagency engagement by the named Learning Disabilities and Autism hospital-discharge worker.
Stated by Oldham Council ASCStated planned
6
Create and disseminate a seven-minute briefing across Adult Social Care on learning from the case.
Stated by Oldham Council ASCStated planned
7
Review how acute hospital admissions and discharges are managed by Adult Social Care mental-health teams.
Stated by Oldham Council ASCStated planned
8
Ensure Adult Social Care mental-health teams track supported individuals’ admissions and engage fully in hospital admission and discharge planning.
Stated by Oldham Council ASCStated planned
9
Complete Oliver McGowan Part 1 learning disability and autism training for Trust staff under the mandated programme.
Stated by Northern Care Alliance NHS Foundation TrustStated completed
10
Develop Oliver McGowan trainer capability for Tiers 1 and 2 training.
Stated by Northern Care Alliance NHS Foundation TrustStated in progress
11
Audit monthly compliance with arrival checks for contact details and cross-referencing ambulance arrivals with patient report forms.
Stated by Northern Care Alliance NHS Foundation TrustStated planned
12
Share learning from this PFD with Greater Manchester acute hospitals and the wider health and care system through Assistant Directors of Quality networks.
Stated by NHS Greater Manchester Integrated Care BoardStated planned
13
Monitor Oliver McGowan mandatory training compliance and completion rates at Directorate and Trust levels.
Stated by NHS Greater Manchester Integrated Care BoardStated in progress
14
Share learning from the locality practice review across Greater Manchester.
Stated by NHS Greater Manchester Integrated Care BoardStated planned
15
Conduct a locality practice review with stakeholders to improve care for patients with learning disabilities and complex needs in Oldham.
Stated by NHS Greater Manchester Integrated Care BoardStated in progress
16
Remind staff about safeguarding vulnerable patients and referral responsibilities and mechanisms through a Take 5 Briefing.
Stated by NHS Greater Manchester Integrated Care BoardStated completed
17
Remind staff of their responsibilities towards patients with learning disabilities and complex needs through a Take 5 Briefing.
Stated by NHS Greater Manchester Integrated Care BoardStated completed

Recipient positions 1

1
Separate concerns are assigned to Northern Care Alliance, Oldham Social Services and Oldham Independent Mental Health Advocate for response.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility

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

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised3

Failure to utilise hospital passports

Failure to provide adequate information about care needs in referrals to specialist services

Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.14

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

Actions described in response 14

Respondent positions 1

Recipient-stated actions 17

Recipient positions 1