Graham Flindle · Prevention of Future Deaths report

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Issued 4 Nov 2022•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Report evidence summary

Concerns raised2

  1. Difficulty identifying concerning cases from high volumes of haemoglobin results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
  2. Lack of widespread understanding and promotion of FIT testing among community health professionals

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. NHS Greater Manchester Integrated Care Board

    Run an ongoing primary-care education and awareness programme on FIT use, patient support and appropriate result follow-up.

  2. NHS Greater Manchester Integrated Care Board

    Present learning from the case to the Greater Manchester System Quality Group.

  3. NHS Greater Manchester Integrated Care Board

    Monitor key learning points and recommendations to ensure they become embedded in practice.

  4. NHS Greater Manchester Integrated Care Board

    Deliver and disseminate primary-care education resources on cancer and anaemia, including a webinar, video and infographic.

  5. NHS Greater Manchester Integrated Care Board

    Alter the suspected cancer referral form to remind referrers to complete FIT before referral.

  6. NHS Greater Manchester Integrated Care Board

    Implement FIT testing before onward referral for patients with suspected colorectal cancer.

  7. NHS Greater Manchester Integrated Care Board

    Cascade learning from this and similar cases to professionals through relevant governance and learning forums.

  8. NHS Greater Manchester Integrated Care Board

    Develop clinical decision-support tools in GP systems to prompt consideration of cancer, prioritising an iron-deficiency anaemia tool.

  9. NHS Greater Manchester Integrated Care Board

    Monitor FIT use by GP practices and primary care networks and provide feedback to areas with low uptake.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Difficulty identifying concerning cases from high volumes of haemoglobin results

Wider context from the report

“2. The inquest was told that interpretation of haemoglobin test results and prompt referral back into secondary care if they were abnormal and remained low despite treatment was important to effective and potentially lifesaving treatment. The volume of blood results that GPs were regularly having to consider was significant and made it difficult to always identify cases that were concerning. Prompts in relation to haemoglobin test may be effective in assisting GPs juggling a large volume of results. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of widespread understanding and promotion of FIT testing among community health professionals

Wider context from the report

“1. The inquest heard that FIT tests were very effective at identifying bowel cancers at an early stage. GPs and other community health care providers, the inquest heard, have a key role in promoting the use of them where there is rectal bleeding/unexplained weight loss and other symptoms that may be consistent with bowel cancer. Use of FIT tests allows far more effective identification of patients who need to be fast tracked onto the cancer pathway. An understanding of just how effective FIT tests are was not always widely understood and promotion of them amongst all community health professionals was, the inquest was told, crucial in reducing deaths from bowel cancer; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Run an ongoing primary-care education and awareness programme on FIT use, patient support and appropriate result follow-up.

Verbatim wording from the response

“The Cancer Alliance is running an ongoing education and awareness programme for primary care practitioners on the use of FIT in patients with possible symptoms of colorectal cancer. This includes indications for use, advice for patients in multiple languages and formats on completing the test and guidance for practices on how they can ensure test results are reviewed and actioned appropriately.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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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

Present learning from the case to the Greater Manchester System Quality Group.

Verbatim wording from the response

“1. Learning presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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

Monitor key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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 and disseminate primary-care education resources on cancer and anaemia, including a webinar, video and infographic.

Verbatim wording from the response

“To increase awareness of the significance of iron deficiency in diagnosis of cancer, the Cancer Alliance recently ran a webinar for primary care colleagues across Greater Manchester on cancer and anaemia. This webinar was recorded and is available on the Gateway C. They have also produced a short summary video and infographic which were shared with primary care practitioners and are available on the Gateway C website. The Cancer Alliance will ensure these are circulated to primary care clinicians.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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

Alter the suspected cancer referral form to remind referrers to complete FIT before referral.

Verbatim wording from the response

“Over the last 12 months guidance of the use of FIT has changed and patients would now have FIT prior to onward referral to secondary care. A positive test would prompt the secondary care clinician to investigate the whole colon. The suspected cancer referral form is being altered to provide a reminder to referrers of the need to do FIT prior to referral.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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 FIT testing before onward referral for patients with suspected colorectal cancer.

Verbatim wording from the response

“Over the last 12 months guidance of the use of FIT has changed and patients would now have FIT prior to onward referral to secondary care. A positive test would prompt the secondary care clinician to investigate the whole colon. The suspected cancer referral form is being altered to provide a reminder to referrers of the need to do FIT prior to referral.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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

Cascade learning from this and similar cases to professionals through relevant governance and learning forums.

Verbatim wording from the response

“2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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 clinical decision-support tools in GP systems to prompt consideration of cancer, prioritising an iron-deficiency anaemia tool.

Verbatim wording from the response

“The Cancer Alliance is currently developing a series of clinical decision support tools within GP computer systems to encourage GPs to "think cancer" when certain codes are entered. A tool for iron deficiency anaemia will be prioritised as part of this work.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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

Monitor FIT use by GP practices and primary care networks and provide feedback to areas with low uptake.

Verbatim wording from the response

“The Cancer Alliance is also monitoring the use of FIT by GP practices and primary care networks and will feedback to areas with low usage to try and improve uptake.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 7 November 2022

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

Official responses located
1/1

Data last updated 7 September 2026