GREATER MANCHESTER - CITY
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If the Coroner feels that evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, he/she may make a Rule 43 report which is sent to the organisation that has responsibility for the circumstances. A recipient of a Rule 43 report must send a written response within 56 days to the Ministry of Justice.
The Coroner has sent a Rule 43 to the following organisation/s ...
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HOSPITAL DEATHS: CLINICAL PROCEDURES AND MEDICAL MANAGEMENT
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1. CENTRAL MANCHESTER NHS FOUNDATION TRUST
2. MANCHESTER PRIMARY CARE TRUST
Recommendation - Published May 2012
To consider a review of providing 24 hour availability of consultant neuro surgical advice and surgery at the Royal Manchester Children's Hospital: the provision of BCG immunisation to children looked after under Section 20 of the Children Act 1989: raising awareness of this case amongst all Greater Manchester PCTs and Social Services so that they can review their procedures to ensure prompt treatment for tuberculosis and that BCG immunisation is not overlooked.
RESPONSE
From: NHS Manchester
Mr. David Regan, Director of Public Health and Partnerships, NHS Manchester +
Manchester City Council
Mr. Mike Livingston, Director of Children's Services, Manchester City Council
Covering letter from NHS Manchester to rule43inquests@aol.com
RESPONSE
From: Central Manchester University Hospitals NHS Foundation Trust
1. Letter
2. Recommendation - Published May 2012 - 3 pages
THE CHRISTIE NHS FOUNDATION TRUST
Recommendation - Published May 2012
To consider a review of processes, protocols and policies to ensure that patient tests are appropriately diarised to minimise the chance of overside due to human error, and the hospital to conduct its own investigation to ascertain what happened and what lessons can be learned from this death.
RESPONSE
From: The Christie NHS Foundation Trust
Click here to download the response ...
1. MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST
2. THE PENNINE ACUTE HOSPITALS NHS TRUST - see also under Greater Manchester South
Recommendation - Published May 2012
To consider a review of the speed at which psychiatric reviews are conducted: the policies for carrying out such reviews: improving families' access to staff involved in such reviews. RESPONSE TO THE RECOMMENDATION FROM MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST
NORTH MANCHESTER GENERAL HOSPITAL
Recommendation - Published May 2012
To consider implementing the recommendations and actions of the internal hospital enquiry, and a general programme of training for all staff regarding care for patients with learning difficulties.
EAST CHESHIRE HOSPITALS NHS TRUST
Recommendation - Published May 2012
To consider a review of record keeping at Macclesfield Hospital: access to a CT scanner: escalation in provision of treatment: the referral and advice procedure and the Trust's incident investigation process.
MENTAL HEALTH RELATED DEATHS
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1. GREATER MANCHESTER WEST MENTAL HEALTH NHS FOUNDATION TRUST
2. SALFORD CITY COUNCIL
Recommendation - Published May 2012
To consider the implementation and audit of the recommendations of the local authority and Mental Health Trust following this death, and a review of psychiatric services for vulnerable patients.
RESPONSE:
Letters from Greater Manchester West Mental Health NHS Foundation Trust
- Letter Reference No. 4
- Letter Reference No. 3
RESPONSE:
From: Salford City Council
1. MANCHESTER PRIMARY CARE TRUST
2. CENTRAL MANCHESTER NHS FOUNDATION TRUST
3. GREATER MANCHESTER POLICE
4. MANCHESTER COMMUNITY ALCOHOL TEAM
5. MANCHESTER CITY COUNCIL
Recommendation - Published May 2012
To consider a review of referral policies when an individual with alcohol related problems contacts a hospital, district nurse or the police, in order to ensure that they are referred to the appropriate agency, and the Alcohol Treatment Team to consider a review of their contact processes and policies.
1. DEPARTMENT OF HEALTH - DH
2. GENERAL MEDICAL COUNCIL - GMC
3. MANCHESTER PRIMARY CARE TRUST - PCT
4. GREATER MANCHESTER POLICE - GMP
5. NORTH WEST AMBULANCE SERVICE - NWAS
6. MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST - MMSCT
Recommendation - Published May 2012
DH - To consider a review of the criteria under which the GMC operates in overdose cases
GMC - To consider a review of their policies and procedures for overdose cases
PCT To review their GMC complaints procedures
GMP- And all police forces - to consider a review of witness expertise
NWAS and Joint Royal Colleges Ambulance Liaison Committee to consider a review of the guidance provided to ambulance crews
MMSCT - To consider a review of training in cases where GPs and psychiatrists give repeat prescriptions.
1. MANCHESTER ADULT SOCIAL SERVICES
2. MANCHESTER CHILDREN'S SOCIAL SERVICES
Recommendation - Published May 2012
To consider a review of information sharing between Adult and Children's services, and of the database to ensure the information given is accurate.
RESPONSE
From: Manchester City Council
1. Response letter
2. Young Carers Referral Pathway
1. MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST
2. CARE QUALITY COMMISSION
Recommendation - Published May 2012
To consider a review of the management and control of ward staff: the involvement of multi-disciplinary teams with alcoholic patients: contact with such patients' families and overall management and leadership.
____________________________________________________________________________________
If the Coroner feels that evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, he/she may make a Rule 43 report which is sent to the organisation that has responsibility for the circumstances. A recipient of a Rule 43 report must send a written response within 56 days to the Ministry of Justice.
The Coroner has sent a Rule 43 to the following organisation/s ...
________________________________________________________________________________________________________________
HOSPITAL DEATHS: CLINICAL PROCEDURES AND MEDICAL MANAGEMENT
________________________________________________________________________________________________________________
1. CENTRAL MANCHESTER NHS FOUNDATION TRUST
2. MANCHESTER PRIMARY CARE TRUST
Recommendation - Published May 2012
To consider a review of providing 24 hour availability of consultant neuro surgical advice and surgery at the Royal Manchester Children's Hospital: the provision of BCG immunisation to children looked after under Section 20 of the Children Act 1989: raising awareness of this case amongst all Greater Manchester PCTs and Social Services so that they can review their procedures to ensure prompt treatment for tuberculosis and that BCG immunisation is not overlooked.
RESPONSE
From: NHS Manchester
Mr. David Regan, Director of Public Health and Partnerships, NHS Manchester +
Manchester City Council
Mr. Mike Livingston, Director of Children's Services, Manchester City Council
Covering letter from NHS Manchester to rule43inquests@aol.com
RESPONSE
From: Central Manchester University Hospitals NHS Foundation Trust
1. Letter
2. Recommendation - Published May 2012 - 3 pages
THE CHRISTIE NHS FOUNDATION TRUST
Recommendation - Published May 2012
To consider a review of processes, protocols and policies to ensure that patient tests are appropriately diarised to minimise the chance of overside due to human error, and the hospital to conduct its own investigation to ascertain what happened and what lessons can be learned from this death.
RESPONSE
From: The Christie NHS Foundation Trust
Click here to download the response ...
1. MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST
2. THE PENNINE ACUTE HOSPITALS NHS TRUST - see also under Greater Manchester South
Recommendation - Published May 2012
To consider a review of the speed at which psychiatric reviews are conducted: the policies for carrying out such reviews: improving families' access to staff involved in such reviews. RESPONSE TO THE RECOMMENDATION FROM MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST
NORTH MANCHESTER GENERAL HOSPITAL
Recommendation - Published May 2012
To consider implementing the recommendations and actions of the internal hospital enquiry, and a general programme of training for all staff regarding care for patients with learning difficulties.
EAST CHESHIRE HOSPITALS NHS TRUST
Recommendation - Published May 2012
To consider a review of record keeping at Macclesfield Hospital: access to a CT scanner: escalation in provision of treatment: the referral and advice procedure and the Trust's incident investigation process.
MENTAL HEALTH RELATED DEATHS
________________________________________________________________________________________________________________
1. GREATER MANCHESTER WEST MENTAL HEALTH NHS FOUNDATION TRUST
2. SALFORD CITY COUNCIL
Recommendation - Published May 2012
To consider the implementation and audit of the recommendations of the local authority and Mental Health Trust following this death, and a review of psychiatric services for vulnerable patients.
RESPONSE:
Letters from Greater Manchester West Mental Health NHS Foundation Trust
- Letter Reference No. 4
- Letter Reference No. 3
RESPONSE:
From: Salford City Council
1. MANCHESTER PRIMARY CARE TRUST
2. CENTRAL MANCHESTER NHS FOUNDATION TRUST
3. GREATER MANCHESTER POLICE
4. MANCHESTER COMMUNITY ALCOHOL TEAM
5. MANCHESTER CITY COUNCIL
Recommendation - Published May 2012
To consider a review of referral policies when an individual with alcohol related problems contacts a hospital, district nurse or the police, in order to ensure that they are referred to the appropriate agency, and the Alcohol Treatment Team to consider a review of their contact processes and policies.
1. DEPARTMENT OF HEALTH - DH
2. GENERAL MEDICAL COUNCIL - GMC
3. MANCHESTER PRIMARY CARE TRUST - PCT
4. GREATER MANCHESTER POLICE - GMP
5. NORTH WEST AMBULANCE SERVICE - NWAS
6. MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST - MMSCT
Recommendation - Published May 2012
DH - To consider a review of the criteria under which the GMC operates in overdose cases
GMC - To consider a review of their policies and procedures for overdose cases
PCT To review their GMC complaints procedures
GMP- And all police forces - to consider a review of witness expertise
NWAS and Joint Royal Colleges Ambulance Liaison Committee to consider a review of the guidance provided to ambulance crews
MMSCT - To consider a review of training in cases where GPs and psychiatrists give repeat prescriptions.
1. MANCHESTER ADULT SOCIAL SERVICES
2. MANCHESTER CHILDREN'S SOCIAL SERVICES
Recommendation - Published May 2012
To consider a review of information sharing between Adult and Children's services, and of the database to ensure the information given is accurate.
RESPONSE
From: Manchester City Council
1. Response letter
2. Young Carers Referral Pathway
1. MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST
2. CARE QUALITY COMMISSION
Recommendation - Published May 2012
To consider a review of the management and control of ward staff: the involvement of multi-disciplinary teams with alcoholic patients: contact with such patients' families and overall management and leadership.