PFD report

John Joseph Malone · Prevention of Future Deaths report

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Issued 14 Jan 2014•Manchester South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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Concerns raised1

  1. Failure of discharge documentation to include vital admission and discharge information
    Part of recurring concern: Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPsPart of recurring concern: Unreliable hospital discharge documentationPart of recurring concern: Unreliable hospital discharge processes
Responses linked to these concerns

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No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

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PFD Monitor interpretation

Failure of discharge documentation to include vital admission and discharge information

Wider context from the report

“I took evidence from the two GP's caring for the deceased and they showed to me, inter alia, a discharge letter from your hospital dated 21st October 2013 a copy of which I append hereto. You will note that this document is woefully short on detail and has significant omissions of vital information for the GP's. On page one of the report there are no details given as to Admission date, admission ward, admission method, admission source, discharge destination or discharge date. The patient sustained a fall within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage. ”

Is this part of a recurring concern?

Yes — Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs; Unreliable hospital discharge documentation; Unreliable hospital discharge processes.

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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