PFD report

Norma Bradbury · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 27 Jan 2021•Manchester City

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.

View original report
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

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Delays in transmitting discharge letters when timely GP involvement is required
    Part of recurring concern: Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPsPart of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable hospital discharge processes
Responses linked to these concerns

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

No linked response statements

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

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

Delays in transmitting discharge letters when timely GP involvement is required

Wider context from the report

“Mrs Bradbury was discharged on 22.02.19. The discharge letter to her GP instructed a review within 1 week to check Mrs Bradbury’s bloods and blood pressure, and to restart Losartan, and titrate the dose to her blood pressure. The consultant giving evidence at the hearing was clear that he expected this to have commenced within a week of discharge. The evidence of Mrs Bradbury’s GP was that the discharge letter was not received until 25.02.19. The GP also advised that the delay in receiving discharge letters was very variable, between days and weeks. I accept that in many cases the discharge letter is no more than a summary of an attendance and requires little or no further action on the part of the GP and the delay is of no consequence. However, where, as here, the discharging hospital requires GP involvement within 1 week of discharge a delay of 3 days in requesting or advising that involvement is not acceptable. While it was not possible to determine any difference in outcome in Mrs Bradbury’s case there is a risk that such a delay would make a difference. ”

Is this part of a recurring concern?

Yes — Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs; Failure to communicate clinically important information reliably between care services; Unreliable hospital discharge processes.

Open source report
Back to top

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