PFD report

Benedict Peters · Prevention of Future Deaths report

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Issued 16 May 2023•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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

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.

Concerns raised2

  1. Lack of policy or protocol governing discharge from the Ambulatory Care Unit without medical review
    Part of recurring concern: Unreliable clinical review and authorisation of discharge decisions
  2. Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit
    Part of recurring concern: Unreliable clinical review and authorisation of discharge decisionsPart 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.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.

    Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 policy or protocol governing discharge from the Ambulatory Care Unit without medical review

Wider context from the report

“It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor. It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place. ”

Is this part of a recurring concern?

Yes — Unreliable clinical review and authorisation of discharge decisions.

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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

Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit

Wider context from the report

“It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor. It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place. ”

Is this part of a recurring concern?

Yes — Unreliable clinical review and authorisation of discharge decisions; Unreliable hospital discharge processes.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.

Verbatim wording from the response

“Mr Peters had been seen and assessed by a Physician Associate (PA), these are professional practitioners working under the aegis of the Royal College of Physicians of London which has produced guidance regarding their responsibilities and scope of practice (https://www.rcplondon.ac.uk/news/fact-finding-physician-associates). Within Manchester University NHS Foundation Trust (MFT), PAs work within an agreed governance framework (enclosed). This has the effect that PAs are not independent practitioners (paragraph 12.7) but work under the delegated authority of a consultant (paragraph 14.2). It is the responsibility of the supervising consultant to ensure that the level of supervision is appropriate to the knowledge and skills of each individual PA.”

Source location

Response from Manchester University NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing policy requires medical authorisation for Ambulatory Care Unit discharge and prevents Physician Associates from discharging patients independently.

Verbatim wording from the response

“2) “No policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place””

Source location

Response from Manchester University NHS Foundation Trust
Page 2 · response
Published 17 May 2023

Open published response

Other statements in published responses

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

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.1

  1. 1

    Remind physician associates to discuss proposed patient discharges with senior medical colleagues and reiterate senior-case discussions as good practice to junior and non-medical clinical staff.

    Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.

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

  1. 1

    Clinical reviews found no presentation or investigation indication of aortic dissection, and consultants stated they would have managed the case similarly.

    Stated by Manchester University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Remind physician associates to discuss proposed patient discharges with senior medical colleagues and reiterate senior-case discussions as good practice to junior and non-medical clinical staff.

Verbatim wording from the response

“We will remind all our PAs of the need to discuss patients for discharge with senior medical colleagues and reiterate to all junior medical staff and non-medical clinical practitioners, that it remains good practice to discuss cases with their seniors for learning and development.”

Source location

Response from Manchester University NHS Foundation Trust
Page 3 · response
Published 17 May 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Clinical reviews found no presentation or investigation indication of aortic dissection, and consultants stated they would have managed the case similarly.

Verbatim wording from the response

“Following receipt of your concerns, I have received assurances from Professor ████████, Consultant Physician and Associate Medical Director for Clinical Governance in the MRI that this is an extremely rare condition and that none of the investigations performed on Mr Peters during”

Source location

Response from Manchester University NHS Foundation Trust
Page 1 · response
Published 17 May 2023

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

Data last updated 7 September 2026