PFD report

Brian Richard Murphy · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 2 Oct 2020•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

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.

Report evidence summary

Concerns raised2

  1. Delays in cardiology tests being carried out
    Part of recurring concern: Unreliable access to clinically required cardiology tests
  2. Delays in patients being referred to the cardiology clinic
    Part of recurring concern: Failure to reliably refer patients to required specialist services
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Implement the changed NT-proBNP testing and referral pathway, including urgency thresholds for echocardiography and heart failure services.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    There were no delays; investigations and referrals followed correct, timely processes and pathways, so the reported cardiology-timescale risk did not arise in this case.

    Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 cardiology tests being carried out

Wider context from the report

“The inquest heard that the system for referrals for cardiology tests meant that there were delays in tests being carried out which led to delays in patients being referred to the cardiology clinic to see a cardiologist. ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required cardiology tests.

Open source report

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 patients being referred to the cardiology clinic

Wider context from the report

“The inquest heard that the system for referrals for cardiology tests meant that there were delays in tests being carried out which led to delays in patients being referred to the cardiology clinic to see a cardiologist. ”

Is this part of a recurring concern?

Yes — Failure to reliably refer patients to required specialist services.

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

Implement the changed NT-proBNP testing and referral pathway, including urgency thresholds for echocardiography and heart failure services.

Verbatim wording from the response

“The test has subsequently changed to a NT-proBNP for which the values are different:-”

Source location

2020-0193-Response-from-NHS-Stockport-CCG_Redacted.pdf
Page 3 · response
Published 26 November 2020

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

There were no delays; investigations and referrals followed correct, timely processes and pathways, so the reported cardiology-timescale risk did not arise in this case.

Verbatim wording from the response

“Your report asks for an account of steps that we will be taking in relation to cardiology investigation timescales in order to reduce potentially avoidable deaths. I find myself in an unusual position in that whilst I am keen to respond appropriately to your request, my review identified that there were no delays in this case and that the correct processes and pathways were followed from the point of consultation with the GP through to the ordering of the echocardiogram and referral to specialist cardiology services.”

Source location

2020-0193-Response-from-NHS-Stockport-CCG_Redacted.pdf
Page 3 · response
Published 26 November 2020

Open published response
Back to top

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