Source · Prevention of Future Deaths
Norma Bradbury
Ref: 2021-0019
Date: 27 Jan 2021
Coroner: Andrew Bridgman
Area: Manchester City Area
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner notes concerns regarding delays in GPs receiving discharge letters, deeming a three-day delay unacceptable when timely follow-up is required, as such delays risk impacting patient outcomes.
Date
27 Jan 2021
56-day deadline
24 Mar 2021 est.
estimated from the report date
Responses identified
0 of 2
Coroner's concerns
The coroner notes concerns regarding delays in GPs receiving discharge letters, deeming a three-day delay unacceptable when timely follow-up is required, as such delays risk impacting patient outcomes.
View full coroner's concerns
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.
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.
Report sections
Investigation and inquest
On 19.03.19 an investigation commenced into the death of Norma Bradbury who died on 03.03.19. The investigation concluded on 15.01.21. The conclusion was one of Natural Causes contributed to by medication The medical cause of death was 1a Intra-cerebral haemorrhage 1b Systemic hypertension and oral anti-coagulation for atrial fibrillation
Circumstances of the death
On 15.02.19 at the MRI Mrs Bradbury underwent aortic valve replacement. She was discharged to home on 22.02.19. On 03.03.19 Mrs Bradbury was found deceased at the side of her bed.
Action should be taken
In my opinion action should be taken to ensure that when, following discharge, a GP is expected to provide follow up care within a short and/or specific timetable the discharge letter is sent on the day of discharge to arrive that same day. I believe you have the power to take such action.
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Report details
- Reference
- 2021-0019
- Date of report
- 27 January 2021
- Coroner
- Andrew Bridgman
- Coroner area
- Manchester City Area
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Mar 2021 (estimated from the report date).
Sent to
- Central Manchester NHS Foundation Trust
- Manchester University NHS Foundation Trust