Norma Bradbury

PFD Report Historic (No Identified Response) Ref: 2021-0019
Date of Report 27 January 2021
Coroner Andrew Bridgman
Coroner Area Manchester City Area
Response Deadline est. 24 March 2021
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Judiciary.uk Report PDF
Coroner's Concerns (AI summary)
A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.
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.
Sent To
  • Central Manchester NHS Foundation Trust
  • Manchester University NHS Foundation Trust
Response Status
Linked responses 0 of 2
56-Day Deadline 24 Mar 2021
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

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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Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Pre-1996 Transfusion Testing
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Delayed patient infection risk notification Incomplete GP Patient Data Transfer
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Laboratory specimen processing
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Effective CDI patient isolation
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Isolation for infectious diarrhoea
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.