“Mrs Bradbury was discharged on 22.02.19”

The 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. 1 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0019

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0