Hospital Death (Clinical Procedures and medical management) related deaths

PFD Category
Reports: 2,483 Areas: 72 Earliest: Feb 2013 Latest: 11 Mar 2026

72% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 33% from 176 (2023) to 234 (2024).

Response Status
Responded 1,777 No Response 17 Historic 613 Pending 31
AI Classification
Action Taken 55%
Action Planned 24%
Noted 15%
Disputed 7%
Based on 652 classified responses
Reports by Quarter
PFD Reports
2,483 results
Yahya Hayat
All Responded
2025-0086 10 Feb 2025 Greater Manchester South
Royal College of Paediatrics and Child …
Concerns summary Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal resuscitation.
Action taken summary The RCPCH explains that while mandatory direct observed training for neonatal intubation has been removed, key capabilities for airway management have been strengthened, aligning with evidence for non
Amelia Ridout
All Responded
2025-0077 7 Feb 2025 Cambridgeshire and Peterborough
British Society for Haematology (BSH) NHS England National Institute for Health and Care …
Concerns summary A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice and missed learning.
Action taken summary NHS England states that developing clinical guidelines or a database for BMA and trephine biopsy does not sit within their remit. However, they commit to investigating evidence regarding training/supe
Katrina Insleay
All Responded
2025-0084 6 Feb 2025 Worcestershire
Worcestershire Acute Hospitals Trust Herefordshire and Worcestershire Health…
Concerns summary The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed follow-up and increased wound infection.
Action taken summary The Health and Care Trust is granting Neighbourhood Team staff access to the Acute Trust's electronic patient record, with 18 of 26 staff already having access. Additionally, the Acute Trust has devel
Terence Grainger
All Responded
2025-0067 5 Feb 2025 Manchester South
Circle Health Group Ltd
Concerns summary Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient deterioration trends.
Action taken summary Circle Health Group has successfully introduced digitised systems for consent, pathology, and imaging requests, with all new equipment designed to integrate with electronic patient records. They affir
Sapphire Bernard
All Responded
2025-0070 5 Feb 2025 West Sussex, Brighton and Hove
NHS England & NHS Improvement NHS Sussex Integrated Care Board
Concerns summary Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
Action taken summary NHS England has opened an additional 80 mental health beds since Spring 2024 and introduced national monitoring of A&E patients waiting over 72 hours for mental health placements, with individual case
Leslie Hurwood
All Responded
2025-0078 5 Feb 2025 Northamptonshire
NORTHAMPTON GENERAL HOSPITAL NHS TRUST
Concerns summary Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct medication procedures.
Action taken summary The Trust immediately reinforced insulin administration practices through ward visits, created and used dedicated huddle sheets, and conducted an audit of insulin patients. They have established an In
Dorothy Reid
All Responded
2025-0071 4 Feb 2025 North East Kent
NHS England Department of Health and Social Care
Concerns summary Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
Action taken summary NHS England's 2023 Urgent & Emergency Care Recovery Plan has improved 4-hour ED performance, with 2.5 million more patients treated within target. They are also collecting weekly data on patients wait
Naomi Suleyman
Partially Responded
2025-0049 29 Jan 2025 London Inner (South)
London Borough of Lewisham Lewisham and Greenwich NHS Trust
Concerns summary Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
Action taken summary The Trust states that ward-based teams now input into centrally located discharge passports, with the nurse in charge responsible for completeness. They have established an urgent concern escalation p
Carla Smith
All Responded
2025-0050 29 Jan 2025 Norfolk
Department of Health and Social Care
Concerns summary Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss of treatment options.
Action taken summary The Department acknowledges concerns about long gynaecological waiting lists and lack of patient monitoring. NHS England is expanding elective care reform initiatives, increasing Clinical Diagnostic U
William Northcott
All Responded
2025-0069 27 Jan 2025 Devon, Plymouth and Torbay
Devon Partnership NHS Trust Devon ICB Medicines and Healthcare Projects +1 more
Concerns summary Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for this cardiotoxic drug.
Action taken summary NHS Devon will provide additional funding to Devon Partnership NHS Trust in the 2025/26 financial year to implement more Clozapine clinics. They will also ensure that any changes to national policy re
Cynthia Gilbert
All Responded
2025-0061 24 Jan 2025 Somerset
Somerset NHS Foundation Trust
Concerns summary Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and the efficacy of post-death investigations.
Action taken summary Somerset NHS Foundation Trust has launched a Quality Improvement project to enhance intentional rounding, recruited two Tissue Viability Nurse Specialists, and implemented new multi-disciplinary team
Brian Kneale
All Responded
2025-0043 23 Jan 2025 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Action taken summary Blackpool Teaching Hospitals NHS Foundation Trust has launched a Clinical Community to embed fluid balance work and developed a new, enhanced fluid balance chart for imminent rollout. They have also r
Fahmida Khanam
All Responded
2025-0039 22 Jan 2025 West Yorkshire (East)
General Medical Council
Concerns summary A doctor treated a close relative, breaching the cardinal principle of medical ethics.
Action taken summary Saville Town Medical Centre will immediately adopt a protocol/procedure to ensure GPs do not treat immediate family members, aligning with GMC guidelines. The GMC clarifies that their guidance advises
Joanna Kowalczyk
All Responded
2025-0040 22 Jan 2025 Gateshead and South Tyneside
North East Ambulance Service General Chiropractic Council
Concerns summary A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks for patients.
Action taken summary The North East Ambulance Service disputes the suggestion that its paramedics are not trained in recognizing transient stroke symptoms, stating their training and JRCALC Guidelines comprehensively cove
Reginald Smith
All Responded
2025-0037 21 Jan 2025 Dorset
British Orthopaedic Association Stryker (UK) Ltd
Concerns summary A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of the defective jig preventing proper investigation.
Action taken summary Stryker disputes the coroner's concerns, stating their Targeting System is not hammered during procedures and is designed for repeated use with high-strength materials, retaining integrity when mainta
Jackson Yeow
All Responded
2025-0032 17 Jan 2025 South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.
Action taken summary Cwm Taf Morgannwg UHB has implemented multiple initiatives including the Optimise Programme, Discharge to Recover then Assess (D2RA) model, a Discharge Hub, and Safe2Start meetings. These measures aim
Vauna Leeming
All Responded
2025-0033 17 Jan 2025 Worcestershire
Worcestershire Acute Hospitals NHS Trust
Concerns summary Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Action taken summary Worcestershire Acute Hospitals NHS Trust held an Extra-Ordinary VTE meeting and increased VTE compliance monitoring. Ward managers are reinforcing the duty for staff to sign prescription charts, and t
Robert McGowan
All Responded
2025-0026 15 Jan 2025 Manchester South
Department of Health and Social Care
Concerns summary Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially treated bacterial endocarditis.
Action taken summary The DHSC acknowledges concerns about healthcare barriers for autistic people. NHS England will issue a reminder to clinicians on making reasonable adjustments, liaise with Disability Stockport for a m
Aarav Chopra
All Responded
2025-0019 13 Jan 2025 Birmingham and Solihull
Department of Health & Social Care Birmingham Women’s and Children’s NHS F…
Concerns summary Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also led to missed patient risk factors.
Action taken summary Birmingham Women's and Children's NHS Foundation Trust has introduced a mandatory PALS course, a 'Consultant of the Week' model, and a Junior Doctor Induction Handbook, and has circulated new guidance
David Tighe
All Responded
2025-0158 9 Jan 2025 Oxfordshire
Oxford University Hospitals NHS Foundat…
Concerns summary The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.
Action taken summary Oxford University Hospitals NHS Foundation Trust has updated its ‘Insertion, Use and Care of Nasogastric Feeding and Drainage Tubes’ policy to include specific Ryles tube guidance, effective February
Gemma Marshall
All Responded
2025-0001 2 Jan 2025 West Yorkshire (Western)
Royal College of Radiologists NHS England
Concerns summary An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of specialist knowledge, compounded by staff shortages.
Action taken summary The Royal College of Radiologists acknowledged concerns about radiologist shortages and outsourcing. They stated that managing gastric band imaging is within training scope and noted they have asked t
Morgan Betchley
All Responded
2025-0004 2 Jan 2025 West Sussex, Brighton & Hove
Sussex Partnership NHS Foundation Trust NHS England
Concerns summary The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
Action taken summary NHS England is developing a national framework for inpatient mental health services to define and promote therapeutic relationships and personalised safety planning. They also note that Sussex Partner
Michael Jervis
All Responded
2024-0712 30 Dec 2024 Cornwall and Isles of Scilly
Royal Cornwall Hospital Trust
Concerns summary Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of a digital alert system.
Action taken summary Royal Cornwall Hospital Trust has implemented mandatory sepsis training for nurses and healthcare assistants, commenced sepsis update training for doctors, and applied sepsis screening tools to all bl
Denise Johnson
All Responded
2025-0030 30 Dec 2024 Suffolk
East Suffolk and North Essex Foundation…
Concerns summary The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
Action taken summary East Suffolk and North Essex Foundation Trust has started three-monthly ERCP Multi-Disciplinary Team meetings to discuss cases and complications. They have also drafted and approved a new cross-site S
William Hare
All Responded
2024-0708 23 Dec 2024 Essex
Mid and South Essex NHS Foundation Trust
Concerns summary Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.
Action taken summary Mid and South Essex NHS Foundation Trust has made significant improvements to diagnostic pathways including increased clinic capacity and new weekly specialist MDT meetings now attended by specialist