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).

Responded 1,777 No Response 17 Historic 613 Pending 31

Action Taken 55%

Action Planned 24%

Noted 15%

Disputed 7%

Based on 652 classified responses

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PFD Reports

613 results

Patricia Webb

Historic (No Identified Response)

2017-0130 20 Apr 2017 Brighton and Hove

Brighton and Sussex University Hospital…

Concerns summary Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.

David Evans

Historic (No Identified Response)

2017-0134 20 Apr 2017 South Wales Central

Cardiff and Vale University Health Board

Concerns summary An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.

Charlotte Agnew

Historic (No Identified Response)

2017-0141 20 Apr 2017 London (City)

North NHS Trust

Concerns summary Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without direct psychiatrist assessment, compounded by significant re-assessment delays.

Elaine Talbot

Historic (No Identified Response)

2017-0131 19 Apr 2017 Manchester (North)

Bury Clinical Commissioning Group

Concerns summary General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially impacting patient outcomes.

Daniel Maher

Historic (No Identified Response)

2017-0124 18 Apr 2017 Surrey

Surrey and Borders Partnership NHS Trust West Sussex County Council

Concerns summary Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.

David Birtwistle

Historic (No Identified Response)

2017-0139 18 Apr 2017 Avon

Brisdoc NHS University Hospital Bristol NHS Trust

Concerns summary A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.

Michael Newell

Historic (No Identified Response)

2017-0123 13 Apr 2017 Preston and West Lancashire

Lancashire Teaching Hospitals NHS Trust

Concerns summary Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.

Jamie Fairclough

Historic (No Identified Response)

2017-0119 12 Apr 2017 Central and South East Kent

Kent and Medway NHS Trust

Concerns summary Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.

Christiana Pelle

Historic (No Identified Response)

2017-0118 10 Apr 2017 London Inner (North)

East London NHS Trust Homerton University NHS Trust

Concerns summary There was a lack of clear guidance for community nurses on GP involvement and significant systemic failures in sharing patient information and escalating concerns between various healthcare and care provider agencies.

Annette Krasinsky-Lloyd

Historic (No Identified Response)

2017-0109 7 Apr 2017 Surrey

Royal Surrey County Hospital NHS Trust

Concerns summary Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.

Theresa Thompson

Historic (No Identified Response)

2017-0110 7 Apr 2017 Cornwall and Isle of Scilly

Public Health England

Concerns summary A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from accepting crucial preventative treatments.

Christina Witney

Historic (No Identified Response)

2017-0112 7 Apr 2017 Wiltshire and Swindon

Great Western Hospitals NHS Trust NHS England

Concerns summary Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.

Isabel Gentry

Historic (No Identified Response)

2017-0111 6 Apr 2017 Avon

Committee of Vaccination and Immunisati… Department of Health and Social Care

Concerns summary The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.

John Haughey

Historic (No Identified Response)

2017-0116 6 Apr 2017 East Riding and Kingston -upon-Hull

Concerns summary The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this hazard and the need for formal risk assessments across sectors.

Steven Amos

Historic (No Identified Response)

2017-0117 6 Apr 2017 Gloucestershire

Gloucestershire Hospitals NHS Foundatio…

Concerns summary Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.

Robert Owens

Historic (No Identified Response)

2017-0102 4 Apr 2017 South Wales Central

CWM Taf University Health Board

Concerns summary Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded by inconsistent practice and lack of specific ITU guidance.

Christina Smith

Historic (No Identified Response)

2017-0107 4 Apr 2017 Somerset

Bute House Surgery

Concerns summary Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, which was also not placed under surveillance, unlike her abdominal aneurysm.

Abigail Baynham

Historic (No Identified Response)

2017-0104 3 Apr 2017 Black Country

Black Country NHS New Cross Hospital

Concerns summary A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a further assessment of her mental state and self-harm risk was missed.

Beryl Foster

Historic (No Identified Response)

2017-0095 29 Mar 2017 Portsmouth and South East Hampshire

Portsmouth Hospitals NHS Trust

Concerns summary The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.

Marian Dale

Historic (No Identified Response)

2017-0086 23 Mar 2017 Manchester (South)

Stockport NHS Trust

Concerns summary The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after death.

Patricia Donovan

Historic (No Identified Response)

2017-0087 22 Mar 2017 South Wales Central

Aneurin Bevan University Health Board

Concerns summary Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource availability issues, despite the recognised risk of serious complications from prolonged waiting.

Scott Hooper

Historic (No Identified Response)

2017-0068 20 Mar 2017 Portsmouth and South East Hampshire

Southampton General Hospital

Concerns summary Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.

Stephen McDermott

Historic (No Identified Response)

2017-0071 17 Mar 2017 Preston and West Lancashire

Lancashire Care Foundation Trust

Concerns summary Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. Staff also lacked adequate training.

Clive Davies

Historic (No Identified Response)

2017-0074 16 Mar 2017 South Wales Central

Welsh Assembly Government Cwm Taf Morgannwg University Health Boa…

Concerns summary Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.

Derek Turnbull

Historic (No Identified Response)

2017-0076 16 Mar 2017 Sunderland

Gateshead Health Foundation Trust

Concerns summary There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.