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

1,518 results

Nesta Jones

2024-0110 28 Feb 2024 North West Wales

Betsi Cadwaladr University Health Board

Concerns summary Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed to conduct a full, timely investigation into the death.

Chloe Tapp

2024-0111 28 Feb 2024 Essex

NHS England Mid and South Essex NHS Trust

Concerns summary An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created unsafe backlogs and sub-optimal care, persisting years after the death.

Gillian Baumgardt

2024-0112 28 Feb 2024 Avon

North Bristol Trust

Concerns summary There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury site between x-ray images, risking wrong-site surgery.

Kerri Mothersole

2024-0122 28 Feb 2024 Mid Kent and Medway

Kent and Medway Integrated Care Board

Concerns summary Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The lack of an integrated imaging system for private providers led to missed diagnostic opportunities.

Kim Stroud

2024-0105 22 Feb 2024 Norfolk

Queen Elizabeth Hospital

Concerns summary There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.

Oliver Beswetherick

2024-0097 21 Feb 2024 London Inner (South)

Concerns summary Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent support.

Severine Kelly

2024-0098 21 Feb 2024 Gloucestershire

Gloucestershire Health and Care NHS Fou…

Concerns summary Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.

Paula Elsley

2024-0361 6 Feb 2024 Berkshire

Ringmead Medical Group

Concerns summary GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the lack of a formal policy for referral thresholds risks missed cancer diagnoses.

Emily Harkleroad

2024-0074 5 Feb 2024 County Durham and Darlington

County Durham and Darlington NHS Founda… Oracle Health UK

Concerns summary A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, especially during peak demand.

Marjorie McEvoy

2024-0050 2 Feb 2024 Liverpool and Wirral

Clatterbridge Cancer Centre

Concerns summary Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.

Terence Briney

2024-0042 29 Jan 2024 Manchester South

Greater Manchester Integrated Care

Concerns summary Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of conducting thorough investigations.

Jeanine Huggins

2024-0040 26 Jan 2024 Norfolk

Norfolk and Norwich University Hospitals

Concerns summary Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell usage ability, hindering emergency alerts.

Paul Bradley

2024-0301 26 Jan 2024 Worcestershire

Worcestershire Acute Hospitals NHS Trust

Concerns summary Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care for a hard-of-hearing patient.

Michael Pegg

2024-0306 26 Jan 2024 Worcestershire

Worcestershire Acute Hospitals NHS Trust NHS England

Concerns summary Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff turnover, which poses a risk to patient safety.

Thomas Ithell

2024-0035 22 Jan 2024 North Wales (East and Central)

Betsi Cadwaladr University Health Board

Concerns summary The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.

Kate O’Donnell

2024-0038 22 Jan 2024 Teesside and Hartlepool

James Cook University Hospital

Concerns summary Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.

Dorota Kuklinska

2024-0027 18 Jan 2024 Birmingham and Solihull

Sandwell and West Birmingham Hospitals … University Hospitals Birmingham NHS Fou…

Concerns summary Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, as clinicians were unaware of existing protocols.

Samuel Parkin

2025-0361 18 Jan 2024 Inner West London

St George’s University Hospitals NHS Fo… NHS England

Concerns summary Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.

Dennis King

2024-0020 15 Jan 2024 Suffolk

NHS England Department of Health and Social Care East of England Ambulance service

Concerns summary Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely delivery of urgent, centralised cardiac care.

Rhys Hill

2024-0021 15 Jan 2024 Manchester South

NHS England Lancashire Teaching Hospitals

Concerns summary Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.

Iona Buckingham

2024-0023 12 Jan 2024 Northamptonshire

NHS England Northampton General Hospitals NHS Trust NHS Northamptonshire Integrated Care Bo…

Concerns summary The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.

Karena Wicking

2024-0016 9 Jan 2024 Cumbria

North Cumbria Integrated Care

Concerns summary The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing anticoagulant prophylaxis for patients with reduced mobility.

Tammy Watkins

2024-0017 5 Jan 2024 Nottingham and Nottinghamshire

Nottinghamshire Healthcare NHS Foundati…

Concerns summary Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.

Elizabeth Roberts

2024-0006 4 Jan 2024 Manchester South

Department of Health and Social Care

Concerns summary Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a local trust level.

James Holgate

2024-0004 3 Jan 2024 East Riding and Hull

Department of Health and Social Care

Concerns summary An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, even if a post-mortem isn't needed, impeding scientific progress.