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
Clear
PFD Reports
613 results
Amy Cooper
Historic (No Identified Response)
2016-0072 25 Feb 2016 Liverpool and Wirral
Department for Health NHS England
Concerns summary Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
Euphemia Aldred
Historic (No Identified Response)
2016-0062 18 Feb 2016 Blackburn, Hyndburn and Ribble Valley
East Lancashire Healthcare NHS Trust
Concerns summary The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Euphemia Aldred's death.
Matthew Crowley
Historic (No Identified Response)
2016-0063 17 Feb 2016 Mid Kent and Medway
Maidstone and Tunbridge Wells NHS Trust
Concerns summary A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
Philip Denning
Historic (No Identified Response)
2016-0058 16 Feb 2016 Nottinghamshire
NHS England Nottinghamshire healthcare NHS Foundati…
Concerns summary Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of available help pose significant risks.
Marilyn Anson
Historic (No Identified Response)
2016-0054 12 Feb 2016 Avon
North Somerset Clinical Commissioning G… Weston Area Health NHS Trust
Concerns summary Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.
Terence  Brooks
Historic (No Identified Response)
2016-0056 12 Feb 2016 Avon
Bath and North East Somerset Clinical C… Care Quality Commission Royal United Hospitals Bath NHS Foundat…
Concerns summary The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection source.
Marion Howes
Historic (No Identified Response)
2016-0046 11 Feb 2016 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary No specific concerns text was provided to summarise.
Alice Dickenson
Historic (No Identified Response)
2016-0021 21 Jan 2016 Central and South East Kent
Kent and Medway Cancer Collaborative
Concerns summary The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.
Leslie Murray
Historic (No Identified Response)
2016-0016 21 Jan 2016 London Inner (West)
St George’s Hospital
Concerns summary Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Leslie Summerfield
Historic (No Identified Response)
2016-0019 20 Jan 2016 Manchester (South)
Central Manchester NHS Trust
Concerns summary The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating their conditions.
Robin Brett
Historic (No Identified Response)
2016-0013 11 Jan 2016 Wiltshire and Swindon
Great Western Hospital NHS Foundation T…
Concerns summary A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Joanne French
Historic (No Identified Response)
2016-0004 7 Jan 2016 West Sussex
Sussex Partnership NHS Trust
Concerns summary Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.
Shalini Ganesh-Ram
Historic (No Identified Response)
2016-0117 22 Dec 2015 London Inner (North)
Royal London Hospital
Concerns summary Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, inadequate interpretation of radiology findings, and improper use of early warning scores for sepsis.
Barbara Rawlinson
Historic (No Identified Response)
2023-0413Deceased 1 Dec 2015 Inner North London
Royal Free London NHS Foundation Trust
Concerns summary Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.
Brian Shillinglaw
Historic (No Identified Response)
2015-0427 6 Nov 2015 Brighton and Hove
Sussex Partnership Trust
Concerns summary The provided text is incomplete and does not contain specific concerns.
Vera Williams
Historic (No Identified Response)
2015-0428 6 Nov 2015 North East and North Central Wales
Betsi Cadwaladr University NHS Trust
Concerns summary Emergency Department doctors and staff lack a digital system to support their work.
Dennis Stark
Historic (No Identified Response)
2015-0420 30 Oct 2015 Blackpool and Fylde
Newton House (formerly Regency Hospital)
Concerns summary A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.
Tamara Mills
Historic (No Identified Response)
2015-0416 29 Oct 2015 Gateshead & South Tyneside
National Institute for Health and Care … NHS England South Tyneside NHS Trust +2 more
Concerns summary Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across repeated hospital visits.
Hireiti Kuflesion
Historic (No Identified Response)
2015-0414 23 Oct 2015 Birmingham and Solihull
Birmingham Women’s NHS Trust N.I.C.E University Hospitals Birmingham NHS Tru…
Concerns summary Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.
Glenda Day
Historic (No Identified Response)
2015-0410 22 Oct 2015 Nottinghamshire
Nottinghamshire Healthcare NHS Trust
Concerns summary A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to safe home leave procedures.
Samantha Beach
Historic (No Identified Response)
2015-0413 21 Oct 2015 Gloucestershire
Gloucestershire Hospitals NHS Trust
Concerns summary There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for a post-natal patient.
Mrs Withers
Historic (No Identified Response)
2015-0371 12 Oct 2015 Northampton
Kettering General Hospital NHS Trust
Concerns summary Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.
Dilys Jenkins
Historic (No Identified Response)
2015-0399 7 Oct 2015 Cardiff and the Vale of Glamorgan
Intensive Care Society of England and W…
Concerns summary Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.
Rosina Drury
Historic (No Identified Response)
2015-0397 2 Oct 2015 London Inner (South)
Kings College Hospital
Concerns summary The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.
Fiona Lewis
Historic (No Identified Response)
2015-0441 17 Sep 2015 Suffolk
Ipswich Hospital
Concerns summary There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.