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
1,518 results
Michelle Whitehead
All Responded
2023-0370 4 Oct 2023 Nottingham City and Nottinghamshire
Nottinghamshire Health NHS Foundation T…
Concerns summary Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious patients and deviated from national guidelines, alongside a lack of guidance for Psychogenic Polydipsia.
John Winsworth
All Responded
2023-0357 29 Sep 2023 Norfolk
Department of Health and Social Care
Concerns summary Critical delays in ambulance response times and subsequent long waits for hospital admission to A&E are causing significant risks due to ongoing pressure on emergency services.
Frederick Le Grice
All Responded
2023-0358 29 Sep 2023 Essex
Department of Health and Social Care
Concerns summary Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to ensure vigilance for symptoms and regular respiratory monitoring.
Brian Moreton
All Responded
2023-0352 25 Sep 2023 Newcastle upon Tyne and North Tyneside
North Cumbria Integrated Care NHS Found…
Concerns summary Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive issue of poor and misleading communication between clinicians and departments impacting patient care.
Alison Ross
All Responded
2023-0343 21 Sep 2023 West Sussex, Brighton and Hove
University Hospitals Sussex NHS Foundat…
Concerns summary There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to medication adherence.
Chantelle Reed
All Responded
2023-0349Deceased 21 Sep 2023 Cambridgeshire and Peterborough
Royal College of Radiologists Royal College of Emergency Medicine NHS England
Concerns summary Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
Kimberley Sampson and Samantha Mulcahy
All Responded
2023-0338 17 Sep 2023 Central and South East Kent
Royal College of Obstetricians and Gyna… NHS England
Concerns summary Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically for Herpes Simplex, put patients at risk.
Geoffrey Brooks
All Responded
2023-0351 15 Sep 2023 Exeter and Greater Devon
Royal Devon University Healthcare Found…
Concerns summary An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to the patient's critical dehydration and contributing to his death.
Geoffrey Hoad
All Responded
2023-0327 13 Sep 2023 Norfolk
Department of Health and Social Care Spire East of England Ambulance Service NHS T…
Concerns summary Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating call categories.
Melissa Kerr
All Responded
2023-0330 13 Sep 2023 Norfolk
Department of Health and Social Care
Concerns summary Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon consultation.
Amanda Kramer
All Responded
2023-0328 11 Sep 2023 East London
North East London Foundation Trust Wood Street Medical Centre Department of Health and Social Care
Concerns summary A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
Cherry Garland
All Responded
2023-0324 8 Sep 2023 Avon
Weston NHS Foundation Trust University Hospitals Bristol
Concerns summary The provided text indicates an extremely important concern was identified, but its specific nature or the risks it poses for future deaths are not detailed.
Sultana Choudhury
All Responded
2023-0321 7 Sep 2023 East London
Department of Health and Social Care Barts Health NHS Foundation Trust
Concerns summary Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Graham Smith
All Responded
2023-0323 7 Sep 2023 Birmingham and Solihull
NHS England
Concerns summary There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication interactions, posing a risk beyond the local Trust.
Harold Pedley
All Responded
2023-0316 1 Sep 2023 Blackpool & Fylde
Department of Health and Social Care Lancashire and South Cumbria Integrated…
Concerns summary Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.
Donna Levy
All Responded
2023-0315 31 Aug 2023 East London
London Borough of Redbridge Council Department of Health and Social Care North East London Foundation Trust
Concerns summary Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation decision overlooked wider health problems.
Christopher Locke
All Responded
2023-0310 24 Aug 2023 Swansea Neath Port Talbot
JD Wetherspoon PLC
Concerns summary Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders in such environments.
Audrey King
All Responded
2023-0312 22 Aug 2023 Cornwall and the Isles of Scilly
Royal Cornwall Hospital Trust
Concerns summary Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient care.
William Nichols
All Responded
2023-0308 18 Aug 2023 Gateshead and South Tyneside
Gateshead Health NHS Foundation Trust Newcastle Upon Tyne Hospitals NHS Found…
Concerns summary Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.
Malcolm Unwin
All Responded
2023-0298 17 Aug 2023 North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and future deaths.
Ian Darwin
All Responded
2023-0291 15 Aug 2023 County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Reginald Bourn
All Responded
2023-0288 8 Aug 2023 Surrey
Health Education England National Institute for Health and Care …
Concerns summary There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking fatal misplacement.
Harry Stobie
All Responded
2023-0284 4 Aug 2023 Milton Keynes
Milton Keynes University Hospital
Concerns summary Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to a senior doctor, potentially missing a critical bleed.
Lee Dryden
All Responded
2025-0402 2 Aug 2023 South Yorkshire (West District)
NHS England Department of Health and Social Care
Concerns summary NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due to high escalation and hospital handover issues.
Finley May
All Responded
2023-0277 26 Jul 2023 East Riding and Hull
Royal College of Obstetricians and Gyna… NHS England
Concerns summary There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if abandoned, to manage obstetric problems.