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).
PFD Reports
613 resultsJoan Robinson
Historic (No Identified Response)
2022-0377
25 Nov 2022
Manchester South
Tameside and Glossop Integrated Care NH…
Concerns summary
Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and Hydration Committee suffers from inconsistent support and attendance.
Joan Rossington
Historic (No Identified Response)
2022-0373
22 Nov 2022
South Yorkshire West
Sheffield Teaching Hospitals NHS Founda…
Concerns summary
External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading to potential delivery of conflicting care and an unsafe environment.
Margaret Russell
Historic (No Identified Response)
2022-0374
22 Nov 2022
South Yorkshire West
Barnsley District General Hospital
Concerns summary
The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.
Malcom Garrett
Historic (No Identified Response)
2022-0241
4 Aug 2022
Manchester South
Department of Health and Social Care
Concerns summary
There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.
Margaret Warwick
Historic (No Identified Response)
2022-0243
4 Aug 2022
Manchester South
Department of Health and Social Care
Concerns summary
Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, and further compounded by theatre capacity and High Dependency Unit bed shortages.
Kellum Thomas
Historic (No Identified Response)
2022-0244
3 Aug 2022
Nottinghamshire and Nottingham
Birmingham Women and Childrens Hospital…
Concerns summary
The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.
Sergio Dunkley
Historic (No Identified Response)
2022-0140
12 May 2022
Sefton, St Helens and Knowsley
Care Quality Commission
NHS England
Concerns summary
Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.
Pauline Keen
Historic (No Identified Response)
2022-0152
12 May 2022
North East Kent
Kent and Medway NHS Social Care Partner…
Concerns summary
A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.
Cynthia Finlay
Historic (No Identified Response)
2022-0138
11 May 2022
Surrey
NHS England
Royal College of Psychiatrists
Concerns summary
There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.
Millie-Rae Needham
Historic (No Identified Response)
2022-0122
25 Apr 2022
South Yorkshire (West District)
Sheffield Teaching Hospitals NHS Founda…
Concerns summary
Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. "Normal birth" language on checklists is also concerning.
Thomas Hoskin
Historic (No Identified Response)
2022-0115
22 Apr 2022
West London
National Institute for Health and Care …
Concerns summary
There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.
Gemma Ingham
Historic (No Identified Response)
2022-0113
19 Apr 2022
Manchester City
GMMH NHS Trust
Concerns summary
Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate community support and clinical rationale.
Manhareen Kaur
Historic (No Identified Response)
2022-0107
8 Apr 2022
Inner West London
London North West University Healthcare…
Concerns summary
There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.
Ryan Merna
Historic (No Identified Response)
2022-0102
5 Apr 2022
Dorset
Dorset Healthcare University NHS Founda…
Concerns summary
The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.
Yvonne Eaves
Historic (No Identified Response)
2022-0096
1 Apr 2022
Manchester City
GMMH NHS Trust
Concerns summary
Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.
Emily Caldicott
Historic (No Identified Response)
2022-0092
23 Mar 2022
Worcestershire
Herefordshire and Worcestershire Health…
Concerns summary
Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.
Donald Compton
Historic (No Identified Response)
2022-0090
20 Mar 2022
South Wales Central
Cwm Taf University Morgannwg Health Boa…
Concerns summary
Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.
Remi Koduah
Historic (No Identified Response)
2022-0085
18 Mar 2022
Cheshire
Mid Cheshire Hospitals NHS Foundation T…
Concerns summary
The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.
Gary Ottway
Historic (No Identified Response)
2022-0087
18 Mar 2022
Inner North London
East London NHS Foundation Trust
Concerns summary
Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical delay.
Billy Longshaw
Historic (No Identified Response)
2022-0084
16 Mar 2022
Greater Manchester (South)
Great Western Hospitals NHS Foundation …
Concerns summary
The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.
Melanie Elms
Historic (No Identified Response)
2022-0079
7 Mar 2022
County of Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary
The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person plan in place.
Arthur Hall
Historic (No Identified Response)
2022-0081
7 Mar 2022
County of Surrey
Frimley Park Hospital
Concerns summary
A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. Signs of sepsis were missed, and no surgical opinion was sought post-discharge.
Marvin Rue
Historic (No Identified Response)
2022-0065
3 Mar 2022
Gwent
Aneurin Bevan University Health Board
Concerns summary
Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.
Alan Hodgson
Historic (No Identified Response)
2022-0067
3 Mar 2022
City of Sunderland
County Durham and Darlington NHS Founda…
Concerns summary
Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.
Vijaykumar Gadhavi
Historic (No Identified Response)
2022-0062
28 Feb 2022
East London
Royal London Hospital
Concerns summary
Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family involvement, and breaches of the Enhanced Care Policy.