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
1,518 resultsRonald Perry
All Responded
2025-0580
14 Nov 2025
Manchester South
Lakes Care Centre
Concerns summary
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Action taken summary
The Lakes Care Centre has appointed a new manager, completed 7 weeks of induction training for all Senior Carers, and improved the use of their Digital Care Record system for auditing. They have also
Margaret Crooks
All Responded
2025-0581
14 Nov 2025
Manchester South
Greater Manchester Integrated Care
Concerns summary
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
Action taken summary
Greater Manchester Integrated Care has reviewed its Comprehensive Stroke Centre service specification and Standard Operating Procedure. Following this, the network plans to add further detail to the S
Joan Talbot
All Responded
2025-0569
11 Nov 2025
Inner South London
Chief Executive Officer
Denmark Hill
King’s College Hospital
+4 more
Concerns summary
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
Action taken summary
Kings College Hospital NHS Trust has established a cross-Trust 'Documentation Quality Improvement Working Group' to improve the use of their EPIC record system. This group will define metrics, identif
Tracey Oldfield
All Responded
2025-0578
11 Nov 2025
Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.
Action taken summary
Royal Cornwall Hospital has established a multidisciplinary group to strengthen governance for timely prescribing of medications for unexpectedly admitted day-case patients. They have identified four
Judith Hughes
All Responded
2025-0563
6 Nov 2025
Cambridgeshire and Peterborough
Chief Medical Officer for North West An…
Concerns summary
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Action taken summary
The Trust's 'Enhanced Care Risk Assessment Form' was revised in 2022 to clarify the distinction between 'previous falls in the last 12 months' and 'inpatient fall during this admission'. Nursing staff
Vivian Nolan
All Responded
2025-0560
5 Nov 2025
Teesside and Hartlepool
President of the British Society of Gas…
Concerns summary
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
Action taken summary
The British Society of Gastroenterology clarifies that current UK guidance emphasizes individualised patient consent, balancing risks and benefits for colonoscopy, including for those over 80. They di
Maureen Christy
All Responded
2025-0561
4 Nov 2025
Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Action taken summary
Blackpool Teaching Hospitals plans to roll out a digital solution called ‘Alertive’ from Q4 2025/2026 to improve the dissemination of critical messages and ensure staff acknowledgment of policies, wit
Kathleen Ward
All Responded
2025-0562
3 Nov 2025
East Riding and Hull
Chief Executive – Hull Royal Infirmary
Concerns summary
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient bed capacity.
Action taken summary
Hull Royal Infirmary is strengthening escalation processes for end-of-life patients and reinforcing compassionate communication. They plan a further rollout of Comfort Observations across the organisa
Alan Horrocks
All Responded
2025-0545
28 Oct 2025
West Yorkshire Western
Bradford Teaching Hospitals NHS Foundat…
Concerns summary
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Action taken summary
Bradford Teaching Hospitals has convened a multi-disciplinary Case Review Panel which has already considered the identified issues regarding observations and the adequacy of investigation reports. The
Raymond Leake
All Responded
2025-0546
28 Oct 2025
East Riding of Yorkshire and City of Kingston Upon Hull
Hull Royal Infirmary
Concerns summary
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Action taken summary
Hull Royal Infirmary implemented new controls in March 2025 including automatic porter dispatch and direct ward contact for urgent scans. They have now completed an initial audit of CT head scan compl
Louisa Walker (1)
All Responded
2025-0543
27 Oct 2025
Berkshire
Royal College of Obstetricians and Gyna…
Concerns summary
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Action taken summary
Maternity Newborn Safety Investigations (MNSI) reviewed its investigation process and confirmed it was correctly followed based on available evidence. The organisation has added a note to its investig
Louisa Walker (2)
All Responded
2025-0544
27 Oct 2025
Berkshire
Royal Berkshire Hospital
Concerns summary
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient safety.
Action taken summary
Following the inquest, the Trust has ensured all obstetric doctors (ST1 and above, Consultants) and Band 7 delivery suite and maternity clinical coordinator midwives have been trained in managing Impa
Stephen Neville
All Responded
2025-0556
24 Oct 2025
Essex
Essex Partnership NHS Foundation Trust
Concerns summary
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical observations were also found to be severely inadequate.
Action taken summary
The Trust has updated its Observation Policy and a new training module, rolled out to all clinical staff by December 2025, with a new observation proforma also being implemented. It has also commissio
Mark Foster
All Responded
2025-0537
23 Oct 2025
Cumbria
Castlegate & Derwent Surgery
Concerns summary
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Action taken summary
The surgery has appointed a new practice manager and GP partner for governance, implemented a new governance structure, and revised its Significant Event Policy. All staff are now instructed to report
Lynn Silcock
All Responded
2025-0636
23 Oct 2025
Shropshire, Telford & Wrekin
NHS England
Shrewsbury and Telford NHS Hospital Tru…
Concerns summary
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.
Action taken summary
NHS England states the specific issues raised fall outside its direct role and remit, primarily resting with Shrewsbury and Telford Hospital NHS Trust (SATH). It notes its existing national Frontline
Rashida Sultana
All Responded
2026-0026
23 Oct 2025
Black Country
Sandwell and Birmingham Hospital NHS Tr…
Concerns summary
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk assessments for Speech and Language Therapy referrals for dysphagia.
Action taken summary
The organisation has approved and implemented an updated 'Emergency Medical Response Policy including Management of Resuscitation' in March 2025, which outlines systems, processes, and structures for
John Rust
All Responded
2025-0524
20 Oct 2025
Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future clinical staff receive essential training on critical equipment.
Action taken summary
The response text is truncated; therefore, no actions taken or planned regarding mandatory training for CSF drainage systems can be identified.
David Jones
All Responded
2025-0514
14 Oct 2025
Nottingham and Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.
Action taken summary
Nottingham University Hospitals NHS Trust has launched an Acute Aortic Dissection Improvement project, which will be undertaken by a newly formed Acute Aortic Dissection Improvement Group. This group
William Roath
All Responded
2025-0518
14 Oct 2025
Worcestershire
University Hospitals Birmingham NHS Fou…
Concerns summary
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors to prevent recurrence are still outstanding.
Action taken summary
University Hospitals Birmingham NHS Foundation Trust has delivered comprehensive training to doctors on recognizing and acting upon swallowing difficulties, emphasizing clear documentation and communi
Paula Doreen
All Responded
2025-0511
14 Oct 2025
Inner South London
Medicine and Healthcare Product Regulat…
Royal College of Physicians
Oracle and Cerner
+2 more
Concerns summary
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Action taken summary
NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training
Joanna Chamberlain
All Responded
2025-0571
11 Oct 2025
West Sussex, Brighton and Hove
NHS England
Concerns summary
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including family and GP input in care plans.
Action taken summary
NHS England is trialling neighbourhood mental health centres in six areas to provide community support for mental health patients not in immediate crisis. They have also shared draft 'Personalised Car
Adrienne Studholme
All Responded
2025-0504
10 Oct 2025
Lancashire and Blackburn with Darwen
East Lancashire NHS Trust
Concerns summary
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.
Action taken summary
The Trust has clarified that seizure activity is escalated regardless of who witnesses it, communicating this to clinical teams. They have also reminded ED and surgical clinicians to ensure urgent con
Matthew Goldsmith
All Responded
2025-0499
9 Oct 2025
East London
Barking, Havering and Redbridge Univers…
Concerns summary
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
Action taken summary
The Trust has implemented an action plan by reconfiguring its radiology IT system for mandatory internal peer review, establishing a Radiology Quality and Safety Team, and rolling out a formal peer re
Derek Crowther
All Responded
2025-0500
9 Oct 2025
Manchester South
Pennine Care NHS Foundation Trust
Concerns summary
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.
Action taken summary
The Trust has launched a new Mandatory Training Policy and a monitoring dashboard to ensure staff complete required Intermediate Life Support training. They have also established a project group to de
William King
All Responded
2025-0496
8 Oct 2025
Milton Keynes
Milton Keynes University Hospital
Royal College of Surgeons
Royal College of Anaesthetists
+1 more
Concerns summary
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a risk of recurrence.
Action taken summary
The Royal College of Surgeons of England plans to update its guidance on consent, develop a practical toolkit and a short set of principles on shared decision-making by Spring 2026, and create an e-le