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). 54% 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 54%
Action Planned 24%
Noted 15%
Disputed 7%
Based on 960 classified responses
Reports by Quarter
PFD Reports
2,483 results
Kai Takagi
Partially Responded
2023-0502 27 Oct 2023 Inner West London
Chelsea and Westminster Hospital NHS England
Concerns summary Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.
Action taken summary NHS England highlights existing national guidance and standards for following up on test results after discharge, stating it is the responsibility of individual Trusts to implement these. It also desc
Myra Maxfield
All Responded
2023-0396 25 Oct 2023 Stoke on Trent and North Staffordshire
NHS England University Hospital’s of North Midlands
Concerns summary Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.
Action taken summary NHS England references existing national NICE guidance for pressure ulcer prevention and management, including risk assessment within six hours, and states it cannot comment on specific service provis
Jennifer Campbell
All Responded
2023-0404 24 Oct 2023 North West Wales
Betsi Cadwaladr University Health Board
Concerns summary A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.
Action taken summary The Health Board has already implemented a new standing operating procedure for endoscopy referrals, including scanning all paper referrals into an email inbox and recording them on WPAS. They are als
Tracy Gambrill
Partially Responded
2023-0405 24 Oct 2023 South Yorkshire (Western)
Royal College of Surgeons of England Society of British Neurological Surgeons NHS England +1 more
Concerns summary Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions and potential safety risks.
Action taken summary The Society of British Neurological Surgeons has already written to all its members to share details of the case and advise surgeons to reflect on their surgical techniques, specifically regarding gau
Kirsty Hendry
All Responded
2023-0394 20 Oct 2023 Manchester South
NHS England
Concerns summary Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.
Action taken summary NHS England has engaged with the Royal College of General Practitioners and National Association of Primary Care to raise awareness of NICE guidance on subarachnoid haemorrhage, leading to future info
Thomas Doyle
All Responded
2023-0397 20 Oct 2023 East London
Barking, Havering and Redbridge Univers… Department of Health and Social Care
Concerns summary The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.
Action taken summary The Trust has implemented multiple actions to improve record keeping, including sharing internal alerts, developing training videos, and requiring medical staff to complete a record-keeping e-learning
Valerie Simmons
All Responded
2023-0400 20 Oct 2023 Cornwall and the Isles of Scilly
Community Nurse Locality Team Lead
Concerns summary Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.
Action taken summary The Trust plans to update its Basic Observations Policy and Community Nursing Clinical Procedure SOP by early 2024 to include guidance on observations for changes in anti-coagulated patients. They wil
Wayne Milne
Historic (No Identified Response)
2023-0393 19 Oct 2023 Sefton, St Helens and Knowsley
Rocky Lane Medical Centre
Concerns summary Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to fatal delays.
Tracey Rose
All Responded
2023-0387 17 Oct 2023 East Riding and Hull
Hull and East Yorkshire NHS Trust
Concerns summary A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.
Action taken summary The Trust has implemented changes to its electronic prescribing system in May 2023, requiring clinicians to type explanations when overriding serious adverse interaction alerts. Learning from Ms Rose'
Jason Bayley
All Responded
2023-0392 17 Oct 2023 Birmingham and Solihull
St Andrew’s Healthcare
Concerns summary Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.
Action taken summary St Andrew's Healthcare acknowledges discrepancies between ePMA and Rio progress notes, stating they will take actions to improve accuracy of progress notes. However, they assert that the missed medica
Peter Carr
All Responded
2023-0403 13 Oct 2023 North London
Department of Health and Social Care
Concerns summary Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout their inpatient stay.
Action taken summary The Department of Health and Social Care reports that the relevant Trust has developed an inpatient protocol for urgent dermatology referrals and cascaded it to staff, along with updated information o
David Hall
All Responded
2023-0382 12 Oct 2023 Manchester South
One Stockport Health and Care Board
Concerns summary A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic social care shortages.
Action taken summary Stockport Metropolitan Borough Council acknowledges the challenges in finding suitable emergency social care placements, particularly for short-notice needs. The Council outlines its existing approach
John Hoare
All Responded
2023-0384 12 Oct 2023 West Yorkshire (Western)
Low Moor Medical Practice
Concerns summary There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to his death.
Action taken summary Low Moor Medical Practice has revised its lithium prescribing practice, now requiring specific doctors to issue and authorise all prescriptions. They have also revised lithium blood monitoring, with a
Margaret Kelly
All Responded
2023-0375 9 Oct 2023 North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.
Action taken summary The Health Board has established a dedicated project team and is in the 'Stabilisation' phase of a three-phase programme to improve urgent and emergency care provision. They have supported the Emergen
Mark McKessy
All Responded
2023-0377 9 Oct 2023 Manchester South
One Stockport Health and Care Board
Concerns summary Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.
Action taken summary Stockport Integrated Care Partnership plans a joint learning event in January 2024 with all involved agencies to agree a joint action plan for strengthening information sharing and improving practice
Lilian Board
All Responded
2023-0368 5 Oct 2023 Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.
Action taken summary The Trust states its policy of providing a 14-day supply of medication upon discharge is standard practice, agreed with primary care partners, and considered appropriate to prevent harm from medicatio
Iris Fordham
All Responded
2023-0373 5 Oct 2023 East London
Department of Health and Social Care Barts Health NHS Foundation Trust
Concerns summary Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.
Action taken summary The Department of Health and Social Care relays that Barts Health NHS Foundation Trust has agreed to implement several actions, including ensuring up-to-date Enhanced Care Assessments for patients at
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.
Action taken summary The Trust has already developed and shared 'Bitesize' training sessions and re-briefed staff on the Rapid Tranquilisation policy, with plans to incorporate consciousness level monitoring into future t
Marion Luckraft
Historic (No Identified Response)
2023-0355 29 Sep 2023 East London
Barking, Havering and Redbridge Univers…
Concerns summary Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for biliary sepsis collectively increased mortality risk.
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.
Action taken summary The Department of Health and Social Care detailed actions taken by EEAST to improve handover times and implemented national investments to boost ambulance capacity, deliver new vehicles/staff, increas
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.
Action taken summary NHS England collaborated with the MHRA to update and strengthen the wording in the Summary of Product Characteristics and Patient Information Leaflet for Nitrofurantoin, emphasizing vigilance for resp
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.
Action taken summary The Trust has implemented a new electronic radiology request system providing radiologists with direct access to full patient records, with mandatory staff training completed in October 2023. It has a
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.
Action taken summary The Trust has introduced daily Safety Huddles and completed refresher education and training on medication administration. They are updating their Medicines Management policy and competency documentat
Chantelle Reed
All Responded
2023-0349Deceased 21 Sep 2023 Cambridgeshire and Peterborough
NHS England Royal College of Radiologists Royal College of Emergency Medicine
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.
Action taken summary The College disputes that chest pain radiating to the neck or jaw should mandate investigation for Acute Aortic Dissection, citing a lack of specific evidence. They state they have worked with NHS Eng
Lauren Bridges
Historic (No Identified Response)
2023-0466 19 Sep 2023 Manchester South
Dorset Healthcare University NHS Founda…
Concerns summary The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.