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
Kimberley Sampson and Samantha Mulcahy
All Responded
2023-0338 17 Sep 2023 Central and South East Kent
NHS England Royal College of Obstetricians and Gyna…
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.
Action taken summary NHS England notes that the Royal College of Obstetricians and Gynaecologists is updating its sepsis guidelines to include timely identification and treatment of herpes simplex, scheduled for publicati
Eclipse Morrison
Historic (No Identified Response)
2023-0334 15 Sep 2023 Warwickshire
George Eliot Hospital NHS Trust Royal College of Midwives Department of Health and Social Care +2 more
Concerns summary Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.
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.
Action taken summary The Trust has implemented an electronic patient record system (Epic), developed a new discharge summary 'smart set' to improve clarity, and created a standard operating procedure with mandatory fields
Geoffrey Hoad
All Responded
2023-0327 13 Sep 2023 Norfolk
Department of Health and Social Care East of England Ambulance Service NHS T… Spire
Concerns summary Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating call categories.
Action taken summary The Trust has implemented additional recruitment for frontline clinicians and control room staff, established an Unscheduled Care Coordination Hub, and introduced an Operational Performance and Improv
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.
Action taken summary The Department of Health and Social Care is investigating global medical tourism, with officials planning to visit Türkiye to discuss regulatory frameworks and patient protections. The government is a
Isabela Suciu
Partially Responded
2023-0326 12 Sep 2023 Inner South London
British Association Perinatal Medicine Queen Elizabeth Hospital Trust NHS England +1 more
Concerns summary Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
Action taken summary The Trust has developed a new guideline combining NEWTT and Kaiser Permanente scores, amended neonatal notes to clarify pathways, and provided education sessions to maternity and transitional care tea
Amanda Kramer
All Responded
2023-0328 11 Sep 2023 East London
North East London Foundation Trust Department of Health and Social Care Wood Street Medical Centre
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.
Action taken summary The Practice has audited all patients on Zopiclone/Zolpidem, resulting in 69 patients having their medication stopped, and has revised prescribing to acute-only. They have also implemented new dosage
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.
Action taken summary The Trust is currently implementing a Trust-wide electronic prescribing system (Careflow Medicines Management) to reduce transcription errors. They confirm an investment in additional pharmacy staff f
Sultana Choudhury
All Responded
2023-0321 7 Sep 2023 East London
Barts Health NHS Foundation Trust Department of Health and Social Care
Concerns summary Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Action taken summary The Department of Health and Social Care noted the Trust's actions and CQC monitoring, and highlighted national patient safety initiatives. These include the Learn from Patient Safety Events (LFPSE) S
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.
Action taken summary NHS England notes that contraindications for Myasthenia Gravis are available in existing resources. For issues with patients not receiving normal medications in emergency settings, they state new guid
James Jones
Historic (No Identified Response)
2023-0320 6 Sep 2023 North West Wales
Betsi Cadwaladr University Health Board
Concerns summary Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.
Harold Pedley
All Responded
2023-0316 1 Sep 2023 Blackpool & Fylde
Lancashire and South Cumbria Integrated… Department of Health and Social Care
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.
Action taken summary The Trust has implemented changes to its process for accepting direct GP referrals to surgical teams, ensuring the Emergency Department directly communicates patient arrival. The surgical team will al
Donna Levy
All Responded
2023-0315 31 Aug 2023 East London
North East London Foundation Trust Department of Health and Social Care London Borough of Redbridge Council
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.
Action taken summary The Trust has implemented weekly multidisciplinary Complex Case discussion meetings and introduced a new Patient Safety Incident Response Framework. They are also increasing nursing capacity, reviewin
Miss C
Historic (No Identified Response)
2023-0309 25 Aug 2023 Northamptonshire
Resuscitation Council UK Northampton General Hospital Trust
Concerns summary The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
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.
Action taken summary JD Wetherspoon PLC has reviewed its policy regarding CPR training for staff but will not be making any changes, maintaining its 25-year-old policy of immediately calling emergency services for medical
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.
Action taken summary The Trust has circulated a Snapcom reminding staff about good record keeping and introduced a 7-day clinical alert in the digital system for handwritten notes. While the EPMA system lacks an alert for
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.
Action taken summary Newcastle Upon Tyne Hospitals NHS Foundation Trust states that following a Serious Incident Investigation after the inquest, proposals to address learning have been fully implemented. This includes pr
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.
Action taken summary Betsi Cadwaladr University Health Board has written to all ward managers, matrons, and heads of nursing to remind them of paper-based bed rail assessment processes and is finalising an updated Bed Rai
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.
Action taken summary Tees, Esk and Wear Valleys NHS Foundation Trust has embedded a revised serious incident review process, now allocating all reviews within 10 days of an incident and increasing review lead capacity. Th
Leonard King
Partially Responded
2023-0294 14 Aug 2023 Milton Keynes
Urgent Health UK Royal College of General Practitioners Royal College of Emergency Medicine +1 more
Concerns summary Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due to a perception it's a childhood disease. Education is needed for timely recognition.
Action taken summary Urgent Health UK has arranged for all Medical and Nurse Directors of its member organisations to receive a copy of the report and asked them to distribute it to frontline clinicians. The report will a
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.
Action taken summary NHS England states that national guidance for nasogastric decompression tubes exists in the Royal Marsden Manual and that product instructions are the responsibility of manufacturers. They have asked
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.
Action taken summary Milton Keynes University Hospital has finalised amendments to its 'ward nursing care plan for patients following PEG insertion' to improve post-procedure monitoring. They are reviewing the policy to i
Dumile Thompson
Historic (No Identified Response)
2023-0281 2 Aug 2023 West Yorkshire (Eastern)
NHS England NHS National Patient Safety Alerting Co…
Concerns summary Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.
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.
Action taken summary NHS England has published recommendations (October 2022) and hosted a national webinar (March 2023) on imaging report sharing to improve processes across Trusts. They also published a delivery plan (J
Finley May
All Responded
2023-0277 26 Jul 2023 East Riding and Hull
NHS England Royal College of Obstetricians and Gyna…
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.
Action taken summary NHS England will communicate the Royal College of Obstetricians and Gynaecologists' (RCOG) updated June 2023 guidance on Kielland's forceps to Integrated Care Boards. This guidance advises that rotati