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).

Responded 1,777 No Response 17 Historic 613 Pending 31

Action Taken 54%

Action Planned 24%

Noted 15%

Disputed 7%

Based on 960 classified responses

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PFD Reports

613 results

Susan Poore

Historic (No Identified Response)

2014-0140 28 Mar 2014 Norfolk

Concerns summary Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.

Phyllis Barnes

Historic (No Identified Response)

2014-0138 24 Mar 2014 Surrey

Royal College of Surgeons North East Hampshire and Farnham Clinic… Frimley Park Hospital NHS Trust

Concerns summary A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.

Norma Sheppard

Historic (No Identified Response)

2014-0129 21 Mar 2014 Staffordshire South

Queens Hospital Burton Upon Trent

Concerns summary Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, with conflicting information between the written discharge and verbal understanding.

Christopher Williams

Historic (No Identified Response)

2014-0131 19 Mar 2014 Cheshire

St Mary’s Hospital Warrington

Concerns summary A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.

Charles Bradley

Historic (No Identified Response)

2014-0118 17 Mar 2014 Liverpool

Arrowe Park Hospital

Concerns summary Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.

Matthew Simmonds

Historic (No Identified Response)

2014-0119 14 Mar 2014 Hampshire (Central)

Concerns summary An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.

Noel Williams

Historic (No Identified Response)

2014-0123 13 Mar 2014 Teesside

South Tees NHS Trust

Concerns summary A critical failure occurred in communicating recent haemoglobin test results to the surgical team. This information was vital for assessing surgical fitness and could have altered treatment or delayed surgery.

Afifa Qaisar

Historic (No Identified Response)

2014-0107 11 Mar 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.

John Fox

Historic (No Identified Response)

2014-0098 5 Mar 2014 : London Inner (West)

St George’s Hospital

Concerns summary Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.

Barry Dillion

Historic (No Identified Response)

2014-0099 5 Mar 2014 Blackburn, Hyndburn & Ribble Valley

East Lancashire Healthcare NHS Trust

Concerns summary Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.

Nellie Travis

Historic (No Identified Response)

2014-0101 5 Mar 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.

Stephen Ellis

Historic (No Identified Response)

2014-0102 5 Mar 2014 Manchester (South)

Department of Health and Social Care

Concerns summary A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.

Kirabo Kiwanuka

Historic (No Identified Response)

2014-0088 3 Mar 2014 London (Inner South)

Royal College of Psychiatrists Royal College of Physicians

Concerns summary Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.

Margaret Easterfield

Historic (No Identified Response)

2014-0091 3 Mar 2014 Kent (South East & Central)

East Kent University Hospital

Concerns summary A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.

Maureen Leaver

Historic (No Identified Response)

2014-0036 27 Feb 2014 West Sussex

Sussex Partnership NHS Foundation Trust

Concerns summary Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.

Herta Woods

Historic (No Identified Response)

2014-0081 26 Feb 2014 Brighton & Hove

Brighton and Sussex University Hospitals

Concerns summary Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.

Stephen Palmer

Historic (No Identified Response)

2014-0072 25 Feb 2014 Brighton & Hove

Brighton and Sussex University Hospitals

Concerns summary Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.

James Sutton

Historic (No Identified Response)

2014-0090 24 Feb 2014 London (North)

Department of Health and Social Care

Concerns summary The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.

Simon McAndrew

Historic (No Identified Response)

2014-0067 19 Feb 2014 London (North)

Central and North West London NHS Found…

Concerns summary Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack of effective care coordination.

Lisa Inkin

Historic (No Identified Response)

2014-0062 13 Feb 2014 London Inner (West)

Kent and Medway Mental Health Directora… Cygnet Health Care NHS England

Concerns summary A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and insufficient supervision for eating disorder patients.

Georgina Swindells

Historic (No Identified Response)

2014-0060 12 Feb 2014 London Inner (North)

Radiology Reporting Online LLP University College London Hospitals NHS…

Concerns summary Unexplained image transfer delays, lack of data for investigation, absence of backup systems, and unclear causes for erroneous scan reports indicate systemic failures in radiology services, risking recurrence and misdiagnosis.

Keith Martin

Historic (No Identified Response)

2014-0055 5 Feb 2014 Surrey

St Peter’s and Ashford Hospitals

Concerns summary Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.

Scarlett Sinclair

Historic (No Identified Response)

2014-0059 3 Feb 2014 Avon

Oxford University Hospitals NHS Trust

Concerns summary The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an unstable condition.

Ryan Chapman

Historic (No Identified Response)

2014-0048 31 Jan 2014 West Sussex

Sussex Partnership NHS Trust

Concerns summary Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.

William Kent

Historic (No Identified Response)

2014-0056 31 Jan 2014 Surrey

Medicines and Healthcare products Regul… Guest Medical St Peter’s and Ashford Hospitals

Concerns summary Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.