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
Christine Nakafeero
All Responded
2023-0270 24 Jul 2023 East London
NHS England Barts Health NHS Foundation Trust Department of Health and Social Care
Concerns summary A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key risk factors.
Action taken summary Barts Health NHS Trust is implementing a fully electronic outpatient outcome system and rolling out LUNA, a digital monitoring tool for patient tracking lists, to prevent patients from being lost to f
Alan Nippard
All Responded
2023-0276 24 Jul 2023 Avon
Royal United Hospitals
Concerns summary Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient patient repositioning.
Action taken summary The Trust has implemented extensive face-to-face training for all nursing, physiotherapy, and occupational therapy staff on Pierce Ward, focusing on pressure sore prevention, risk assessment, and the
Thomas Barton
All Responded
2023-0264 21 Jul 2023 Manchester South
Department of Health and Social Care Greater Manchester Integrated Care
Concerns summary Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.
Action taken summary Greater Manchester Integrated Care reports that Trafford Council has redesigned its homecare offer and identified discharge barriers. NHS GM has funded home from hospital support, completed capacity a
Marion Nickson
All Responded
2023-0265 21 Jul 2023 Manchester South
Care Quality Commission NHS England
Concerns summary Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that hinder effective falls prevention.
Action taken summary NHS England highlights its National Audit of Inpatient Falls programme and the 'FallSafe' e-learning module, and reports engaging with the Greater Manchester ICP on local actions. It notes that Stockp
Corinne Haslam
Partially Responded
2023-0266 21 Jul 2023 Manchester South
Department of Health and Social Care Pennine Care NHS Foundation Trust
Concerns summary Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient safety risks.
Action taken summary The Department of Health and Social Care acknowledges concerns regarding physical healthcare in mental health settings and electronic patient record compatibility. It notes that shared care records ar
Peter Harris
All Responded
2023-0260 20 Jul 2023 City of London
Barking, Havering and Redbridge Univers…
Concerns summary Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.
Action taken summary The Trust has added an additional section to its Radiology Reporting Guidelines for "Expected Cancer" to ensure all cancer findings are alerted to referrers. A new Fail-Safe Radiology Result Communica
Marianne Erika
All Responded
2023-0262 20 Jul 2023 Manchester South
NHS England
Concerns summary Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.
Action taken summary NHS England refers to its 'Delivery plan for recovering urgent and emergency care services' (January 2023) and reports that the Greater Manchester Imaging Network has funded reporting radiographers an
Albert Dovey
All Responded
2023-0263 20 Jul 2023 Manchester South
NHS England
Concerns summary Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after a fall.
Action taken summary NHS England has implemented a 2-year delivery plan for urgent and emergency care recovery, including increasing ambulance service capacity, achieving targets for 5,000 more staffed hospital beds and o
Andrew Vizard
Historic (No Identified Response)
2023-0273 20 Jul 2023 Nottinghamshire
Nottingham Healthcare Trust
Concerns summary Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Carole McQuinn
All Responded
2023-0253 19 Jul 2023 North Yorkshire and York
Leeds Teaching hospitals and York Hospi…
Concerns summary Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.
Action taken summary The Trust plans to expedite the update of its clinical record-keeping guidance by February 2024, draft a patient safety briefing on documenting clinical communications for all staff by September 2023,
Evelyn Dutton
All Responded
2023-0254 19 Jul 2023 Manchester South
NHS England
Concerns summary Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their health.
Action taken summary NHS England has implemented the Delivery plan for recovering urgent and emergency care services, published a UEC Good Practice Guide, and committed additional funding for hospital discharge, resulting
Thelma Radmore
All Responded
2023-0256 19 Jul 2023 Manchester South
Department of Health and Social Care
Concerns summary Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail patients.
Action taken summary The Department of Health and Social Care outlined actions already taken, including significant funding for increased bed capacity and virtual wards, leading to observed improvements in ambulance respo
Michael Amesbury
All Responded
2023-0259 19 Jul 2023 Manchester South
Greater Manchester Integrated Care
Concerns summary Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.
Action taken summary NHS Greater Manchester has implemented a regional digital referral and advice solution called "Patient Pass" to improve patient pathways and information sharing between trusts. This system, which is b
Shane West
All Responded
2023-0267 19 Jul 2023 Swansea Neath Port Talbot
Swansea Bay University Health Board
Concerns summary Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Action taken summary Swansea Bay University Health Board plans to review its nursing and medical recording systems and remind staff about accurate medication record-keeping, appropriate assessment of patients with learnin
Philip Hawkins
Historic (No Identified Response)
2023-0248 18 Jul 2023 North Wales East and Central
Welsh Ambulance Service Trust Betsi Cadwaladr University Health Board
Concerns summary Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.
Ronald Ashdown
All Responded
2023-0249 18 Jul 2023 Essex
Mid and South Essex NHS Foundation Trust
Concerns summary A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Action taken summary The Trust has introduced a new Personal Care Policy and Best Practice Guidance for Documentation. They have also implemented a new quality assurance process for investigations, including uploading all
Colin Greenway
All Responded
2023-0252 18 Jul 2023 Norfolk
Queen Elizabeth Hospital
Concerns summary Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.
Action taken summary The Trust removed outdated VTE guidelines, replaced them with NICE guidance, mandated VTE-specific online training for new junior doctors, and introduced a Junior Doctor Dashboard to monitor performan
Christine Dickinson
All Responded
2023-0255 18 Jul 2023 Manchester South
Stockport NHS Foundation Trust
Concerns summary Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Jane Wadsworth
All Responded
2023-0251Deceased 17 Jul 2023 Manchester South
Tameside and Glossop Integrated Care NH… NHS England
Concerns summary Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.
Action taken summary NHS England acknowledged the report but stated the concerns fall under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust. They noted the Trust is implementing improvement work and
John James
All Responded
2023-0242 11 Jul 2023 East London
Barts Health NHS Foundation Trust
Concerns summary A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.
Action taken summary Barts Health NHS Trust will update Millennium training to ensure multi-professional teams know how to use the electronic prescribing system's flag for delayed medication. They are also developing a me
Christopher Smith
All Responded
2023-0420 7 Jul 2023 Nottingham City and Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.
Gordon Renfrew
All Responded
2023-0230 6 Jul 2023 Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.
Elizabeth Agbejimi
All Responded
2023-0232 6 Jul 2023 Lincolnshire
REDACTED
Concerns summary A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.
Victoria Storey
Partially Responded
2023-0222 30 Jun 2023 Surrey
Ministry of Justice Department of Health and Social Care
Concerns summary A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a Class A, Schedule 1 drug, despite official advice for its urgent inclusion.
Matthew Phipps
Historic (No Identified Response)
2023-0219 29 Jun 2023 East London
Barking, Havering and Redbridge Univers…
Concerns summary The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.