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

1,516 results

Kalila Griffiths

2020-0299 18 Dec 2020 East London

Concerns summary Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.

Andrew Gibbins

2020-0290 17 Dec 2020 Suffolk

Norfolk and Suffolk Foundation Trust West Suffolk Hospital and The Wedgewood…

Concerns summary A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.

Robert Goodman

2020-0285 15 Dec 2020 Hampshire, Portsmouth and Southampton

University Hospital Southampton NHS Fou…

Concerns summary The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within 8 hours for patients on any anticoagulant, leading to delayed diagnosis.

Eddie Coffey

2020-0287 15 Dec 2020 Hertfordshire

Department of Health and Social Care East and North Hertfordshire NHS Trust

Concerns summary The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring during labour. Concerns remain about current training and the use of incorrect guidelines in maternity units.

Don Fernandes

2021-0172 15 Dec 2020 Oxfordshire

Oxford University Hospitals NHS Foundat…

Concerns summary Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce x-ray exposure led to confusion about the need for confirmation, risking tube misplacement.

Christopher Swain

2020-0284 14 Dec 2020 West Sussex

Sussex Partnership NHS Foundation Trust

Concerns summary Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.

Katy Samuels

2020-0282 11 Dec 2020 Coventry

Chief Executive and Mental Health lead …

Concerns summary The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.

Claire Lilley

2020-0297 11 Dec 2020 Inner London South

Oxleas NHS Trust

Concerns summary Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.

Shyama Rampadaruth

2021-0005 11 Dec 2020 Inner North London

Whipps Cross Hospital

Concerns summary A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.

Kimberley Smith

2020-0279 9 Dec 2020 Surrey

Surrey and Borders Partnership NHS Foun…

Concerns summary The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.

Leslie Harris

2020-0280 9 Dec 2020 Manchester South

NHS England Public Health England

Concerns summary The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.

Peter Unsworth

2020-0267 1 Dec 2020 Surrey

General Medical Council and St. Peter’s… NHS Improvement Royal College of Physicians +1 more

Concerns summary Critical consultant advice on a complex medical situation was neither recorded in writing nor confirmed, risking misunderstandings between medical teams.

Brandon-Robert Collins-Hayward

2021-0088 1 Dec 2020 Dorset

Royal College of Obstetricians and Gyna… Royal College of Paediatrics and Child …

Concerns summary Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential sepsis creates future death risks.

Eleanor Sherman

2020-0254 26 Nov 2020 Warwickshire

Warwick Hospital

Concerns summary Repeated misdiagnoses occurred at the hospital, despite clear GP instructions, due to systemic failures in accessing electronic patient records and slow scanning of notes.

Yo Li

2020-0245 19 Nov 2020 Surrey

NHS England British Association of Perinatal Medici…

Concerns summary National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement for NHS Trusts to ensure clinician familiarity or policy compliance with existing guidelines.

Katherine Hogan

2020-0243 18 Nov 2020 Mid Kent and Medway

Maidstone and Tunbridge Wells NHS Found…

Concerns summary Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to address reported staffing issues or implement requested increases.

Carolyne Senior

2020-0231 11 Nov 2020 South Yorkshire (West)

Barnsley Hospital NHS Foundation Trust

Concerns summary Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.

Margaret Sales

2020-0233 11 Nov 2020 Norfolk

Queen Elizabeth Hospital

Concerns summary Incomplete patient records, difficulty contacting on-call medical staff, and a critical failure to refer the patient for post-discharge monitoring created significant care gaps.

Leslie Clewarth

2020-0229 10 Nov 2020 West Yorkshire

Mid Yorkshire Hospitals NHS Trust

Concerns summary Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.

Stanley Babbs

2020-0225 6 Nov 2020 East London

Queen’s Hospital

Concerns summary Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.

Linda Doherty

2020-0224 5 Nov 2020 Surrey

Surrey and Sussex Healthcare NHS Trust

Concerns summary Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary team consultation.

Ann Smith

2020-0223 5 Nov 2020 Essex

Princess Alexandra Hospital

Concerns summary There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.

Clara Moniatis

2020-0221 3 Nov 2020 Essex

Barts and Whipps Trust

Concerns summary Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.

Michael Robert Collins

2021-0092 30 Oct 2020 East London

Royal London Hospital

Concerns summary The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.

Sarah Gibbs

2020-0220 29 Oct 2020 Norfolk

Norfolk and Norwich University Hospital

Concerns summary Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.