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
Stuart Tokam
Partially Responded
2021-0271 13 Aug 2021 East London
St Pancras Hospital Department of Health and Social Care
Concerns summary There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited assessment for urgent cases.
Alice Pettersson
Historic (No Identified Response)
2021-0267 10 Aug 2021 Inner West London
Department of Health and Social Care
Concerns summary The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.
Terence Tuttle
Partially Responded
2021-0265 9 Aug 2021 Norfolk
Hellesdon Hospital Queen Elizabeth Hospital
Concerns summary Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, excluding family expertise.
Mary Lincoln
All Responded
2021-0275 2 Aug 2021 West Yorkshire (East)
Pinderfields General Hospital
Concerns summary The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated or understood by all relevant staff.
James Nowshadi
All Responded
2021-0260 29 Jul 2021 Cambridgeshire and Peterborough
Department of Health and Social Care Royal College of Psychiatrists Public Health England
Concerns summary Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future fatalities.
Jacob Owczarek
Partially Responded
2021-0259 28 Jul 2021 Nottinghamshire
Care Quality Commission Doncaster and Bassetlaw Teaching Hospit…
Concerns summary Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert systems for test results, along with poor recording of radiology discussions.
Ben King
All Responded
2021-0250 20 Jul 2021 Norfolk
Norfolk and Norwich University Hospital Jeesal Residential Care Services
Concerns summary The provided text is a generic statement of concern, without specifying the particular matters that led to the risk of future deaths.
Rebecca Pykett
All Responded
2021-0264 17 Jul 2021 Stoke-on-Trent & North Staffordshire Coroner’s Court
North Staffordshire Combined Healthcare… NHS England
Concerns summary The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.
Brian Jackson
Partially Responded
2021-0246 16 Jul 2021 Liverpool and Wirral
National Institute for Health and Care … Liverpool Heart and Chest Hospital
Concerns summary Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
Chimezie Daniels
All Responded
2021-0255 16 Jul 2021 Inner North London
NHS Improvement NHS England Medicines and Healthcare products Regul…
Concerns summary CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with multiple alarms.
Fred Reynolds
All Responded
2021-0241 15 Jul 2021 Mid Kent and Medway
Kent and Medway Social Care Partnership…
Concerns summary Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the patient's condition.
Catherine Best
All Responded
2021-0244 15 Jul 2021 Swansea, Neath & Port Talbot
Swansea Bay University Health Board
Concerns summary An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
Henry Holcombe
All Responded
2021-0257 15 Jul 2021 Brighton & Hove
Sussex Partnership Foundation NHS Trust
Concerns summary The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Rhian Roberts
Historic (No Identified Response)
2021-0242 14 Jul 2021 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.
Jonathan Kingsman
All Responded
2021-0238 13 Jul 2021 Cambridgeshire & Peterborough
Department of Health and Social Care
Concerns summary The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.
Valmai West
All Responded
2021-0239 13 Jul 2021 Gwent
Aneurin Bevan University Health Board
Concerns summary Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Abiodun Oritogun
All Responded
2021-0248 13 Jul 2021 London Inner South
University Hospital Lewisham
Concerns summary Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by capacity, not clinical need.
Stephen Walker
All Responded
2021-0254 12 Jul 2021 Inner North London
Royal Free Hospital
Concerns summary Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate systemic failures in patient care and information management.
Johanna Moreland
All Responded
2021-0240 11 Jul 2021 Mid Kent and Medway
Medway NHS Foundation Trust
Concerns summary Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols were not followed due to miscommunication and poor record-keeping.
Maria Stancliffe-Cook
All Responded
2021-0235 8 Jul 2021 Avon
Department of Health and Social Care Avon and Wiltshire Mental Health Partne…
Concerns summary A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the care coordinator and a recent suicide attempt.
Benjamin Clark
All Responded
2021-0236 8 Jul 2021 Newcastle Upon Tyne and North Tyneside
Northumbria Health Care Trust
Concerns summary Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity in observation levels, suboptimal note-keeping, and insufficient daily reassessment of falls risk.
Brian Rochell
Historic (No Identified Response)
2021-0229 7 Jul 2021 South Yorkshire (West District)
Sheffield Teaching Hospitals NHS Founda…
Concerns summary Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. This delay in addressing competence issues poses a risk to future patients.
Kishorkumar Patel and Kofi Aning
All Responded
2021-0233 7 Jul 2021 East London
Royal College of Anaesthetists Faculty of Intensive Care Medicine
Concerns summary The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This lack of simplification and standardisation risks incorrect filter usage and patient safety.
Brooke Martin
All Responded
2021-0299 2 Jul 2021 Milton Keynes
Department of Health and Social Care
Concerns summary Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises risk assessments and specialist care.
Katie Locke
Historic (No Identified Response)
2021-0222 29 Jun 2021 Hertfordshire
Hertfordshire Constabulary Hertfordshire Partnership University NH… National Probation Service
Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.