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 1,780 No Response 16 Historic 613 Pending 29

Action Taken 54%

Action Planned 24%

Noted 15%

Disputed 7%

Based on 960 classified responses

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PFD Reports

1,519 results

Amy Allan

2019-0343 30 Sep 2019 London Inner (North)

Great Ormond Street Hospital NHS Trust

Concerns summary Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.

Anthony McCormack

2019-0317 27 Sep 2019 Birmingham and Solihull

Birmingham and Solihull Mental Health N…

Concerns summary A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked resources for adequate patient assessment and monitoring.

John Shrosbree

2019-0260-wp26754 26 Sep 2019 Milton Keynes

Milton Keynes University Hospital

Concerns summary Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.

Daniel Williams

2019-0309 24 Sep 2019 London Inner (South)

St Thomas NHS Foundation Trust

Concerns summary Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.

Annette Hewins

2019-0310 24 Sep 2019 South Wales Central

Cwm Taf Morgannwg University Health Boa…

Concerns summary Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, and poor detail in patient observation charts indicate significant training and procedural failures.

Rebecca Marshall

2019-0313 24 Sep 2019 London Inner (South)

Kent and Medway NHS and Social Care Tru…

Concerns summary The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of future deaths related to hospital and mental health care.

Muhammed Haleem

2019-0316 24 Sep 2019 Manchester (North)

North west Ambulance Service Pennine Care NHS Trust

Concerns summary The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.

Francis Hodge

2019-0338 24 Sep 2019 London Inner (South)

University Hospital Lewisham

Concerns summary Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the absence of a patient information leaflet.

Ian Bromley

2019-0307 19 Sep 2019 Manchester (South)

Pennine Care NHS Trust

Concerns summary The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was inconsistently effective due to varying individual approaches and workloads.

Blaithin Buckley

2019-0465 16 Sep 2019 Northamptonshire

General Council

Concerns summary An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.

William Oliver

2019-0494 12 Sep 2019 Manchester (North)

Blackpool Clinical Commissioning Group Department of Health and Social Care North West Ambulance Service

Concerns summary The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround times, leading to significant delays.

Maureen Jarvis

2019-0357 11 Sep 2019 Staffordshire South

Midland Partnership NHS Trust

Concerns summary A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, disseminated policy on physical health examinations for admitted psychiatric patients.

Tillie Spencer-Adams

2019-0356 5 Sep 2019 Hertfordshire

East and North Hertfordshire NHS Trust

Concerns summary Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.

Kim Morris

2019-0261 27 Aug 2019 Leicester City and Leicestershire

Leicester NHS Trust

Concerns summary A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, causing distress and inadequate support prior to discharge.

Christopher Summerhayes

2019-0263 22 Aug 2019 South Wales Central

Cardiff & Vale University Health Board

Concerns summary Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.

Tony Dunne

2019-0265 20 Aug 2019 London Inner (North)

East London NHS Trust

Concerns summary A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge from the emergency department for intending to jump, missing a critical intervention opportunity.

Thelma Joyce

2019-0500 20 Aug 2019 Oxfordshire

Concerns summary The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.

Geraint Hughes

2019-0268 18 Aug 2019 Cornwall and the Isles of Scilly

Cornwall Partnershipship NHS Trust

Concerns summary Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not identified by supervisory reviews.

David Smith

2019-0271 14 Aug 2019 Manchester (City)

Manchester University NHS Trust

Concerns summary Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.

Prabhaker Kapoor

2019-0278 6 Aug 2019 Birmingham and Solihull

University Hospitals Birmimgham NHS Tru…

Concerns summary Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause Analysis report.

Carol Jennings

2019-0279 2 Aug 2019 Norfolk

Queen Elizabeth Hospital

Concerns summary Inadequate and unchased referrals to the Tissue Viability Nurse, combined with systemic failures in detailed wound record-keeping, led to delayed and insufficient care for severe leg ulcers.

Gladys Borgogno

2019-0286 31 Jul 2019 Stoke-on-Trent & North Staffordshire

University Hospital of North Midlands

Concerns summary Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical attention for post-discharge vomiting.

Alex Blake

2019-0259 29 Jul 2019 London Inner (South)

NHS Professionals Ltd Nursing and Midwifery Council

Concerns summary Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.

Gladys Sayles

2019-0253 26 Jul 2019 West Yorkshire (West)

Leeds Teaching Hospitals NHS Trust

Concerns summary Guidelines for Aspen collar use, bespoke training for application, and communication between healthcare providers and suppliers regarding fitting and patient care all require urgent review and improvement.

Allan Joslin

2019-0241 17 Jul 2019 Exeter and Greater Devon

Concerns summary There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack of formal assessment and treatment, contravening equality legislation.