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). 56% of classified responses show concrete action taken. Reports rose 33% from 176 (2023) to 234 (2024).

Response Status
Responded 1,777 No Response 18 Historic 613 Pending 30
AI Classification
Action Taken 56%
Action Planned 24%
Noted 14%
Disputed 6%
Based on 1,159 classified responses
Reports by Quarter
PFD Reports
2,483 results
Yusuf Seyit
All Responded
2021-0111 16 Apr 2021 London Inner South
University Hospital Lewisham
Concerns summary A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a critical antibiotic was not confirmed.
Saima Hussain Mann
All Responded
2021-0109 15 Apr 2021 Manchester South
Greater Manchester Mental Health NHS Fo…
Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.
Ann Coles
All Responded
2021-0101 13 Apr 2021 County of Surrey
Royal College of GPs Royal College of Physicians
Concerns summary A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.
Anthony Wilkinson
All Responded
2021-0102 13 Apr 2021 South Yorkshire (West District)
South West Yorkshire Partnership NHS Fo… Care Quality Commission Stars Social Support Ltd
Concerns summary The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.
Gary Day
All Responded
2021-0107 13 Apr 2021 Inner North London
Moorfields Eye Hospital NHS Foundation …
Concerns summary Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.
Janet Willcock
All Responded
2021-0105 9 Apr 2021 City of Brighton & Hove
University Hospitals Sussex NHS Foundat…
Concerns summary Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered an urgent cardiology referral.
Imre Thomas
Historic (No Identified Response)
2021-0097 4 Apr 2021 Lancashire and Blackburn with Darwen
NHS England
Concerns summary Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.
Joan Coley
Partially Responded
2021-0093 31 Mar 2021 Birmingham and Solihull
UK Foundation Programme Sandwell and West Birmingham Hospitals … Birmingham Medical School +3 more
Concerns summary Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor handover between wards, create inherent safety risks.
Steven Costello
All Responded
2021-0095 31 Mar 2021 West Sussex
Brighton and Sussex University Hospital…
Concerns summary Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff training.
Nicholas Winterton
Partially Responded
2021-0204 31 Mar 2021 City of London
Public Health England National Institute for Cardiovascular O… Society for Cardiothoracic Surgery +1 more
Concerns summary The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.
Roy Morris
All Responded
2021-0094 29 Mar 2021 Buckinghamshire
Oxford Health NHS Foundation Trust
Concerns summary Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.
Nicholas Rousseau
All Responded
2021-0087 28 Mar 2021 Milton Keynes
Milton Keynes University Hospital
Concerns summary Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack of standardized care.
Bathsheba Shepherd
Historic (No Identified Response)
2021-0099 28 Mar 2021 London (West)
Central and North West London NHS Found…
Concerns summary Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to a lack of documentation pose ongoing risks.
Sheldon Farnell
All Responded
2021-0081 25 Mar 2021 City of Sunderland
Department of Health and Social Care
Concerns summary Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Azra Hussain
All Responded
2021-0082 25 Mar 2021 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Care Commissioning Group for Birmingham… Care Quality Commission +1 more
Concerns summary Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.
Sean Fegan
All Responded
2021-0083 25 Mar 2021 Nottingham City and Nottinghamshire
Change Grow Live GP Nottinghamshire County Council +1 more
Concerns summary Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading to misinterpretation of needs.
Ben O’Hara
All Responded
2021-0077 17 Mar 2021 Inner North London
St Pancras Hospital
Concerns summary Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care coordinator, hindering comprehensive mental health care.
Timothy Steele
Historic (No Identified Response)
2021-0076 15 Mar 2021 City of Brighton and Hove
Sussex Partnership NHS Foundation Trust
Concerns summary Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).
Jamie Poole
All Responded
2021-0075 15 Mar 2021 Stoke-on-Trent & North Staffordshire Coroner’s Court
NHS England
Concerns summary It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.
Elizabeth Robinson
All Responded
2021-0072 12 Mar 2021 Gwent
Aneurin Bevan University Health board
Concerns summary Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Emma Dorman
All Responded
2021-0071 11 Mar 2021 West Yorkshire, Western Division
South West Yorkshire Partnership
Concerns summary Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
Rodney Gates
All Responded
2021-0070 8 Mar 2021 Mid Kent and Medway
Medway Maritime Hospital
Concerns summary Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.
Grazyna Walczak
All Responded
2021-0063 4 Mar 2021 Inner North London
St Pancras Hospital
Concerns summary The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
Paula Speirs
All Responded
2021-0064 4 Mar 2021 Inner North London
Weymouth Street Hospital
Concerns summary There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.
Averil Hart
All Responded
2021-0058 3 Mar 2021 Cambridgeshire and Peterborough
Academy of Medical Medical Royal Colleg… General Medical Council NHS England +1 more
Concerns summary Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.