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).

Responded 1,777 No Response 18 Historic 613 Pending 30

Action Taken 56%

Action Planned 24%

Noted 14%

Disputed 6%

Based on 1,159 classified responses

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PFD Reports

1,516 results

Agnes Lambert

2018-0410 17 Dec 2018 London Inner (North)

Camden & Islington NHS Trust

Concerns summary Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.

Neil Swaisland

2018-0385 12 Dec 2018 Milton Keynes

Milton Keynes Clinical Commissioning Gr… Milton Keynes Council

Concerns summary The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.

Matthew Craven

2018-0365 22 Nov 2018 Manchester (South)

Pennine Care NHS Trust

Concerns summary A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.

Dawn Gill

2018-0354 16 Nov 2018 London Inner (North)

Royal London Hospital

Concerns summary The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart was lost, and there was a concerning delay in locating her despite multiple searches.

Matthew Arkle

2018-0361 13 Nov 2018 Suffolk

Norfolk and Suffolk NHS Trust

Concerns summary Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions and lack of CCTV review policy contributed to the incident.

Gerwyn Thomas

2018-0342 6 Nov 2018 Camarthenshire and Pembrokeshire

West Wales General Hospital

Concerns summary Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate patient nutrition.

Dorothy Strickley

2018-0305 31 Oct 2018 Leicester City and Leicestershire South

University of Leicester Hospitals NHS T…

Concerns summary Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in staff training and discharge documentation protocols.

Elizabeth Self

2018-0308 29 Oct 2018 South Yorkshire (West)

Concerns summary Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant delays in diagnosis.

Eileen Cooke

2018-0311 25 Oct 2018 West Yorkshire (East)

Mid Yorkshire Hospitals NHS Trust

Concerns summary A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a systemic problem with hasty discharges.

Kalma Ram-Henman

2018-0306 23 Oct 2018 Brighton and Hove

Brighton & Sussex University Hospitals …

Concerns summary Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.

Michael Wheeler

2018-0414 4 Oct 2018 Birmingham and Solihull

Birmingham Clinical Commissioning Group NHS England

Concerns summary Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, overstretching Home Treatment Teams.

Theresa Button

2018-0333 3 Oct 2018 West Yorkshire (East)

Leeds Teaching Hospitals NHS Trust

Concerns summary Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.

Michael Hopkins

2018-0331 1 Oct 2018 West Yorkshire (West)

Bradford Teaching Hospitals NHS Trust

Concerns summary Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.

Joan Blaber

2024-0090 1 Oct 2018 West Sussex, Brighton and Hove

Brighton and Sussex University NHS Hosp…

Concerns summary Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.

Mary Ryder

2018-0323 27 Sep 2018 Manchester (South)

Department of Health and Social Care

Concerns summary Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.

Sheila Hadfield

2018-0334 27 Sep 2018 Manchester (South)

Department of Health and Social Care

Concerns summary A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling to meet the patient's requirements.

Bridget Marie Connell-Graham

2018-0297 26 Sep 2018 Manchester (South)

Department for Health

Concerns summary The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking premature births.

Annette Hill

2024-0602 21 Sep 2018 Avon

Southmead Hospital

Concerns summary An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.

Michael Drewell

2018-0259 30 Aug 2018 West Yorkshire (Eastern)

Leeds Teaching Hospitals NHS Trust

Concerns summary A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.

Karl Willis

2018-0256 24 Aug 2018 Exeter and Greater Devon

Concerns summary "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.

Patricia Cragg

2018-0255 23 Aug 2018 Plymouth Torbay and South Devon

Plymouth Hospitals NHS Trust

Concerns summary The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy to guide responses.

Louie Bradley

2018-0261 21 Aug 2018 Manchester (West)

Royal Bolton Hospitals NHS Trust

Concerns summary Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently omitted from standard Trust documentation.

Enric Elliott

2018-0300 14 Aug 2018 London Inner (West)

Whittington Health NHS Trust

Concerns summary Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, despite late booking indicating increased risk.

Flora Baber

2018-0229-wp26369 13 Aug 2018 London Inner (North)

Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS Trust

Concerns summary Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical failure to record opioid sensitivity across healthcare providers.

Deidre Harvey

2018-0266 8 Aug 2018 South Wales Central

British National Formulary Cwm Taf University Health Board Welsh Government +3 more

Concerns summary External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing dangerous patient items was ineffective.