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). 55% 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 55%
Action Planned 24%
Noted 15%
Disputed 7%
Based on 652 classified responses
Reports by Quarter
PFD Reports
2,483 results
Raymond Leake
All Responded
2025-0546 28 Oct 2025 East Riding of Yorkshire and City of Kingston Upon Hull
Hull Royal Infirmary
Concerns summary An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Action taken summary Hull Royal Infirmary implemented new controls in March 2025 including automatic porter dispatch and direct ward contact for urgent scans. They have now completed an initial audit of CT head scan compl
Louisa Walker (1)
All Responded
2025-0543 27 Oct 2025 Berkshire
Royal College of Obstetricians and Gyna…
Concerns summary There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Action taken summary Maternity Newborn Safety Investigations (MNSI) reviewed its investigation process and confirmed it was correctly followed based on available evidence. The organisation has added a note to its investig
Louisa Walker (2)
All Responded
2025-0544 27 Oct 2025 Berkshire
Royal Berkshire Hospital
Concerns summary A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient safety.
Action taken summary Following the inquest, the Trust has ensured all obstetric doctors (ST1 and above, Consultants) and Band 7 delivery suite and maternity clinical coordinator midwives have been trained in managing Impa
Sophie Towle
Partially Responded
2025-0552 24 Oct 2025 Nottingham and Nottinghamshire
Department of Health and Social Care Nottingham Healthcare NHS Foundation Tr… Sherwood Forest Hospitals NHS Foundatio…
Concerns summary There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the specialist Personality Disorder Hub was disbanded, reducing expert care.
Action taken summary Nottinghamshire Healthcare has collaborated with Sherwood Forest Hospital to create a joint management policy for patients with inserted foreign bodies, which is currently being trialled. The Trust ha
Stephen Neville
All Responded
2025-0556 24 Oct 2025 Essex
Essex Partnership NHS Foundation Trust
Concerns summary Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical observations were also found to be severely inadequate.
Action taken summary The Trust has updated its Observation Policy and a new training module, rolled out to all clinical staff by December 2025, with a new observation proforma also being implemented. It has also commissio
Mark Foster
All Responded
2025-0537 23 Oct 2025 Cumbria
Castlegate & Derwent Surgery
Concerns summary The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Action taken summary The surgery has appointed a new practice manager and GP partner for governance, implemented a new governance structure, and revised its Significant Event Policy. All staff are now instructed to report
Lynn Silcock
All Responded
2025-0636 23 Oct 2025 Shropshire, Telford & Wrekin
Shrewsbury and Telford NHS Hospital Tru… NHS England
Concerns summary A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.
Action taken summary NHS England states the specific issues raised fall outside its direct role and remit, primarily resting with Shrewsbury and Telford Hospital NHS Trust (SATH). It notes its existing national Frontline
Rashida Sultana
All Responded
2026-0026 23 Oct 2025 Black Country
Sandwell and Birmingham Hospital NHS Tr…
Concerns summary Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk assessments for Speech and Language Therapy referrals for dysphagia.
Action taken summary The organisation has approved and implemented an updated 'Emergency Medical Response Policy including Management of Resuscitation' in March 2025, which outlines systems, processes, and structures for
John Rust
All Responded
2025-0524 20 Oct 2025 Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future clinical staff receive essential training on critical equipment.
Action taken summary The response text is truncated; therefore, no actions taken or planned regarding mandatory training for CSF drainage systems can be identified.
Mohan Hothi
No Identified Response
2025-0513 14 Oct 2025 East London
Barking, Havering and Redbridge Univers…
Concerns summary The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
David Jones
All Responded
2025-0514 14 Oct 2025 Nottingham and Nottinghamshire
Nottingham University Hospitals NHS Tru…
Concerns summary The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.
Action taken summary Nottingham University Hospitals NHS Trust has launched an Acute Aortic Dissection Improvement project, which will be undertaken by a newly formed Acute Aortic Dissection Improvement Group. This group
William Roath
All Responded
2025-0518 14 Oct 2025 Worcestershire
University Hospitals Birmingham NHS Fou…
Concerns summary A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors to prevent recurrence are still outstanding.
Action taken summary University Hospitals Birmingham NHS Foundation Trust has delivered comprehensive training to doctors on recognizing and acting upon swallowing difficulties, emphasizing clear documentation and communi
Paula Doreen
All Responded
2025-0511 14 Oct 2025 Inner South London
Oracle and Cerner Lewisham and Greenwich NHS Trust NHS England +2 more
Concerns summary National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Action taken summary NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training
Joanna Chamberlain
All Responded
2025-0571 11 Oct 2025 West Sussex, Brighton and Hove
NHS England
Concerns summary A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including family and GP input in care plans.
Action taken summary NHS England is trialling neighbourhood mental health centres in six areas to provide community support for mental health patients not in immediate crisis. They have also shared draft 'Personalised Car
Adrienne Studholme
All Responded
2025-0504 10 Oct 2025 Lancashire and Blackburn with Darwen
East Lancashire NHS Trust
Concerns summary Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.
Action taken summary The Trust has clarified that seizure activity is escalated regardless of who witnesses it, communicating this to clinical teams. They have also reminded ED and surgical clinicians to ensure urgent con
Matthew Goldsmith
All Responded
2025-0499 9 Oct 2025 East London
Barking, Havering and Redbridge Univers…
Concerns summary Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
Action taken summary The Trust has implemented an action plan by reconfiguring its radiology IT system for mandatory internal peer review, establishing a Radiology Quality and Safety Team, and rolling out a formal peer re
Pauline Stirling
Partially Responded
2025-0503 9 Oct 2025 Gateshead and South Tyneside
Malhorta Group Prestwick Care
Concerns summary Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient safety and persistent record-keeping failures.
Action taken summary Malhotra Group has implemented an electronic care recording system (Nourish) which now includes specific fields for positional tilts and enhanced wound management oversight. They have also updated the
Derek Crowther
All Responded
2025-0500 9 Oct 2025 Manchester South
Pennine Care NHS Foundation Trust
Concerns summary Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking future deaths.
Action taken summary The Trust has launched a new Mandatory Training Policy and a monitoring dashboard to ensure staff complete required Intermediate Life Support training. They have also established a project group to de
William King
All Responded
2025-0496 8 Oct 2025 Milton Keynes
Milton Keynes University Hospital Royal College of Surgeons Royal College of Anaesthetists +1 more
Concerns summary Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a risk of recurrence.
Action taken summary The Royal College of Surgeons of England plans to update its guidance on consent, develop a practical toolkit and a short set of principles on shared decision-making by Spring 2026, and create an e-le
Amanda Wood
Partially Responded
2025-0495 7 Oct 2025 Manchester South
Tameside and Glossop Integrated Care NH… Chief Executive
Concerns summary No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Action taken summary The Trust disputes the necessity of a sepsis screen prior to discharge, explaining that the patient's low NEWS score and triage category did not trigger the sepsis pathway in line with existing policy
Steven Turzynski
All Responded
2025-0492 6 Oct 2025 Gwent
Aneurin Bevan University Health Board Velindre University Nhs Trust
Concerns summary Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Action taken summary Velindre University NHS Trust has undertaken a comprehensive review, implementing improvements to nutritional assessment, strengthening communication, and introducing guidelines for dietetic assessmen
Beatrice Smith
Partially Responded
2025-0493 2 Oct 2025 Cumbria
Cheshire SK4 1RD Dodge Hill Harbour Healthcare Limited +3 more
Concerns summary No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of inadequate practices.
Action taken summary Harbour Healthcare Limited completed a Serious Untoward Incident Root Cause Analysis, introduced daily safety huddles, implemented Wound Care Champions, and provided comprehensive staff training on wo
Milos Jankovic
Partially Responded
2025-0490 1 Oct 2025 East London
Minister for Health and Social Services… [REDACTED] Chief Executive of Digital H…
Concerns summary Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to missed surveillance and preventable cancers.
Action taken summary The Cabinet Secretary for Health and Social Care disputes that GPs should be involved in recalling patients for Barrett's Oesophagus surveillance, stating this responsibility lies with secondary care
Mohammad Asghar
Partially Responded
2025-0489 29 Sep 2025 East London
[REDACTED] Barts Health NHS Foundation Trust Chief Executive Officer
Concerns summary The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability to learn from adverse events.
Action taken summary Barts Health NHS Foundation Trust acknowledges failures in its governance and decision-making for patient safety investigations. It is commissioning an independent review of its PSIRF governance proce
Susan Barrett
All Responded
2025-0590 29 Sep 2025 Essex
East Suffolk and North Essex NHS Founda…
Concerns summary Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate care for pressure ulcers and an increased risk of future deaths.
Action taken summary The Trust has confirmed funding for a 0.6wte Band 6 Tissue Viability CNS substantive post, with the establishment control form approved and active recruitment underway to embed a Tissue Viability Serv