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 1,780 No Response 16 Historic 613 Pending 29

Action Taken 56%

Action Planned 24%

Noted 14%

Disputed 6%

Based on 1,159 classified responses

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PFD Reports

1,521 results

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

Department of Health and Social Care Welsh Government Cwm Taf University Health Board +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.

Keith Dransfield

2018-0273 8 Aug 2018 South Yorkshire (West)

Concerns summary An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed to safety concerns.

Susan Elliott

2018-0275 6 Aug 2018 Sunderland

City Hospitals NHS Trust

Concerns summary An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical impression without a definitive diagnosis and potentially delaying necessary surgery.

Aniyah Winston

2018-0241 25 Jul 2018 Manchester (South)

Department for Health

Concerns summary Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer Syntocinon, highlighting systemic issues in challenging inappropriate care.

Paul Allan

2018-0251 25 Jul 2018 London (Inner) West

Pennine Acute Hospitals NHS Trust

Concerns summary The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap in mental health support.

Nigel Malloy

2018-0232 19 Jul 2018 Southampton & New Forrest

South Staffordshire & Shropshire NHS Tr…

Concerns summary There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.

William Watson

2018-0237 19 Jul 2018 Cornwall & Isles of Scilly

Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group

Concerns summary Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and non-emergency transfers, risking avoidable deaths.

Adam Carter

2018-0226 12 Jul 2018 Blackpool & Fylde

Lancashire Care NHS Trust

Concerns summary Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.

Kathleen Allen

2018-0213 4 Jul 2018 Birmingham and Solihull

University Hospitals Birmingham NHS Tru…

Concerns summary Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed escalation.

Stephen Whitehead

2018-0293 28 Jun 2018 Manchester (North)

British Society of Gastroenterology Department of Health and Social Care

Concerns summary The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.

Angela West

2018-0212 27 Jun 2018 London Inner (North)

Barts Health NHS Trust

Concerns summary High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.

Lauren Sandell

2018-0205 25 Jun 2018 London (East)

Concerns summary Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.

Graham Fox

2018-0192 22 Jun 2018 Avon

University Hospitals Bristol NHS Trust

Concerns summary Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

John Hazlewood

2018-0189 21 Jun 2018 Leicester City and Leicestershire South

Leicestershire NHS Trust University Hospitals Leicester NHS Trust

Concerns summary On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received insufficient self-harm training.

Patricia Palin

2018-0183 19 Jun 2018 Shropshire Telford & Wrekin

Shrewsbury and Telford Hospital NHS Tru…

Concerns summary Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to inadequate examination and protocol adherence.

Alfred Meek

2018-0190 14 Jun 2018 South Yorkshire (East)

Doncaster and Bassetlaw NHS Trust

Concerns summary Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients at risk of falls.

Rosemary Scott

2018-0172 5 Jun 2018 Dorset

Dorset County Hospital

Concerns summary Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of machines for PEEP therapy, compromised respiratory support.

Henry Heselton

2018-0152 18 May 2018 Surrey

Southern Health NHS Trust

Concerns summary Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and GPs.

Neville Welton

2018-0150 17 May 2018 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.

Kirsty Tolley

2018-0139 9 May 2018 Norfolk

Queens Elizabeth Hospital NHS Trust

Concerns summary Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a lack of clear medical cause of death.

Edward Joyce

2018-0142 9 May 2018 London Inner (South)

Chelsea & Westminster Hospital

Concerns summary A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.