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

Filter:

PFD Reports

1,521 results

Joanne Richardson

2018-0134 8 May 2018 Dorset

Dorset Healthcare University Hospital N…

Concerns summary Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed patient care.

Jonathan Earp

2018-0135 8 May 2018 Gloucestershire

Gloucestershire Hospitals NHS Trust

Concerns summary Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.

William Dickens

2018-0137 8 May 2018 London Inner (South)

South London & Maudsley NHS Trust

Concerns summary Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.

Martin Baker

2018-0130 3 May 2018 Plymouth, Torbay and South Devon

Livewell South West

Concerns summary Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.

Kenneth Horne

2018-0131 3 May 2018 Stoke-on-Trent & North Staffordshire

Royal Stoke University Hospital

Concerns summary Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent serious fall.

Christine Withers

2018-0127 1 May 2018 Black Country

Dudley NHS Trust

Concerns summary Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating condition.

Catherine Burns

2018-0132 28 Apr 2018 Blackpool & Fylde

Blackpool Teaching Hospitals NHS Trust

Concerns summary Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.

Katy Roberts

2018-0136 27 Apr 2018 London Inner (South)

South London & Maudsley NHS Trust

Concerns summary Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for challenging decisions or raising concerns for patients and families.

Adrian Jennings

2018-0111 19 Apr 2018 Manchester (South)

Pennine Care NHS Trust

Concerns summary Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

James Sheffield

2018-0214 12 Apr 2018 Manchester (West)

Salford Royal NHS Trust

Concerns summary Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.

George Goldby

2018-0104 11 Apr 2018 Nottinghamshire

Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.

Matthew Faulkner

2018-0097 29 Mar 2018 Hertfordshire

East of England Ambulance Service Luton and Dunstable Hospital Princess Alexander Hospital

Concerns summary Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.

Maureen Campbell-Scott

2018-0090 27 Mar 2018 London (East)

North East London Trust

Concerns summary Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.

Barbara Johnson

2018-0084 21 Mar 2018 Manchester (South)

Pennine Acute NHS Trust

Concerns summary Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.

Peter O’Donnell

2018-0201 20 Mar 2018 Manchester (West)

Department of Health and Social Care

Concerns summary Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.

Jean Griffiths

2018-0080 15 Mar 2018 Manchester (West)

Department of Health and Social Care

Concerns summary A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.

Thomas Curtin

2018-0076 14 Mar 2018 Cornwall and the Isles of Scilly

Concerns summary Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.

Peter Stojilkovic

2018-0077 14 Mar 2018 Manchester (South)

Pennine Care NHS Trust

Concerns summary Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online sources.

Catherine Kennedy

2018-0075 13 Mar 2018 Manchester (South)

Pennine Care NHS Trust

Concerns summary Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.

William Abrahams

2018-0074 6 Mar 2018 London Inner (North)

Concerns summary The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.

Mike Fell

2018-0100 5 Mar 2018 London Inner (North)

Barts Health NHS Trust Royal College of Anaesthetists

Concerns summary Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.

David Ireland

2018-0057 27 Feb 2018 Exeter and Greater Devon

Devon NHS Trust

Concerns summary The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was unaware of this critical pathway.

James Quinton

2018-0056 22 Feb 2018 South Yorkshire (East)

Doncaster Royal Infirmary

Concerns summary Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.

Alan MacDonald

2018-0053 21 Feb 2018 London Inner (North)

Concerns summary A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission in Addcounsel's practices.

Elaine Bradbrook

2018-0044 14 Feb 2018 Nottinghamshire

United Lincolnshire Hospitals NHS Trust

Concerns summary Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.