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 1,780 No Response 16 Historic 613 Pending 29
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
Charles Williamson
All Responded
2019-0326 30 Sep 2019 Manchester (South)
Department of Health and Social Care Greater Manchester Health and Social Ca… Mayor of Greater Manchester
Concerns summary A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.
Amy Allan
All Responded
2019-0343 30 Sep 2019 London Inner (North)
Great Ormond Street Hospital NHS Trust
Concerns summary Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Anthony McCormack
All Responded
2019-0317 27 Sep 2019 Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked resources for adequate patient assessment and monitoring.
John Shrosbree
All Responded
2019-0260-wp26754 26 Sep 2019 Milton Keynes
Milton Keynes University Hospital
Concerns summary Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.
Daniel Williams
All Responded
2019-0309 24 Sep 2019 London Inner (South)
St Thomas NHS Foundation Trust
Concerns summary Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Annette Hewins
All Responded
2019-0310 24 Sep 2019 South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, and poor detail in patient observation charts indicate significant training and procedural failures.
Myla Deviren
Historic (No Identified Response)
2019-0311 24 Sep 2019 Cambridgeshire and Peterborough
Herts Urgent care Limited NHS 111 Public Health England
Concerns summary NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.
Rebecca Marshall
All Responded
2019-0313 24 Sep 2019 London Inner (South)
Kent and Medway NHS and Social Care Tru…
Concerns summary The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of future deaths related to hospital and mental health care.
Muhammed Haleem
All Responded
2019-0316 24 Sep 2019 Manchester (North)
North west Ambulance Service Pennine Care NHS Trust
Concerns summary The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.
Francis Hodge
All Responded
2019-0338 24 Sep 2019 London Inner (South)
University Hospital Lewisham
Concerns summary Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the absence of a patient information leaflet.
Karis Braithwaite
Historic (No Identified Response)
2019-0415 20 Sep 2019 London (East)
Goodmayes Hospital NHS Trust
Concerns summary Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment team, highlighting a systemic failure in handover procedures.
Caspian Thorn
Historic (No Identified Response)
2019-0305 19 Sep 2019 Manchester (South)
HSIB
Concerns summary Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.
Ian Bromley
All Responded
2019-0307 19 Sep 2019 Manchester (South)
Pennine Care NHS Trust
Concerns summary The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was inconsistently effective due to varying individual approaches and workloads.
Taejelle Francois
Historic (No Identified Response)
2019-0297 16 Sep 2019 West Yorkshire (West)
Calderdale and Huddersfield NHS Trust
Concerns summary A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.
Blaithin Buckley
All Responded
2019-0465 16 Sep 2019 Northamptonshire
General Council
Concerns summary An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.
William Oliver
All Responded
2019-0494 12 Sep 2019 Manchester (North)
Blackpool Clinical Commissioning Group Department of Health and Social Care North West Ambulance Service
Concerns summary The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround times, leading to significant delays.
Maureen Jarvis
All Responded
2019-0357 11 Sep 2019 Staffordshire South
Midland Partnership NHS Trust
Concerns summary A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, disseminated policy on physical health examinations for admitted psychiatric patients.
Millie Creasy
Historic (No Identified Response)
2019-0293 6 Sep 2019 Bedfordshire & Luton
Luton & Dunstable NHS Trust
Concerns summary A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.
Tillie Spencer-Adams
All Responded
2019-0356 5 Sep 2019 Hertfordshire
East and North Hertfordshire NHS Trust
Concerns summary Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.
Kim Morris
All Responded
2019-0261 27 Aug 2019 Leicester City and Leicestershire
Leicester NHS Trust
Concerns summary A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, causing distress and inadequate support prior to discharge.
Christopher Summerhayes
All Responded
2019-0263 22 Aug 2019 South Wales Central
Cardiff & Vale University Health Board
Concerns summary Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Euan Ellis
Historic (No Identified Response)
2019-0264 22 Aug 2019 Plymouth, Torbay and South Devom
Derriford Hospital Trust
Concerns summary The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would be followed to prevent future deaths.
Tony Dunne
All Responded
2019-0265 20 Aug 2019 London Inner (North)
East London NHS Trust
Concerns summary A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge from the emergency department for intending to jump, missing a critical intervention opportunity.
Daphne Wigley
Historic (No Identified Response)
2019-0266 20 Aug 2019 Mid Kent and Medway
Medway Maritime Hospital
Concerns summary The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.
Thelma Joyce
All Responded
2019-0500 20 Aug 2019 Oxfordshire
NHS England
Concerns summary The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.