Hospital Death (Clinical Procedures and medical management) related deaths

PFD Category
Reports: 2,487 Areas: 72 Earliest: Feb 2013 Latest: 19 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 33
AI Classification
Action Taken 56%
Action Planned 24%
Noted 14%
Disputed 6%
Based on 1,159 classified responses
Reports by Quarter
PFD Reports
2,487 results
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.
Geraint Hughes
All Responded
2019-0268 18 Aug 2019 Cornwall and the Isles of Scilly
Cornwall Partnershipship NHS Trust
Concerns summary Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not identified by supervisory reviews.
David Smith
All Responded
2019-0271 14 Aug 2019 Manchester (City)
Manchester University NHS Trust
Concerns summary Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.
Joseph Charles
Partially Responded
2019-0277 6 Aug 2019 London (North)
Department of Health and Social Care North Middlesex University Hopsital
Concerns summary There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, despite clear guidance for lower limb procedures.
Prabhaker Kapoor
All Responded
2019-0278 6 Aug 2019 Birmingham and Solihull
University Hospitals Birmimgham NHS Tru…
Concerns summary Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause Analysis report.
Carol Jennings
All Responded
2019-0279 2 Aug 2019 Norfolk
Queen Elizabeth Hospital
Concerns summary Inadequate and unchased referrals to the Tissue Viability Nurse, combined with systemic failures in detailed wound record-keeping, led to delayed and insufficient care for severe leg ulcers.
Fern-Marie Choya
Historic (No Identified Response)
2019-0281 31 Jul 2019 London Inner (North)
London Ambulance Service NHS Trust Whittington Health NHS Trust
Concerns summary The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in obstetric care and leading to inappropriate medical treatment.
Gladys Borgogno
All Responded
2019-0286 31 Jul 2019 Stoke-on-Trent & North Staffordshire
University Hospital of North Midlands
Concerns summary Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical attention for post-discharge vomiting.
Alex Blake
All Responded
2019-0259 29 Jul 2019 London Inner (South)
NHS Professionals Ltd Nursing and Midwifery Council
Concerns summary Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Gladys Sayles
All Responded
2019-0253 26 Jul 2019 West Yorkshire (West)
Leeds Teaching Hospitals NHS Trust
Concerns summary Guidelines for Aspen collar use, bespoke training for application, and communication between healthcare providers and suppliers regarding fitting and patient care all require urgent review and improvement.
Sam Grant
Historic (No Identified Response)
2019-0285 26 Jul 2019 Milton Keynes
Milton Keynes Clinical Commissioning Gr… Public Health England
Concerns summary Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information sharing between health agencies and the removal of medically qualified staff in schools, hindered comprehensive care.
Xander Curran-Pass
Historic (No Identified Response)
2019-0249 24 Jul 2019 Manchester (South)
National Institute for Health and Care … Department of Health and Social Care Stepping Hill Hospital
Concerns summary Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.
Zona Tebbs
Historic (No Identified Response)
2019-0248 19 Jul 2019 South Yorkshire (East)
Public Health England Yorkshire and the Humber Region
Concerns summary Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital information being overlooked due to convoluted dissemination methods and outdated guidance.
Allan Joslin
All Responded
2019-0241 17 Jul 2019 Exeter and Greater Devon
NHS England
Concerns summary There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack of formal assessment and treatment, contravening equality legislation.
David Jukes
All Responded
2019-0329 12 Jul 2019 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… Birmingham and Solihull Mental Health N… Black Country Partnership NHS Foundatio… +2 more
Concerns summary Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the patient, despite being notified, creating significant risk.
Lindsey Bailey
All Responded
2019-0235 11 Jul 2019 Staffordshire (South)
Midlands Partnership NHS Trust
Concerns summary Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, potentially hindering her treatment and care.
Miriam Tighe
Historic (No Identified Response)
2019-0234 4 Jul 2019 Manchester (West)
Edge Hill Residential Home Oldham Clinical Commissioning Group Pennine Care NHS Trust +1 more
Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.
John Doyle
Partially Responded
2019-0226 3 Jul 2019 London (East)
North East London NHS Trust Goodmayes Hospital
Concerns summary Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a risk due to rapidly changing technology.
Jennifer Withey
All Responded
2019-0225 3 Jul 2019 Cornwall and the Isles of Scilly
NHS England NHS Pathways
Concerns summary The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between organizations create unnecessary delays in urgent patient care.
Andrew McCall
All Responded
2019-0228 1 Jul 2019 Stoke-on-Trent & North Staffordshire
NHS England
Concerns summary A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Ezra Boulton
Partially Responded
2019-0222 1 Jul 2019 Portsmouth and South East Hampshire
Midwifery and Maternity Portsmouth Hosp… Portsmouth Hospitals NHS Trust
Concerns summary Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness of criminal implications of infant overlay with alcohol/drugs.
Frank Stockton
Historic (No Identified Response)
2019-0466 27 Jun 2019 Blackpool & Fylde
Blackpool Teaching Hospital Glenroyd Medical Practice
Concerns summary Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.