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
Ioannis Avgousti
All Responded
2019-0135A 24 Apr 2019 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Deborah Hopkinson
All Responded
2019-0133 24 Apr 2019 Manchester (North)
Pennine Acute Hospitals NHS Trust
Concerns summary Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.
Kerry Hunter
All Responded
2019-0137 23 Apr 2019 Suffolk
Norfolk & Suffolk NHS Trust
Concerns summary The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.
Graham Jones
All Responded
2019-0131A 18 Apr 2019 Gloucestershire
Gloucestershire Hospitals NHS Trust
Concerns summary Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.
Roger Neaves
Historic (No Identified Response)
2019-0130 18 Apr 2019 Plymouth Torbay and South Devon
Derriford Hospital Trust
Concerns summary Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.
Megan Jones
Historic (No Identified Response)
2019-0126 17 Apr 2019 Isle of Wight
Hampshire and Isle of Wight Clinical Co…
Concerns summary A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.
Nathan Cooke
Historic (No Identified Response)
2019-0125 17 Apr 2019 Isle of Wight
Hampshire and Isle of Wight Clinical Co…
Concerns summary There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Jonathan Yates
All Responded
2019-0132A 16 Apr 2019 Gloucestershire
Gloucestershire Hospitals NHS Trust
Concerns summary The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.
Thomas Collings
All Responded
2019-0260 15 Apr 2019 Sunderland
GE Healthcare South Tyneside and Sunderland NHS Trust
Concerns summary Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.
Jennifer Lewis
All Responded
2019-0003 15 Apr 2019 Kent (North-West)
Oxleas NHS Trust
Concerns summary There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.
Nyall Brown
All Responded
2019-0134A 15 Apr 2019 Norfolk
Norfolk & Suffolk NHS Trust
Concerns summary Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring issue despite existing staff expectations.
Emma Butler
All Responded
2019-0133A 12 Apr 2019 Buckinghamshire
Oxford Health NHS Trust
Concerns summary Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.
Archie Grieves
Historic (No Identified Response)
2019-0190 12 Apr 2019 Gateshead & South Tyneside
Gateshead Health NHS Trust
Concerns summary No specific concerns were detailed in the provided text.
Anthony Buckingham
All Responded
2019-0123 9 Apr 2019 Suffolk
Norfolk and Suffolk NHS Trust
Concerns summary The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.
Tina Tait
Historic (No Identified Response)
2019-0129 8 Apr 2019 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Trust
Concerns summary Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
Ronald Clark
Partially Responded
2019-0151 8 Apr 2019 Portsmouth and South East Hampshire
NHS Improvement Medicines and Healthcare products Regul…
Concerns summary Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.
George Twiddy
Partially Responded
2019-0150 8 Apr 2019 Portsmouth and South East Hampshire
Hampshire County Council southern Health NHS Trust
Concerns summary Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.
Jennifer Handy
All Responded
2019-0121 5 Apr 2019 South Wales Central
Cwm Taf Health Board General Medical Council
Concerns summary The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.
Alice Dixon
Historic (No Identified Response)
2019-0132 5 Apr 2019 Surrey
Ashford and St Peter’s Hospitals NHS Tr…
Concerns summary A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.
Terence Thornton
Partially Responded
2019-0114 3 Apr 2019 Plymouth Torbay and South Devon
Derriford Hospital University Hospitals Plymouth NHS Trust
Concerns summary Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.
Ronald Lowe
All Responded
2019-0113 3 Apr 2019 Birmingham and Solihull
University Hospitals Birmingham NHS Tru…
Concerns summary A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect understanding of duties.
Aryan Akhgar
All Responded
2019-0115 3 Apr 2019 South Yorkshire (West)
Sheffield Children’s Hospital Sheffield Clinical Commissioning Group
Concerns summary A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.
Elsa Reid
Historic (No Identified Response)
2019-0139 2 Apr 2019 Black Country
New Cross Hospital NHS Trust Wolverhampton City Council
Concerns summary Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.
Tarek Chowdhury
Historic (No Identified Response)
2019-0131 2 Apr 2019 London (West)
HM Prison & Probation Service Home Office NHS England
Concerns summary There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.
Stuart Clark
All Responded
2019-0125A 2 Apr 2019 Exeter and Greater Devon
Royal Devon and Exeter NHS Trust
Concerns summary A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.