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). 55% of classified responses show concrete action taken. Reports rose 33% from 176 (2023) to 234 (2024).

Response Status
Responded 1,777 No Response 17 Historic 613 Pending 31
AI Classification
Action Taken 55%
Action Planned 24%
Noted 15%
Disputed 7%
Based on 652 classified responses
Reports by Quarter
PFD Reports
2,483 results
Zara Cheesman
Partially Responded
2025-0481 25 Sep 2025 Nottingham and Nottinghamshire
East Midlands Ambulance Service NHS Tru… Chief Executive
Concerns summary Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff on paediatric guidelines.
Action taken summary East Midlands Ambulance Service has appointed senior clinicians to lead specific areas including children and young people, adopted the UK Sepsis Trust’s paediatric sepsis assessment tool, and expande
Pamela Honeybone
All Responded
2025-0485 25 Sep 2025 North Yorkshire and York
York and Scarborough Teaching Hospitals…
Concerns summary Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk to patient safety across hospital sites.
Action taken summary The Trust has reviewed and strengthened its patient identification policy using findings from the case, leading to significant improvement in audit results. The Patient Safety Incident Response Framew
Honoria Culshaw (1)
All Responded
2025-0479 24 Sep 2025 Manchester South
Manchester University NHS Foundation Tr…
Concerns summary Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment for infection.
Action taken summary Manchester University NHS Foundation Trust is currently implementing new processes within its electronic patient record (HIVE) to allow discharge letters to be sent to additional healthcare providers.
Honoria Culshaw (2)
All Responded
2025-0480 24 Sep 2025 Manchester South
Lancashire Teaching Hospitals NHS Found…
Concerns summary A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
Action taken summary The Trust has implemented a new 'Wound Swab Policy and Guidance for Device Related Infections' and delivered training to cardiology staff on expected management. A Standard Operating Procedure for pre
Tony Jackson
All Responded
2025-0475 23 Sep 2025 East London
Barts Health NHS Foundation Secretary of State for Dept. Health & S… Chief Executive Officer
Concerns summary A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering learning and remediation of sub-optimal practice.
Action taken summary Barts Health NHS Trust has reviewed the case through its Surgical M&M process and shared learning. It completed audits of Best Interests Decisions and clinical record availability, disseminating revis
Kwabena Amoateng
No Identified Response
2025-0429 19 Sep 2025 East London
National Medical Director NHS England NHS North-East London Integrated Care B…
Concerns summary A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.
Keith Hankin
All Responded
2025-0472 17 Sep 2025 West Sussex, Brighton and Hove
Chief Executive Care Quality Commission Department of Health and Social Care +2 more
Concerns summary A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and potential detriment to patient safety.
Action taken summary The CQC confirmed that Goring Hall Hospital (GHH) implemented additional measures, including sharing coroner's findings with governance committees, updated documentation for antimicrobials, clarifying
Gareth Johnson
All Responded
2025-0464 12 Sep 2025 South Wales Central
Chief Executive Cardiff & Vale Universi… Cabinet Secretary for Health and Social…
Concerns summary Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Action taken summary The Health Board has developed an Electrical Failure Emergency Action Card (E1) outlining immediate actions, escalation principles, staff roles, and communication protocols for power failures, with an
Michael Moore
All Responded
2025-0463 11 Sep 2025 Norfolk
NHS England
Concerns summary Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
Action taken summary NHS England disputes the coroner's claim of a further decline in cancer waiting times, highlighting improved performance and met targets. Regionally, a 'capacity and demand' review and validation of t
Keith Reynolds
All Responded
2025-0461 10 Sep 2025 Newcastle and North Tyneside
NEWCASTLE UPON TYNE HOSPITALS NHS FOUND…
Concerns summary Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring urgent treatment.
Action taken summary The Trust has established a Mechanical Thrombectomy (MT) Steering Group, agreed a plan for a 24/7 service, and implemented a joint INR rota with James Cook University Hospital to secure sufficient sta
Nicola Mulliss
All Responded
2025-0453 4 Sep 2025 Newcastle and North Tyneside
Newcastle upon Tyne Hospitals NHS Found…
Concerns summary A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Action taken summary The Trust clarifies that routine swabbing of all leaking wounds is not clinically appropriate but commits to strengthening pathways. This will ensure appropriate cultures, including wound swabs, are u
Peter Thomas
All Responded
2025-0450 3 Sep 2025 South Wales Central
National Institution for Health and Car…
Concerns summary The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without adequate guidance.
Action taken summary NICE's prioritisation board will reconsider updating the guidance on alcohol withdrawal and pharmacological treatment in February-March 2026, following an earlier conclusion that an update should be c
Edward Funnell
All Responded
2025-0445 2 Sep 2025 South Wales Wales
Powys Teaching Hospital Board
Concerns summary Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to unaddressed issues.
Action taken summary The Health Board has reviewed and updated pressure ulcer documentation, introduced a new Tissue Viability Nurse referral proforma, and monitors pressure ulcers via the Datix system. They also plan fur
Sarah Heaver
All Responded
2025-0010-wp117472 1 Sep 2025 Kent and Medway
Kent and Medway NHS and Social Care Par… East Kent Hospitals University NHS Foun…
Concerns summary Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric care.
Action taken summary The Trust has implemented changes to ensure consistent prescriber cover, including a three-week rolling rota for independent prescribers and transferring annual leave booking responsibility to Operati
Audrey Newman
Partially Responded
2025-0443 29 Aug 2025 Manchester South
Stockport NHS Foundation Trust CEO
Concerns summary A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic testing.
Action taken summary The Trust is rolling out training for medical staff on using the Theatreman IT booking system for lumbar punctures, formulating an escalation flowchart for anaesthetics, and implementing new policies
Edwin Price
All Responded
2025-0440 28 Aug 2025 Somerset
Somerset NHS Foundation Trust
Concerns summary A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were taken to address these systemic gaps.
Action taken summary The Trust has aligned its Falls Risk Assessment policy, making it mandatory within 12 hours of admission with weekly reviews, and ensures patient risk status is clearly displayed. Medical matrons now
Kore Padgett
All Responded
2025-0441 28 Aug 2025 West Yorkshire West
Calderdale and Huddersfield NHS Foundat…
Concerns summary There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.
Action taken summary The Trust is developing and implementing specialised training for staff on hard collar application and management, creating a Standard Operating Procedure (SOP) for collar initiation, and revising car
Lee Stammers
All Responded
2025-0438 22 Aug 2025 South Yorkshire East
Doncaster Royal Infirmary
Concerns summary Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, risking patient harm.
Action taken summary The Trust has revised its departmental procedure for monitoring observations and implemented restrictions on student nurse access to the Symphony system, making full name and GMC number login mandator
Charles Stonley
Partially Responded
2025-0432 20 Aug 2025 Liverpool and Wirral
NHS England Improvement (PFDs) Health Services Safety Investigations B… National Director FOR Mental Health +1 more
Concerns summary Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Action taken summary NHS England has tasked local health systems to improve patient flow and reduce long waits in mental health crisis pathways, and is developing a national patient safety toolkit for EDs. The Department
Masood Hamid
All Responded
2025-0434 20 Aug 2025 Manchester North
Chief Executive North West Ambulance Se… Chief Executive Pennine Care NHS Founda… Chief Executive Oldham Borough Council +1 more
Concerns summary There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.
Action taken summary North West Ambulance Service reviewed Mr Hamid’s case and stated their view that communication with Greater Manchester Police was good, but an individual incorrect decision by Police led to the delaye
Mary Fitzpatrick
All Responded
2025-0435 20 Aug 2025 Inner North London
Chief Executive Whittington Health NHS …
Concerns summary An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in an elderly patient.
Action taken summary Whittington Health NHS Trust has developed a new electronic form for daily skin checks which is being embedded, and is drafting new policies for pressure ulcer prevention and deteriorating patients, t
Emily Hewerdine
Partially Responded
2025-0431 18 Aug 2025 Nottingham and Nottinghamshire
Doncaster and Bassetlaw Teaching Hospit… Chief Executive
Concerns summary Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.
Action taken summary The Trust has implemented a Safety Improvement Plan, introduced weekly audits using the Tendable application, and is transitioning to electronic fluid balance charting with ongoing staff training. Add
Robert Simpson
All Responded
2025-0423 12 Aug 2025 Birmingham and Solihull
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOU…
Concerns summary A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management and escalation.
Action taken summary The Trust confirmed issues stemmed from nursing non-compliance, with immediate actions including increased monitoring by senior nursing managers, sharing learning across quality forums, and implementi
Kenneth Edwards
All Responded
2025-0414 7 Aug 2025 Manchester South
Stockport NHS Foundation Trust
Concerns summary A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Action taken summary The Trust has reinforced standards for consent, handover, and clinical documentation, and continues close collaboration with its out-of-hours radiology service and engagement in Radiology Education an
Tracey Ostler
All Responded
2025-0416 7 Aug 2025 Surrey
Department of Health and Social Care Surrey and Borders NHS Foundation Trust South East Coast Ambulance Service +4 more
Concerns summary A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.
Action taken summary The Health Service Safety Investigations Body will launch two national investigations: one into the care of mental health crisis patients in emergency departments starting October 2025, and another in