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
John Thorp
All Responded
2019-0067 26 Feb 2019 London (West)
London North West University NHS Trust
Concerns summary Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.
Geoffrey Jackson
Historic (No Identified Response)
2019-0071 26 Feb 2019 Manchester (South)
Manchester University Hospitals NHS Tru…
Concerns summary The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Nathan Mooney
All Responded
2019-0072 26 Feb 2019 Manchester (South)
Department of Health and Social Care
Concerns summary The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Kathleen McGeary
All Responded
2019-0081 26 Feb 2019 Nottinghamshire
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, and medication errors highlighted a concerning culture of acceptance.
John Pearce
All Responded
2019-0068 25 Feb 2019 London Inner (North)
Central and North West London NHS Trust
Concerns summary The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to significant delays in hospital admission.
Brenda Gowan
All Responded
2019-0064 25 Feb 2019 London (East)
Royal London Hospital
Concerns summary Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety equipment.
Gabriele Kreichgauer
Historic (No Identified Response)
2019-0082 22 Feb 2019 London Inner (South)
Barts Health NHS Trust
Concerns summary The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Terrence Smith
Historic (No Identified Response)
2019-0095 21 Feb 2019 Surrey
College of Policing Joint Royal Colleges Ambulance Liaison … Mitie +4 more
Concerns summary The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially misleading information, impacting emergency response.
Malcolm Rathmell
All Responded
2019-0059 20 Feb 2019 Nottinghamshire
Nottinghamshire University Hospitals NH…
Concerns summary Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.
Kenneth Whittington
All Responded
2019-0049 14 Feb 2019 Brighton and Hove
Brighton and Sussex University Hospital…
Concerns summary Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.
John Scott
All Responded
2019-0051 14 Feb 2019 Brighton and Hove
NHS Pathways South East Coast Ambulance Service
Concerns summary No specific concerns text was provided for summarization.
John Mellor
Partially Responded
2019-0053 14 Feb 2019 Manchester (North)
Northern Care Alliance NHS Group Oldham Care Commissioning Group Pennine Care NHS Trust +1 more
Concerns summary There was a systemic failure to conduct required blood tests for renal failure patients due to unclear responsibilities, missing shared care arrangements, and reliance on patients to relay vital information to primary care.
Anthony Watson
All Responded
2019-0044 12 Feb 2019 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… NHS England
Concerns summary A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of local beds and distant, unappealing out-of-area options, exacerbated by age-segregated units.
Heather Carey
All Responded
2019-0046 12 Feb 2019 Manchester (South)
Department of Health and Social Care NHS Tameside and Glossop Clinical Commi…
Concerns summary Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing suicide risk.
Madeline Staples
Historic (No Identified Response)
2019-0041 11 Feb 2019 North Wales (East and Central)
Welsh Ambulance Services NHS Trust Betsi Cadwaladr University Health Board
Concerns summary Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, placing patients' lives at ongoing risk.
Robert Hughes
All Responded
2019-0042 11 Feb 2019 Gloucestershire
2gether NHS Trust
Concerns summary The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for patients.
Calary Davis
All Responded
2019-0043 11 Feb 2019 South Wales Central
Cwm taf University Health Board
Concerns summary Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.
Paul Gillam
Partially Responded
2019-0045 11 Feb 2019 Cornwall & the Isles of Scilly
Alcohol Action Team Cornwall Council Cornwall NHS Trust Drug +1 more
Concerns summary Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between Addaction and the Community Mental Health Team.
Stephen Kennedy
All Responded
2019-0039 7 Feb 2019 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Birmingham Cross City Clinical Commissi… Department of Health and Social Care
Concerns summary A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.
Ruth Whitmore
Historic (No Identified Response)
2019-0473 6 Feb 2019 Norfolk
Queen Elizabeth Hospital
Concerns summary Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.
Gwyneth Edwards
Historic (No Identified Response)
2019-0472 5 Feb 2019 Bedfordshire & Luton
Bedford Hospital
Concerns summary Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.
Mary Johnson
All Responded
2019-0495 1 Feb 2019 Herefordshire
Wye Valley NHS Trust
Concerns summary Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
Stephen Harte
All Responded
2019-0077 1 Feb 2019 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… Care Quality Commission
Concerns summary Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.
Sophie Holman
Partially Responded
2019-0035 29 Jan 2019 London (East)
Department of Health and Social Care NHS England
Concerns summary Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.
Dennis Warner
Historic (No Identified Response)
2019-0470 28 Jan 2019 London (West)
Care Quality Commission Royal United Hospital
Concerns summary An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal imaging, delayed senior review, and failed contact attempts.