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).

Responded 1,780 No Response 16 Historic 613 Pending 33

Action Taken 56%

Action Planned 24%

Noted 14%

Disputed 6%

Based on 1,159 classified responses

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PFD Reports

1,521 results

Elsie Tindle

2016-0098 8 Mar 2016 Sunderland

Department of Health and Social Care

Concerns summary The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.

Ranjan Mistry

2016-0093 4 Mar 2016 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary Multiple systemic failures included inadequate falls risk assessment, missing neurological charts, poor communication between medical and nursing staff, immediate shredding of handover sheets, and insufficient incident reporting.

Curt Falk

2016-0083 2 Mar 2016 London Inner (North)

Department of Health and Social Care

Concerns summary A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.

Christ Morrison

2016-0084 2 Mar 2016 London Inner (South)

Queen Mary’s Hospital for Children

Concerns summary Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.

Devinder Seth

2016-0075 26 Feb 2016 London (East)

Royal London Hospital

Concerns summary Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.

Wilfred Pearson

2016-0088 24 Feb 2016 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.

Edith Kirkham

2016-0068 23 Feb 2016 Manchester (South)

Tameside Hospital NHS Trust

Concerns summary Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records were also unavailable.

Freda Weston

2016-0080 23 Feb 2016 Manchester (South)

Stockport NHS Foundation Trust

Concerns summary Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.

Clifford Crofts

2016-0066 22 Feb 2016 Surrey

Ashford and St Peter’s Hospital Trust

Concerns summary A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.

Brenda Morris

2016-0065 19 Feb 2016 London Inner (North)

East London NHS Foundation Trust

Concerns summary Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.

Eric Gaskell

2016-0057 16 Feb 2016 Manchester (West)

Royal Bolton Hospital

Concerns summary Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy hours.

Peter Tye

2016-0050 15 Feb 2016 Plymouth, Torbay and South Devon

Department of Health and Social Care

Concerns summary Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.

Adam Withers

2016-0059 15 Feb 2016 Surrey

NHS England Surrey and Borders Partnership NHS Trust Department of Health and Social Care

Concerns summary Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.

Sandra Wood

2016-0048 12 Feb 2016 North West Kent

Maidstone and Tonbridge Wells NHS Trust

Concerns summary The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.

Margaret Hions

2016-0047 12 Feb 2016 Carmarthenshire and Pembrokeshire

West Wales General Hospital

Concerns summary Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

David Hughes

2016-0040 9 Feb 2016 Leicestershire City and South Leicestershire

Leicestershire Partnership NHS Trust

Concerns summary Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.

Douglas Kay

2016-0033 5 Feb 2016 Nottinghamshire

Doncaster and Bassetlaw Hospital NHS Fo…

Concerns summary There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.

David Mostari

2016-0034 5 Feb 2016 Bedfordshire and Luton

Bedford Hospital NHS Trust

Concerns summary Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted outside of weekdays.

Isla Lord

2016-0035 5 Feb 2016 Bedfordshire and Luton

Princess Alexandra Hospital NHS Trust

Concerns summary A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.

Marc Poole

2016-0045 2 Feb 2016 South Yorkshire (East)

Doncaster and Bassetlaw NHS Foundation …

Concerns summary Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.

Louise Locke

2016-0026 29 Jan 2016 Central Hampshire

Southern Health NHS Foundation Trust

Concerns summary Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.

Antony Briggs

2016-0028 28 Jan 2016 Manchester (South)

Stockport NHS Foundation Trust

Concerns summary Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.

Joanna Bowring

2016-0027 27 Jan 2016 Mid Kent and Medway

Kent and Medway NHS and Social Care Par…

Concerns summary Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.

Steven Rogers

2016-0017 20 Jan 2016 Manchester (South)

Stockport NHS Foundation Trust

Concerns summary A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.

Derek Hare

2016-0018 20 Jan 2016 Manchester (South)

Tameside Hospital NHS Trust

Concerns summary The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of a critical abdominal issue.