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). 57% 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 57%

Action Planned 24%

Noted 13%

Disputed 6%

Based on 1,429 classified responses

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PFD Reports

2,487 results

Agnes Lambert

2018-0410 17 Dec 2018 London Inner (North)

Camden & Islington NHS Trust

Concerns summary Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.

Neil Swaisland

2018-0385 12 Dec 2018 Milton Keynes

Milton Keynes Clinical Commissioning Gr… Milton Keynes Council

Concerns summary The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.

Paliben Dullabh

11 Dec 2018 London Inner (North)

Concerns summary The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI scans.

Simon Healey

Partially Responded

2018-0378 6 Dec 2018 Berkshire

Independent Healthcare Providers Network Ramsay Healthcare UK

Concerns summary Private hospitals' NEWS escalation policies need reviewing due to limited critical care capacity. Post-operative care for complex procedures is concerning as general ward staff may lack specific training for rare complications.

John Kirby

Partially Responded

2018-0379 6 Dec 2018 Brighton and Hove

Medico Legal Manager Sussex NHS Trust

Concerns summary Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.

Sylvia Mitchell

Partially Responded

2018-0383 5 Dec 2018 Black Country

Oaks Medical Centre Sandwell and West Birmingham NHS Trust

Concerns summary Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.

Michelle Roach

Historic (No Identified Response)

2018-0302 28 Nov 2018 Berkshire

Royal Berkshire Hospital Waterfield Practice

Concerns summary GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.

Matthew Craven

2018-0365 22 Nov 2018 Manchester (South)

Pennine Care NHS Trust

Concerns summary A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.

Karen Moran

Historic (No Identified Response)

2018-0336-wp26431 22 Nov 2018 Manchester (South)

Tameside and Glossop Clinical Commissio…

Roy Burgess

Historic (No Identified Response)

2018-0364 21 Nov 2018 South Yorkshire (East)

Department of Health and Social Care Doncaster Bassetlaw Teaching Hospital

Concerns summary The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted in a lack of documented doctor input.

Dawn Gill

2018-0354 16 Nov 2018 London Inner (North)

Royal London Hospital

Concerns summary The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart was lost, and there was a concerning delay in locating her despite multiple searches.

Sheila Graham

Historic (No Identified Response)

2018-0355 16 Nov 2018 Stoke-on-Trent & North Staffordshire

Midlands Partnership NHS Trust

Concerns summary Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information recording and assessment.

Emmett Gillah

Historic (No Identified Response)

2018-0357 16 Nov 2018 Surrey

Kent and Medway NHS Social Care Trust

Concerns summary Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. Staff were also unaware of KMPT's discharge policies.

Thomas Jackson

Partially Responded

2018-0352 13 Nov 2018 Staffordshire (South)

Department of Health and Social Care Midlands Partnership NHS Foundation Tru…

Concerns summary Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.

Matthew Arkle

2018-0361 13 Nov 2018 Suffolk

Norfolk and Suffolk NHS Trust

Concerns summary Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions and lack of CCTV review policy contributed to the incident.

Joseph Page

Historic (No Identified Response)

2018-0347 12 Nov 2018 South Wales Central

Cardiff & Vale University Health Board

Concerns summary Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.

Gerwyn Thomas

2018-0342 6 Nov 2018 Camarthenshire and Pembrokeshire

West Wales General Hospital

Concerns summary Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate patient nutrition.

Daniel Stokes

Historic (No Identified Response)

2018-0346 5 Nov 2018 South Yorkshire (East)

Concerns summary Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure in emergency drug administration protocols for prisoners.

Karl Cassimjee

Historic (No Identified Response)

2018-0339 2 Nov 2018 Manchester (West)

Greater Manchester Mental Health NHS Tr… Manchester Royal Infirmary

Stephen Taylor

1 Nov 2018 Worcestershire

Concerns summary Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.

Dorothy Strickley

2018-0305 31 Oct 2018 Leicester City and Leicestershire South

University of Leicester Hospitals NHS T…

Concerns summary Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in staff training and discharge documentation protocols.

Elizabeth Self

2018-0308 29 Oct 2018 South Yorkshire (West)

Concerns summary Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant delays in diagnosis.

Timothy Mason

Partially Responded

2018-0351 26 Oct 2018 Kent (North-West)

Maidstone & Tunbridge Wells NHS Trust NHS England

Concerns summary Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an unwell patient. Concerns include inadequate staff instructions, training, and systems for providing the Men ACWY vaccination.

Eileen Cooke

2018-0311 25 Oct 2018 West Yorkshire (East)

Mid Yorkshire Hospitals NHS Trust

Concerns summary A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a systemic problem with hasty discharges.

Andrea Franzosi

Historic (No Identified Response)

2018-0314 25 Oct 2018 Gloucestershire

Gloucestershire NHS Trust

Concerns summary Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.