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

Angela West

2018-0212 27 Jun 2018 London Inner (North)

Barts Health NHS Trust

Concerns summary High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.

Lauren Sandell

2018-0205 25 Jun 2018 London (East)

Concerns summary Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.

Sylvia Davies

Historic (No Identified Response)

2023-0415 25 Jun 2018 Inner North London

Virgin care Coventry LLP Coventry and Rugby Clinical Commissioni…

Concerns summary Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing safety risks.

Graham Fox

2018-0192 22 Jun 2018 Avon

University Hospitals Bristol NHS Trust

Concerns summary Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

John Hazlewood

2018-0189 21 Jun 2018 Leicester City and Leicestershire South

Leicestershire NHS Trust University Hospitals Leicester NHS Trust

Concerns summary On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received insufficient self-harm training.

Patricia Palin

2018-0183 19 Jun 2018 Shropshire Telford & Wrekin

Shrewsbury and Telford Hospital NHS Tru…

Concerns summary Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to inadequate examination and protocol adherence.

Colin Johns

Historic (No Identified Response)

2018-0203 18 Jun 2018 Black Country

Black Country NHS Foundation Trust

Concerns summary There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient effort to find a suitable bed for a high-risk patient.

Sneh Chaudhry

Historic (No Identified Response)

2018-0182 15 Jun 2018 London (West)

Concerns summary Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.

Alfred Meek

2018-0190 14 Jun 2018 South Yorkshire (East)

Doncaster and Bassetlaw NHS Trust

Concerns summary Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients at risk of falls.

Rita Taylor

Partially Responded

2018-0225 12 Jun 2018 Surrey

Care Quality Commission Epsom General Hospital Royal College of Physicians

Concerns summary Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient care plan.

Marcus Hance

Partially Responded

2018-0173 7 Jun 2018 Isles of Scilly

Cornwall NHS Trust NHS Kernow Clinical Commissioning Group

Concerns summary The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed appointments, prevented access to crucial mental health care.

William Bartram

Historic (No Identified Response)

2018-0174 6 Jun 2018 London (East)

Barts Health NHS Trust

Concerns summary Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to missed critical health issues.

Rosemary Scott

2018-0172 5 Jun 2018 Dorset

Dorset County Hospital

Concerns summary Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of machines for PEEP therapy, compromised respiratory support.

John Derwent

Historic (No Identified Response)

2018-0171 4 Jun 2018 Manchester (South)

Pennine NHS Trust Tameside and Glossop Clinical Commissio…

Concerns summary Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential mental health treatment.

Brian Bicat

Partially Responded

2018-0277 29 May 2018 West Yorkshire (West)

Bradford District Care Foundation Trust Alliance Pharmaceutical Diprobase Bayer Public Limited +4 more

Concerns summary Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent prescribing system alerts pose significant fire risks.

Robin Richards

Historic (No Identified Response)

2018-0126 25 May 2018 Somerset

Department of Health and Social Care Somerset NHS Trust

Concerns summary A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, compromised care for an individual with Asperger's Syndrome.

Caroline Scott

Historic (No Identified Response)

2018-0155 21 May 2018 Milton Keynes

Central and North West London Hospital …

Concerns summary Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.

Alfie Scambler-Holt

Historic (No Identified Response)

2018-0156 21 May 2018 Manchester (South)

Concerns summary The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.

Henry Heselton

2018-0152 18 May 2018 Surrey

Southern Health NHS Trust

Concerns summary Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and GPs.

Graeme Mathieson

Historic (No Identified Response)

2018-0153 18 May 2018 Plymouth Torbay and South Devon

Concerns summary GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from services.

Neville Welton

2018-0150 17 May 2018 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.

Bernard Fagg

Historic (No Identified Response)

2018-0245 17 May 2018 Mid Kent and Medway

Medway NHS Trust

Concerns summary Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration risks.

Doris Ridgwell

Partially Responded

2018-0151 15 May 2018 Surrey

Care Quality Commission Epsom & St Helier University Hospital N…

Concerns summary A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to fatal complications.

Gladys Rich

Partially Responded

2018-0149 14 May 2018 Northamptonshire

Avenue House Nursing and Care Home Care Quality Commission Kettering General Hospital +1 more

Concerns summary The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.

Charles Grainger

Historic (No Identified Response)

2018-0353 12 May 2018 Derby and Derbyshire

NHS Southern Derbyshire Clinical Commis… Milford House Care Home Derbyshire County Council

Concerns summary Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.