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).
PFD Reports
1,521 resultsRosa Anderson
All Responded
2013-0263
17 Oct 2013
Liverpool
Aintree Hospitals NHS Trust
Concerns summary
The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Action taken summary
Aintree University Hospital has already implemented a discharge advice sheet for laparoscopic procedures, which is provided to all relevant patients prior to discharge. They are also implementing gene
Jared William McDowall
All Responded
2013-0245
27 Sep 2013
Avon
University Hospitals Bristol NHS Founda…
Concerns summary
Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Action taken summary
University Hospitals Bristol has developed a composite action plan to address concerns regarding communication between neonatal and cardiac units for premature babies, and the cut-off weight guideline
Rose Jean Coles
All Responded
2013-0246
27 Sep 2013
Avon
University Hospitals Bristol NHS Founda…
Concerns summary
Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
Action taken summary
University Hospitals Bristol has developed a composite action plan to address concerns regarding communication between neonatal and cardiac units for premature babies, and the cut-off weight guideline
Gwilym Pugh Jones
All Responded
2013-0239-wp23941
25 Sep 2013
North Wales (East and Central)
Betsi Cadwaladr University Hospital Boa…
Jude Augustus Gordon
All Responded
2013-0237
24 Sep 2013
South Yorkshire (West)
Department of Health and Social Care
Concerns summary
Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Action taken summary
The Department of Health confirms that a National Early Warning Score (NEWS) system has already been advocated by the Royal College of Physicians, with guidance and e-learning materials produced to st
Labhuden Amarshi Vaghadia
All Responded
2013-0201
5 Sep 2013
Leicester City & South Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary
A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.
Action taken summary
The Trust conducted extensive reviews of Mrs Vaghadia's death and current nursing practices, re-iterating vital communication principles through an implemented divisional strategy. They performed two
Karen Sutton
All Responded
2013-0223
4 Sep 2013
Leicester City & South Leicestershire
University Hospitals Leicester NHS Trust
Concerns summary
Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication policy.
Action taken summary
The Trust has written to all consultants reminding them of their duty to contact specialist teams for patients with complex needs. They also plan to implement new software by April 2014 to provide dai
Derek Brierley
All Responded
2013-0244
20 Aug 2013
Manchester North
Pennine Acute Trust
Concerns summary
The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for competence and training.
Action taken summary
The Trust has re-drafted and shared a pathway for managing urinary retention, making supra-pubic aspiration a first-line intervention. They have initiated a training program for staff on catheter inse
Ronald Ellwood
All Responded
2013-0222
15 Aug 2013
Staffordshire (South)
Queen’s Hospital
Concerns summary
The provided concerns text is too truncated to identify specific safety issues.
Action taken summary
Burton Hospitals NHS Foundation Trust disputes the need for fresh air from open windows in critical care, stating it would compromise patient safety and the existing air conditioning system designed t
Mina Topley-Bird
All Responded
2021-0100
County Durham and Darlington
Department of Health and Social Care
West Park Hospital
Concerns summary
Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.
Action taken summary
Tees, Esk and Wear Valleys NHS Foundation Trust immediately implemented a checklist for Accident and Emergency patients from outside the area to ensure information gathering and sharing. They are also
Paul Sartori
All Responded
2021-0123
East London
North East London NHS Foundation Trust
Barts Health NHS Trust
Royal College of Emergency Medicine
Concerns summary
Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.
Action taken summary
Barts Health has updated streaming policy at Whipps Cross to include THINK AORTA guidance, delivered related training, and updated its Heart Attack Centre feedback template. They will ensure pre-arriv
Ian Cockfield
All Responded
2022-0158
East London
Department of Health and Social Care an…
Concerns summary
The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from the given text.
Action taken summary
The Department of Health and Social Care notes existing NICE guidelines for falls risk assessment and that NICE is updating this guidance, due 2024, to include patients under 65 with mental health pro
Mark Sumnall
All Responded
2022-0160
Derby and Derbyshire
Derbyshire County Council and NHS Derby…
Concerns summary
The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital staff are unaware of its purpose, leading to critical care plans not being accessed.
Action taken summary
NHS Derby and Derbyshire has refreshed and re-issued Red Bag Guidance, updated the transfer checklist, delivered training in care homes, and issued urgent communications to Ambulance and Hospital Trus
Rita Britten
All Responded
2022-0162
West Yorkshire Western
NHS England
Resuscitation Council UK
Concerns summary
Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are compromised, creates a significant safety risk.
Action taken summary
Resuscitation Council UK clarifies that its existing basic life support guidelines already provide recommendations for choking, including alternative techniques when abdominal thrusts are not possible
Jack Hurn
All Responded
2022-0167
Birmingham and Solihull
Worcestershire Acute Hospitals NHS trust
Concerns summary
The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist consultations, despite available national and regional pathways.
Action taken summary
The Trust reopened the serious incident investigation to address identified shortcomings and has restructured its central patient safety team to align with the National Patient Safety Strategy. It is
David Hulme
All Responded
2022-0199
Plymouth, Torbay and South Devon
University Hospitals Plymouth NHS Trust
Concerns summary
The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis at this regional centre.
Action taken summary
University Hospitals Plymouth has approved funding for four Consultant Pathologist posts and is actively recruiting, though acknowledging national shortages may prolong the process. They have also imp
Daniel Xavier
All Responded
2022-0203
East London
Barts Health NHS Trust
Department of Health and Social Care
Concerns summary
Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. Insufficient consideration was given to the patient's learning disability.
Action taken summary
The Department of Health and Social Care has introduced a new legal requirement for CQC registered service providers to ensure employees receive learning disability and autism training, effective July
Joshua Burgess
All Responded
2024-0077
Staffordshire and Stoke on Trent
Brook Medical Centre
Godfrey Care
University Hospitals of North Midlands …
Concerns summary
Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally instructed or acted upon by clinical staff.
Action taken summary
Godfrey Care completed a medication communication and lessons learned session, revised and updated their medication policy to require written confirmation for verbal changes, and updated their weekly/
Michael Nye
All Responded
2024-0082
Berkshire
Berkshire and Surrey Pathology Services
Royal Berkshire Hospital
Concerns summary
Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on sepsis recognition and escalation policies.
Action taken summary
The Trust's Lead Nurse for Sepsis has delivered focused training in the ED and critical care settings, and pathology test results are now returned from the lab within a reduced timeframe, targeting a
Syeda Fatima
All Responded
2025-0613
Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary
Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.
Action taken summary
The Trust has undertaken a comprehensive review and outlined key initiatives to address cultural and systemic issues in their maternity service. These include implementing twice-daily multidisciplinar
Dominic Philip
All Responded
2025-0617
Northamptonshire
Medicines and Healthcare Products Regul…
Department of Health and Social Care
Royal College of Radiologists
+1 more
Concerns summary
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Action taken summary
The Department for Health and Social Care stated that other agencies are best placed to respond to the specific concerns and shared NHS England's comments regarding existing professional guidance for