Hospital Death (Clinical Procedures and medical management) related deaths

PFD Category
Reports: 2,483 Areas: 72 Earliest: Feb 2013 Latest: 11 Mar 2026

72% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 33% from 176 (2023) to 234 (2024).

Response Status
Responded 1,777 No Response 17 Historic 613 Pending 31
AI Classification
Action Taken 55%
Action Planned 24%
Noted 15%
Disputed 7%
Based on 652 classified responses
Reports by Quarter
Clear
PFD Reports
1,518 results
William Green
All Responded
2025-0113 28 Feb 2025 Shropshire, Telford & Wrekin
Shrewsbury and Telford NHS Trust NHS England
Concerns summary The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to take, including for those without capacity.
Action taken summary NHS England reports that Shrewsbury and Telford Hospital NHS Trust has developed a Safety Improvement Plan, including establishing a working group to review patient counselling on medications, using l
Khadija Kerri
All Responded
2025-0109 25 Feb 2025 South Yorkshire (East)
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and treating a patient's fractures.
Action taken summary Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has reviewed its Failsafe Alert for Radiological Findings (Communication Protocol) and plans for its approval and implementation by July
Amy Padley
All Responded
2025-0105 24 Feb 2025 SWANSEA & NEATH PORT TALBOT
SWANSEA BAY UNIVERSITY HEALTH BOARD
Concerns summary Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.
Action taken summary Swansea Bay University Health Board has completed the development of a comprehensive Standard Operating Procedure (SOP) and Care Pathway for individuals with co-occurring mental health and substance u
Pamela Marking
All Responded
2025-0107 24 Feb 2025 Surrey
Royal College of Emergency Medicine Difficult Airway Society Association of Anaesthetists of GB and … +7 more
Concerns summary Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their competency.
Action taken summary NHS England noted the anaesthesia concerns were outside its remit and highlighted the ongoing Leng Review for Physician Associate (PA) roles. It referenced existing NHSE guidance on safe PA deployment
Lady Lola Crouch
All Responded
2025-0101 21 Feb 2025 Essex
Mid & South Essex NHS Trust
Concerns summary The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to urgent patient deterioration.
Action taken summary The Trust has established a hospital out-of-hours service in the surgical department and reiterated the Medical Emergency call and NEWS escalation processes to staff. They also state that necessary ch
Ann Cotgrove
All Responded
2025-0103 21 Feb 2025 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Action taken summary The Health Board has developed a case summary presentation which will be shared across services through clinical governance meetings to ensure learning from the case. They are also actively progressin
Kenneth Clayton
All Responded
2025-0094 19 Feb 2025 Manchester South
Department of Health and Social Care
Concerns summary Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management protocols.
Action taken summary DHSC outlines national plans for 2025-26 to improve urgent and emergency care, including targets for A&E waiting times, increasing same-day emergency care, and reducing discharge delays. The governmen
Philip Unwin
All Responded
2025-0095 19 Feb 2025 Staffordshire and Stoke on Trent
NHS England Royal Stoke University Hospital
Concerns summary Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for patient-to-nurse ratios.
Action taken summary NHS England reports that Royal Stoke University Hospital has implemented new pathways for Acute Medicine in ED Same Day Emergency Care, introduced a daily ED Huddle and a 'Senior Decision Maker' role,
Margaret Rodgers
All Responded
2025-0096 19 Feb 2025 Surrey
Surrey and Sussex Healthcare NHS Trust
Concerns summary Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely ill patients.
Carl Eastman
All Responded
2025-0093 17 Feb 2025 Inner North London
Royal Free London NHS Foundation Trust
Concerns summary There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, indicating potential skills deficits.
Action taken summary Royal Free London NHS Foundation Trust has updated its policy to remove the requirement for consultant radiologist review before requesting CT scans, and clarified this to staff. They have also review
Brigitte Favre
All Responded
2025-0639 12 Feb 2025 Suffolk
Suffolk and North East Essex Integrated… West Suffolk Hospital
Concerns summary A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking adverse outcomes.
Action taken summary West Suffolk NHS Foundation Trust has implemented a new Oncology discharge planning tool, launched in February 2026, to standardise communication and inform discharge decision-making. They are also ex
Nicholas J’Dourou
All Responded
2025-0081 11 Feb 2025 Inner London North
Royal College of Psychiatrists
Concerns summary A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards raises concerns about insufficient monitoring.
Action taken summary The Royal College of Psychiatrists has provided advice on cross-titration of medication through existing publications and supports the use of the Maudsley Prescribing Guidelines. For video observation
John Tompkins
All Responded
2025-0082 11 Feb 2025 Inner London North
Royal Free Hospital
Concerns summary The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Action taken summary Royal Free Hospital has conducted a comprehensive systems-based review into Mr Tompkins' death and committed to several future actions. These include developing a formal escalation pathway for MDT dis
Yahya Hayat
All Responded
2025-0086 10 Feb 2025 Greater Manchester South
Royal College of Paediatrics and Child …
Concerns summary Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal resuscitation.
Action taken summary The RCPCH explains that while mandatory direct observed training for neonatal intubation has been removed, key capabilities for airway management have been strengthened, aligning with evidence for non
Amelia Ridout
All Responded
2025-0077 7 Feb 2025 Cambridgeshire and Peterborough
British Society for Haematology (BSH) National Institute for Health and Care … NHS England
Concerns summary A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice and missed learning.
Action taken summary NHS England states that developing clinical guidelines or a database for BMA and trephine biopsy does not sit within their remit. However, they commit to investigating evidence regarding training/supe
Katrina Insleay
All Responded
2025-0084 6 Feb 2025 Worcestershire
Herefordshire and Worcestershire Health… Worcestershire Acute Hospitals Trust
Concerns summary The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed follow-up and increased wound infection.
Action taken summary The Health and Care Trust is granting Neighbourhood Team staff access to the Acute Trust's electronic patient record, with 18 of 26 staff already having access. Additionally, the Acute Trust has devel
Terence Grainger
All Responded
2025-0067 5 Feb 2025 Manchester South
Circle Health Group Ltd
Concerns summary Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient deterioration trends.
Action taken summary Circle Health Group has successfully introduced digitised systems for consent, pathology, and imaging requests, with all new equipment designed to integrate with electronic patient records. They affir
Sapphire Bernard
All Responded
2025-0070 5 Feb 2025 West Sussex, Brighton and Hove
NHS Sussex Integrated Care Board NHS England & NHS Improvement
Concerns summary Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
Action taken summary NHS England has opened an additional 80 mental health beds since Spring 2024 and introduced national monitoring of A&E patients waiting over 72 hours for mental health placements, with individual case
Leslie Hurwood
All Responded
2025-0078 5 Feb 2025 Northamptonshire
NORTHAMPTON GENERAL HOSPITAL NHS TRUST
Concerns summary Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct medication procedures.
Action taken summary The Trust immediately reinforced insulin administration practices through ward visits, created and used dedicated huddle sheets, and conducted an audit of insulin patients. They have established an In
Dorothy Reid
All Responded
2025-0071 4 Feb 2025 North East Kent
Department of Health and Social Care NHS England
Concerns summary Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
Action taken summary NHS England's 2023 Urgent & Emergency Care Recovery Plan has improved 4-hour ED performance, with 2.5 million more patients treated within target. They are also collecting weekly data on patients wait
Carla Smith
All Responded
2025-0050 29 Jan 2025 Norfolk
Department of Health and Social Care
Concerns summary Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss of treatment options.
Action taken summary The Department acknowledges concerns about long gynaecological waiting lists and lack of patient monitoring. NHS England is expanding elective care reform initiatives, increasing Clinical Diagnostic U
William Northcott
All Responded
2025-0069 27 Jan 2025 Devon, Plymouth and Torbay
Medicines and Healthcare Projects Devon ICB Pembroke Medical Practice +1 more
Concerns summary Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for this cardiotoxic drug.
Action taken summary NHS Devon will provide additional funding to Devon Partnership NHS Trust in the 2025/26 financial year to implement more Clozapine clinics. They will also ensure that any changes to national policy re
Cynthia Gilbert
All Responded
2025-0061 24 Jan 2025 Somerset
Somerset NHS Foundation Trust
Concerns summary Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and the efficacy of post-death investigations.
Action taken summary Somerset NHS Foundation Trust has launched a Quality Improvement project to enhance intentional rounding, recruited two Tissue Viability Nurse Specialists, and implemented new multi-disciplinary team
Brian Kneale
All Responded
2025-0043 23 Jan 2025 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Action taken summary Blackpool Teaching Hospitals NHS Foundation Trust has launched a Clinical Community to embed fluid balance work and developed a new, enhanced fluid balance chart for imminent rollout. They have also r
Fahmida Khanam
All Responded
2025-0039 22 Jan 2025 West Yorkshire (East)
General Medical Council
Concerns summary A doctor treated a close relative, breaching the cardinal principle of medical ethics.
Action taken summary Saville Town Medical Centre will immediately adopt a protocol/procedure to ensure GPs do not treat immediate family members, aligning with GMC guidelines. The GMC clarifies that their guidance advises