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 1,781 No Response 16 Historic 613 Pending 32

Action Taken 57%

Action Planned 24%

Noted 13%

Disputed 6%

Based on 1,431 classified responses

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PFD Reports

2,487 results

Christopher Brennan

Historic (No Identified Response)

2016-0433 5 Dec 2016 London (South)

Resuscitation Council (UK) South London and Maudsley NHS Trust

Concerns summary The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their prior successful use in airway obstructions.

Brian Gerrard

Historic (No Identified Response)

2016-0432 5 Dec 2016 Cheshire

Abbey Court Independent Hospital

Concerns summary Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led to inaccurate decision-making and documentation.

Peter Usher

2016-0428 2 Dec 2016 London (East)

North East London NHS Trust

Concerns summary Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.

Emma Timbrell

Historic (No Identified Response)

2016-0426 30 Nov 2016 Worcestershire

Worcestershire Health and Care NHS Trust

Concerns summary Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited means.

John Atkinson

2016-0429 29 Nov 2016 South Yorkshire (East)

Rotherham NHS Trust

Concerns summary Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Rex Hall

2016-0422 29 Nov 2016 Birmingham and Solihull

Health and Care Professions Council

Concerns summary Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.

Beryl Farmer

2016-0420 24 Nov 2016 Black Country

Sandwell and West Birmingham Hospital N…

Concerns summary A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.

Patrick Steer

Partially Responded

2016-0427 23 Nov 2016 Manchester (West)

Warrington Wrightington, Wigan and Leigh Teaching …

Concerns summary Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.

Denis Plater

21 Nov 2016 Mid Kent and Medway

Concerns summary Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring system, and inadequate monitoring of agency staff training.

Christopher MacMorland

2016-0415 16 Nov 2016 Portsmouth and South East Hampshire

Portsmouth Hospitals NHS Trust

Concerns summary Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing consultant-recommended patient transfers.

Margaret Wakefield

2016-0413 14 Nov 2016 Cornwall and the Isles of Scilly

Royal Cornwall Hospital

Concerns summary Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital treatments.

David Knight

2016-0414 14 Nov 2016 Cornwall and the Isles of Scilly

Department for Health NHS England

Concerns summary National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.

Karen Thorne

2016-0408 11 Nov 2016 Manchester (West)

Department of Health and Social Care

Concerns summary Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.

Melanie Lowe

2016-0404 11 Nov 2016 Essex

North Essex University NHS Trust

Concerns summary The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.

Simon Harper

Historic (No Identified Response)

2016-0410 9 Nov 2016 South Yorkshire (West)

Department for Health

Concerns summary Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.

Maurice Isaacs

Partially Responded

2016-0411 7 Nov 2016 South Wales Central

Cardiff and the Vale University Health … Minister for Health Welsh Assembly Gove…

Concerns summary Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.

Ivy Morris

Historic (No Identified Response)

2016-0393 2 Nov 2016 Shropshire, Telford and Wrekin

Shrewsbury and Telford NHS Trust

Concerns summary Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent experience for an essential procedure.

Trevor Hunking

2016-0391 1 Nov 2016 Plymouth Torbay and South Devon

Health Education England

Concerns summary A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.

James Flynn

Historic (No Identified Response)

2016-0390 31 Oct 2016 Milton Keynes

Oxford University Hospital

Concerns summary Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.

Frederick Squires

2016-0389 31 Oct 2016 Milton Keynes

Concerns summary A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.

Barbara Turner

Historic (No Identified Response)

2016-0386 28 Oct 2016 Derby and Derbyshire

Derby Teaching Hospitals NHS Trust

Concerns summary The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.

Alfred Grimshaw

2016-0387 28 Oct 2016 Blackburn, Hyndham and Ribble Valley

East Lancashire Healthcare NHS Trust

Concerns summary A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.

Leslie Lerner

Historic (No Identified Response)

2016-0487 28 Oct 2016 Brighton and Hove

Brighton and Sussex University Hospital…

Concerns summary Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review and analgesia.

Alfie Rose

2016-0382 26 Oct 2016 Birmingham and Solihull

Dudley Group of Hospitals NHS Foundatio… University Hospitals Birmingham NHS Tru…

Concerns summary Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.

Matthew Llewellyn-Jones

2016-0385 25 Oct 2016 Exeter and Greater Devon

Devon Partnership Trust

Concerns summary Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family information on admission.