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

Filter:

PFD Reports

2,487 results

Maureen Flynn

2016-0310 26 Aug 2016 Manchester (South)

Stepping Hill Hospital

Concerns summary A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.

Kyles Lowes

Partially Responded

2016-0307 26 Aug 2016 North Northumberland

NEAS NHS Trust NHS Northumberland Clinical Commissioni…

Concerns summary Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed responses. The proposed solution relies on staff goodwill and doesn't fully mitigate risks.

Michael Dundon

2016-0305 23 Aug 2016 West Yorkshire (East)

Department of Health and Social Care

Concerns summary Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk assessment, staff awareness, and training.

Nicholas Sullivan

Historic (No Identified Response)

2016-wp25385 22 Aug 2016 Manchester City

Manchester Mental Health and Social Car… North Manchester General Hospital

George Watson

Historic (No Identified Response)

2016-wp25378 19 Aug 2016 Coventry

Coventry University Hospital University Hospitals Coventry and Warwi…

Concerns summary Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.

Margaret Richardson

Historic (No Identified Response)

2016-wp25380 19 Aug 2016 Essex

North Essex Mental Health Partnership T…

Nathan Lowe

2016-wp25387 19 Aug 2016 City of London

Hertfordshire Partnership University NH…

Diana Ritchie

2016-wp25376 18 Aug 2016 Brighton and Hove

Brighton and Sussex University Hospital…

Harry Glibbery

2016-wp25368 16 Aug 2016 Plymouth Torbay and South Devon

Plymouth Hospitals NHS Trust

Jean Stockley

2016-wp25360 12 Aug 2016 West Sussex

Royal Sussex County Hospital

Michael Blow

Historic (No Identified Response)

2016-wp25367 12 Aug 2016 Portsmouth and South East Hampshire

Portsmouth Hospitals NHS Trust

Anthony Preston

Historic (No Identified Response)

2016-wp25351 11 Aug 2016 Rutland and North Leicestershire

Cheadle Leicestershire Partnership NHS Trust Priory Hospital

Thomas Jordan

Partially Responded

2016-0287 10 Aug 2016 Yorkshire West (East)

Head of Healthcare HMP Leeds Leeds Teaching Hospitals +2 more

Concerns summary Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.

Winston Harris

2016-wp25349 3 Aug 2016 Birmingham and Solihull

Birmingham City Council Sandwell and West Birmingham Hospitals …

Joshua Knox-Hooke

2016-wp25346 1 Aug 2016 London Greater (East)

North Middlesex University Hospital NHS…

Pamela Gressman

2016-wp25347 1 Aug 2016 County Durham and Darlington

Tees, Esk and Wear Valleys NHS Foundati…

Concerns summary There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.

Danny Sweet

2016-wp25341 29 Jul 2016 Cornwall and the Isles of Scilly

Cornwall Partnership Foundation Trust

Leslie Morrison

Partially Responded

2016-wp25337 28 Jul 2016 Manchester City

Central Manchester University Hospitals… Manchester Mental Health and Social Car… Regard Care

Cerith Pugh

2016-0271 27 Jul 2016 Carmarthenshire and Pembrokeshire

Hywel Dda University Health Board

Concerns summary Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a mechanism for clinical override.

James Hedge

2016-wp25334 27 Jul 2016 South Wales Central

Medicines and Healthcare Products Regul… NHS England NHS Wales +1 more

Concerns summary Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.

Margaret Tuck

2016-0273 26 Jul 2016 London Inner (North)

Royal London Hospital

Concerns summary Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.

Leslie Matthews

Partially Responded

2016-0276 26 Jul 2016 County Durham and Darlington

County Durham and Darlington NHS Founda… Medicines and Healthcare Products Regul… Patient Safety Lead

Terence Adams

Partially Responded

2016-wp25340 26 Jul 2016 London Inner (North)

Care UK HMP Pentonville

Concerns summary Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.

Stephen Bird

2016-0265 22 Jul 2016 Buckinghamshire

BMI The Shelburne Hospital

Concerns summary Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.

Alan Stead

2016-0261 22 Jul 2016 Staffordshire (South)

Concerns summary Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.