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

Freda Weston

2016-0080 23 Feb 2016 Manchester (South)

Stockport NHS Foundation Trust

Concerns summary Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.

Clifford Crofts

2016-0066 22 Feb 2016 Surrey

Ashford and St Peter’s Hospital Trust

Concerns summary A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.

Brenda Morris

2016-0065 19 Feb 2016 London Inner (North)

East London NHS Foundation Trust

Concerns summary Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.

Geoffrey Moyse

Partially Responded

2016-0067 19 Feb 2016 Brighton and Hove

Brighton and Sussex University Hospital… Brighton and Hove Integrated Care Servi… Brighton and Hove Clinical Commissionin…

Concerns summary The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Geoffrey Moyse's death.

Euphemia Aldred

Historic (No Identified Response)

2016-0062 18 Feb 2016 Blackburn, Hyndburn and Ribble Valley

East Lancashire Healthcare NHS Trust

Concerns summary The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Euphemia Aldred's death.

Vanessa Dadswell

Partially Responded

2016-0060 17 Feb 2016 Surrey

Sussex Partnership NHS Foundation Trust West Sussex County Council

Concerns summary Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.

Matthew Crowley

Historic (No Identified Response)

2016-0063 17 Feb 2016 Mid Kent and Medway

Maidstone and Tunbridge Wells NHS Trust

Concerns summary A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.

Eric Gaskell

2016-0057 16 Feb 2016 Manchester (West)

Royal Bolton Hospital

Concerns summary Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy hours.

Philip Denning

Historic (No Identified Response)

2016-0058 16 Feb 2016 Nottinghamshire

NHS England Nottinghamshire healthcare NHS Foundati…

Concerns summary Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of available help pose significant risks.

Peter Tye

2016-0050 15 Feb 2016 Plymouth, Torbay and South Devon

Department of Health and Social Care

Concerns summary Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.

Eileen Thompson

Partially Responded

2016-0051 15 Feb 2016 Warwickshire

George Eliot Hospital NHS Trust NHS England Welsh Government

Concerns summary A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a wall, creating a risk of the bed moving and potentially injuring patients.

Adam Withers

2016-0059 15 Feb 2016 Surrey

Surrey and Borders Partnership NHS Trust NHS England Department of Health and Social Care

Concerns summary Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.

Sandra Wood

2016-0048 12 Feb 2016 North West Kent

Maidstone and Tonbridge Wells NHS Trust

Concerns summary The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.

Marilyn Anson

Historic (No Identified Response)

2016-0054 12 Feb 2016 Avon

North Somerset Clinical Commissioning G… Weston Area Health NHS Trust

Concerns summary Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.

Terence Brooks

Historic (No Identified Response)

2016-0056 12 Feb 2016 Avon

Bath and North East Somerset Clinical C… Care Quality Commission Royal United Hospitals Bath NHS Foundat…

Concerns summary The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection source.

Margaret Hions

2016-0047 12 Feb 2016 Carmarthenshire and Pembrokeshire

West Wales General Hospital

Concerns summary Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

Marion Howes

Historic (No Identified Response)

2016-0046 11 Feb 2016 Brighton and Hove

Brighton and Sussex University Hospital…

Concerns summary No specific concerns text was provided to summarise.

David Hughes

2016-0040 9 Feb 2016 Leicestershire City and South Leicestershire

Leicestershire Partnership NHS Trust

Concerns summary Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.

Douglas Kay

2016-0033 5 Feb 2016 Nottinghamshire

Doncaster and Bassetlaw Hospital NHS Fo…

Concerns summary There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.

David Mostari

2016-0034 5 Feb 2016 Bedfordshire and Luton

Bedford Hospital NHS Trust

Concerns summary Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted outside of weekdays.

Isla Lord

2016-0035 5 Feb 2016 Bedfordshire and Luton

Princess Alexandra Hospital NHS Trust

Concerns summary A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.

Ryan Singh Bhogal

Partially Responded

2016-0038 2 Feb 2016 Black Country

Lockfield Surgery New Cross Hospital

Concerns summary GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical records during admission.

Marc Poole

2016-0045 2 Feb 2016 South Yorkshire (East)

Doncaster and Bassetlaw NHS Foundation …

Concerns summary Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.

Louise Locke

2016-0026 29 Jan 2016 Central Hampshire

Southern Health NHS Foundation Trust

Concerns summary Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.

Antony Briggs

2016-0028 28 Jan 2016 Manchester (South)

Stockport NHS Foundation Trust

Concerns summary Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.