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

Samantha Beach

Historic (No Identified Response)

2015-0413 21 Oct 2015 Gloucestershire

Gloucestershire Hospitals NHS Trust

Concerns summary There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for a post-natal patient.

David Baddeley

2015-0451 21 Oct 2015 Manchester (South)

Greater Manchester NHS Area Team

Concerns summary Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.

William Abel

2015-0406 20 Oct 2015 Leicester City and Leicestershire South

Leicester Partnership NHS Trust

Concerns summary Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.

Vasilis Ktorakis

2015-0377 19 Oct 2015 London Inner (North)

Whittington Hospital NHS Trust

Concerns summary Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing feedback prevented staff learning and improvement.

Adrian Smith

Partially Responded

2015-0378 16 Oct 2015 Birmingham and Solihull

Heart of England NHS Foundation Trust NHS England

Concerns summary A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.

Alan Tear

2015-0373 14 Oct 2015 Leicester City and Leicestershire South

University Hospitals of Leicester NHS T…

Concerns summary Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was unclear.

Mrs Withers

Historic (No Identified Response)

2015-0371 12 Oct 2015 Northampton

Kettering General Hospital NHS Trust

Concerns summary Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.

Suzanne Greenwood

2015-0370 9 Oct 2015 Manchester (West)

Priory Hospital

Concerns summary Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.

Patrick Carrick

2015-0374 9 Oct 2015 Newcastle Upon Tyne

North Tyneside General Hospital

Concerns summary There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes were inadequately completed.

Rebecca Jones

2015-0504 8 Oct 2015 Hertfordshire

Department of Health and Social Care

Concerns summary Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.

Maureen Chatterley

2015-0404 8 Oct 2015 Manchester (West)

Royal Bolton Hospital

Concerns summary Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.

Dilys Jenkins

Historic (No Identified Response)

2015-0399 7 Oct 2015 Cardiff and the Vale of Glamorgan

Intensive Care Society of England and W…

Concerns summary Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.

Geoffrey Parry

2015-0400 7 Oct 2015 Cardiff and the Vale of Glamorgan

Cardiff and Vale University Health Board

Concerns summary Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.

Rosina Drury

Historic (No Identified Response)

2015-0397 2 Oct 2015 London Inner (South)

Kings College Hospital

Concerns summary The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.

Jean Hannon

2015-0458 30 Sep 2015 Blackburn, Hyndburn and Ribble Valley

East Lancashire Healthcare NHS Trust

Concerns summary A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.

Ethan Johnson

2015-0393 29 Sep 2015 Milton Keynes

Milton Keynes Hospital

Concerns summary There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant attendance.

Parv Patel

2015-0457 29 Sep 2015 London (North)

Department of Health and Social Care

Concerns summary The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from recognising seriously ill children despite low scores.

Harry Pryal

2015-0391 28 Sep 2015 Manchester (West)

5 Boroughs Partnership NHS Trust Department of Health and Social Care Wigan Borough Clinical Commissioning Gr…

Concerns summary A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.

William Harnell

2015-0384 22 Sep 2015 Plymouth, Torbay and South Devon

Department of Health and Social Care Plymouth Hospitals NHS Trust Social Services Truro Cornwall

Concerns summary Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.

Liam Smith

Partially Responded

2015-0382 18 Sep 2015 Worcestershire

Governor HMP Hewell Worcestershire Health and Care Trust

Concerns summary Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.

Fiona Lewis

Historic (No Identified Response)

2015-0441 17 Sep 2015 Suffolk

Ipswich Hospital

Concerns summary There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.

Lee Bates

Partially Responded

2015-0381 17 Sep 2015 London Inner (South)

Guys and St Thomas NHS Trust Cambian Group

Concerns summary A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates an ongoing risk of avoidable deaths.

Mary James

4 Sep 2015 Powys

Concerns summary Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.

Rosalind Baird

2 Sep 2015 Portsmouth and South East Hampshire

Concerns summary There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.

Frederick Sutton

27 Aug 2015 Manchester (South)

Concerns summary Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.