Hospital Death (Clinical Procedures and medical management) related deaths

PFD Category

Reports: 2,487 Areas: 72 Earliest: Feb 2013 Latest: 19 Mar 2026

71% response rate (above 62% average). 57% of classified responses show concrete action taken. Reports rose 33% from 176 (2023) to 234 (2024).

Responded 1,770 No Response 18 Historic 619 Pending 33

Action Taken 57%

Action Planned 24%

Noted 13%

Disputed 6%

Based on 1,612 classified responses

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PFD Reports

2,487 results

Neil Westerman

2015-0091 11 Mar 2015 Manchester (South)

Stockport NHS Foundation Trust

Concerns summary Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, especially at night.

Darren Linfoot

Historic (No Identified Response)

2015-0089 9 Mar 2015 Berkshire

West London Mental Health NHS Trust

Concerns summary Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.

Leonardus Vries

2015-0088 9 Mar 2015 Worcestershire

Royal Orthopaedic Hospital NHS Foundati…

Concerns summary Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.

Connor Turner

2015-0082 6 Mar 2015 West Yorkshire (East)

Leeds Teaching Hospitals NHS Trust

Concerns summary There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of apparatus function and user competence before patient discharge.

Thor Dalhaug

2015-0063 6 Mar 2015 Lincolnshire (Central)

United Lincolnshire Hospitals NHS Trust

Concerns summary Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.

Mary Marshall

2015-0084 6 Mar 2015 Manchester (West)

Department of Health and Social Care

Concerns summary A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.

Archie Hexall

2015-0081 5 Mar 2015 London (Inner South)

Lewisham and Greenwich NHS Trust

Concerns summary A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.

Michael Pollard

2015-0078 5 Mar 2015 Leicester (City & South)

University Hospitals of Leicester NHS T…

Concerns summary An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, up-to-date system.

Colin Tyson

2015-0080 4 Mar 2015 South Yorkshire (East)

Concerns summary Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.

David Bladen

2015-0079 4 Mar 2015 South Yorkshire (East)

National Institute for Health and Care …

Concerns summary There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.

Brian Francis

Partially Responded

2015-0085 4 Mar 2015 Powys, Bridgend & Glamorgan Valleys

Abertawe Bro Morgannwg University Healt… National Assembly for Wales

Concerns summary A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.

Thomas Taylor

Historic (No Identified Response)

2015-0076 3 Mar 2015 County Durham

County Durham and Darlington NHS Founda…

Concerns summary The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.

Paige Bell

2015-0075 3 Mar 2015 Sunderland

Department of Health and Social Care

Concerns summary Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.

Peter Wright

2015-0073 2 Mar 2015 Staffordshire (South)

South Staffordshire and Shropshire NHS …

Concerns summary Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the hospital lacks adequate out-of-hours doctor cover, relying on paramedics.

Simon Costin

2015-0071 26 Feb 2015 Leicester (City & South)

Concerns summary Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication and care continuity for mental health patients across different trusts.

Richard Jones

2015-0068 20 Feb 2015 Wiltshire & Swindon

Avon and Wiltshire NHS Mental Health Pa… Department of Health and Social Care Ministry of Defence +3 more

Concerns summary Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.

Lexie Harrison

Partially Responded

2015-0070 20 Feb 2015 West Yorkshire (East)

British Society of Paediatric Gastroent… Leeds Teaching Hospitals NHS Trust Sheffield Children’s NHS Foundation Tru…

Concerns summary A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.

Laura Hill

2015-0092 20 Feb 2015 Carmarthenshire & Pembrokeshire

Hywel Dda University Health Board

Concerns summary There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs regarding Section 136 procedures, absconding, and powers of detention.

Alexander Ball

2015-0069 19 Feb 2015 Cumbria

Cumbria Partnership NHS Foundation Trust

Concerns summary Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, resulted in inadequate care coordination for complex patients.

Barrie Lewis

2015-0065 19 Feb 2015 Powys, Bridgend & Glamorgan Valleys

Cwm Taf Health Board

Concerns summary The provided text describes the deceased's manner of death but does not articulate any specific systemic failures or safety concerns that need addressing to prevent future deaths.

John Dack

2015-0151 19 Feb 2015 London Inner (North)

Concerns summary Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted in serious consequences.

Alan Jones

Partially Responded

2015-0059 18 Feb 2015 Swansea & Neath Port Talbot

NHS England NHS Wales Royal College of General Practitioners +1 more

Concerns summary Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented important patient conditions from being clearly highlighted as alerts.

Henry Powell

2015-0058 18 Feb 2015 Leicester (City & South)

Leicester Partnership Trust University Hospitals of Leicester

Concerns summary Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between hospital and community services, and inadequate coordination for equipment provision and follow-up.

George Marks

2015-0057 17 Feb 2015 Mid Kent & Medway

Mayday Health Care Plc

Concerns summary Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.

Mohammed Yousaf

Historic (No Identified Response)

2015-0056 16 Feb 2015 Manchester (North)

Department of Health and Social Care Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and Gyna…

Concerns summary There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with dissemination, application, and applicability, particularly concerning informed consent.