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 1,612 classified responses

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PFD Reports

2,487 results

Marjorie Ellery

2014-0519 26 Nov 2014 Surrey

Frimley Park Hospital

Concerns summary Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.

Amanda Hawkins

Partially Responded

2014-0516 26 Nov 2014 Staffordshire (South)

West Midlands Police Walsall and Dudley Mental Health NHS Tr…

Concerns summary Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.

Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer

2014-0520 25 Nov 2014 London Inner (North)

Concerns summary Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.

Stephen Mayoll

2014-0515 25 Nov 2014 Portsmouth & South East Hampshire

Portsmouth Hospitals NHS Trust

Concerns summary The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.

Sandra Bodrozic

Historic (No Identified Response)

2014-0560 24 Nov 2014 London Inner (North)

Camden & Islington NHS Foundation Trust

Concerns summary Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.

Harold Penny

2014-0507 24 Nov 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.

William Jackson

2014-0509 24 Nov 2014 Cumbria (North & West)

Newcastle Foundation NHS Trust

Concerns summary The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which risks lives.

William Hafele

2014-0511 24 Nov 2014 Surrey

Surrey Police Surrey and Borders Partnership NHS Foun…

Concerns summary Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete failure to investigate Mr. Hafele's whereabouts.

Tracey Bannister

2014-0506 21 Nov 2014 Black Country

Walsall Healthcare NHS Trust

Concerns summary Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.

Martin McCabe

Historic (No Identified Response)

2014-0505 20 Nov 2014 Powys, Bridgend & Glamorgan Valleys

Cwm Taf Health Board

Concerns summary The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.

George Werb

Partially Responded

2014-0510 19 Nov 2014 Exeter & Greater Devon

Devon Clinical Commissioning Group NHS England

Concerns summary The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family involvement, and inadequate communication.

Elsie Mallalieu

2014-0501 17 Nov 2014 Manchester (South)

Tameside NHS Foundation Trust

Concerns summary Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.

Peter Dorney

2014-0504 17 Nov 2014 Avon

Southmead Hospital

Concerns summary Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.

Patricia Mellor

Historic (No Identified Response)

2014-0491 12 Nov 2014 Nottinghamshire

Medicines and Healthcare Product Regula… National Institute for Health and Care … National Patient Safety Agency +1 more

Concerns summary Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.

Neophytos Constantinou

Historic (No Identified Response)

2014-0498 12 Nov 2014 London Inner (North)

Chalfont Road Surgery Royal Free London NHS Foundation Trust

Concerns summary Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.

Beryl Walters

Historic (No Identified Response)

2014-0489 11 Nov 2014 Black Country

College of Emergency Medicine National Institute for Clinical Excelle…

Concerns summary Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.

Roseanne Cooke

2014-0485 10 Nov 2014 Manchester (South)

Concerns summary Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.

Mark Hancock

Historic (No Identified Response)

2014-0484 10 Nov 2014 Manchester (South)

Concerns summary Critical failures include poor record-keeping, absent risk assessments, inadequate post-concern patient assessment, and a lack of procedures for managing patients requiring admission when beds are unavailable.

Mark Hudson

2014-0478 4 Nov 2014 Blackpool & Fylde

Blackpool Teaching Hospitals NHS Trust

Concerns summary Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.

Sandra Higham

2014-0479 3 Nov 2014 London (Inner South)

Department of Health and Social Care

Concerns summary A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.

Christopher Ajayi

2014-0558 31 Oct 2014 London (Inner South)

South London and Maudsley trust

Concerns summary A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe failures in discharge planning and care coordination.

Maureen Ellett

2014-0473 31 Oct 2014 Brighton and Hove

Royal Sussex County Hospital Brighton and Sussex University Hospital…

Concerns summary Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.

Polly Carpenter

2014-0469 28 Oct 2014 Exeter & Great Devon

Devon Partnership NHS Trust

Concerns summary The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.

Betty Smith

Historic (No Identified Response)

2014-0467 27 Oct 2014 Kent (South East & Central)

East Kent Hospitals University NHS Foun…

Concerns summary Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.

Jackson Mitchell

Partially Responded

2014-0468 27 Oct 2014 Norfolk

NHS England Queen Elizabeth Hospital King’s Lynn NH… Norfolk and Norwich University Hospital…

Concerns summary The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.