Hospital Death (Clinical Procedures and medical management) related deaths

PFD Category
Reports: 2,483 Areas: 72 Earliest: Feb 2013 Latest: 11 Mar 2026

72% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 33% from 176 (2023) to 234 (2024).

Response Status
Responded 1,777 No Response 17 Historic 613 Pending 31
AI Classification
Action Taken 55%
Action Planned 24%
Noted 15%
Disputed 7%
Based on 652 classified responses
Reports by Quarter
PFD Reports
2,483 results
Winnie Harrop
All Responded
2025-0151 19 Mar 2025 Manchester South
NHS England Department of Health and Social Care
Concerns summary Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing critical information in discharge letters.
Action taken summary NHS England reports that Tameside and Glossop Integrated Care NHS Foundation Trust has completed the immediate deployment of the Royal College of Emergency Medicine Guideline for Procedural Sedation i
Renate Mark
All Responded
2025-0149 18 Mar 2025 Northumberland
NORTHUMBRIA HEALTHCARE NHS FOUNDATION T…
Concerns summary The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line of sight' observation for high-risk patients. Inadequate scrutiny of witness statements hinders learning.
Action taken summary Northumbria NHS is briefing all clinical staff on the accurate understanding and use of 'witnessed' versus 'unwitnessed' falls. Trust Governance Leads will now be involved in all internal investigatio
Alonzo Wood
All Responded
2025-0152 18 Mar 2025 West Sussex, Brighton and Hove
National Institute for Health and Care … Royal College of Obstetricians and Gyna…
Concerns summary Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to inconsistent reliance on individual clinical judgment.
Action taken summary The RCOG acknowledges the concern but states that due to clinical variability, individualised care and professional judgment are essential, and there is no national guidance on antenatal CTG interpret
Colin Colley
All Responded
2025-0145 17 Mar 2025 South Wales Central
Cardiff & Vale University Health Board
Concerns summary Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, enhanced supervision, and proper documentation, risking future deaths.
Action taken summary Cardiff and Vale University Health Board has delivered extensive falls prevention training (March 2025) and launched a new education package (May 2025), with an e-learning module in development. They
Billie Wicks
All Responded
2025-0146 17 Mar 2025 Inner North London
Royal College of Paediatrics and Child … Royal Free Hospital Royal College of Emergency Medicine
Concerns summary The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on adult onset asthma and ineffective safety netting advice contributed to the death.
Action taken summary The Royal College of Emergency Medicine clarifies existing guidelines and standards related to staffing and physiological observations, including that a new ED version of the national paediatric early
Barry Myers
All Responded
2025-0141 12 Mar 2025 West Sussex, Brighton and Hove
NHS England University Hospitals Sussex NHS Foundat…
Concerns summary Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.
Action taken summary NHS England states that mechanical thrombectomy services have been commissioned since 2019, with 24/7 access now available across the South East region via specialist centres and mutual aid. All PFD r
Christopher Bradbury
All Responded
2025-0134 11 Mar 2025 Staffordshire
Royal Stoke University Hospital NHS England
Concerns summary A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and an absence of an audit trail for omitted medication doses, creates significant patient safety risks.
Action taken summary NHS England will seek to ensure emphasis on escalation of deteriorating patients within statutory and mandatory training for infection and prevention control this year. For national guidelines on seve
Allan Taylor
All Responded
2025-0138 11 Mar 2025 Sunderland
South Tyneside and Sunderland NHS Found…
Concerns summary Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. This lack of escalation and compliance likely contributed to an unwitnessed fall.
Action taken summary The Trust conducted an urgent review and has amended its EICO guideline, renaming it Enhanced Therapeutic Observation and Care (ETOC). The new guideline clarifies observation levels, assessment, escal
Henok Gebrsslasie
All Responded
2025-0124 6 Mar 2025 Coventry
Coventry and Warwickshire Partnership N…
Concerns summary Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have not been implemented in a psychiatric unit for over 42 months.
Action taken summary Coventry and Warwickshire Partnership NHS Trust has implemented several safety improvements, including reducing ligature points and fitting door top alarms in all acute inpatient wards. They have also
Annette Lewis
All Responded
2025-0126 6 Mar 2025 South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and errors in emergency departments.
Action taken summary Cwm Taf Morgannwg University Health Board has implemented an active and updated General Surgery policy, applying to both General Surgeons and the Emergency Department. This policy provides clear guide
Mark Fernandez
All Responded
2025-0147 4 Mar 2025 Manchester North
Northern Care Alliance NHS Foundation T… Oldham Council NHS Greater Manchester Integrated Care …
Concerns summary Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term carers and social services.
Action taken summary NHS GM has issued 'Take 5 Briefings' to staff on responsibilities for patients with learning disabilities and complex needs, safeguarding, and the importance of hospital passports. A locality practice
William Green
All Responded
2025-0113 28 Feb 2025 Shropshire, Telford & Wrekin
Shrewsbury and Telford NHS Trust NHS England
Concerns summary The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to take, including for those without capacity.
Action taken summary NHS England reports that Shrewsbury and Telford Hospital NHS Trust has developed a Safety Improvement Plan, including establishing a working group to review patient counselling on medications, using l
Khadija Kerri
All Responded
2025-0109 25 Feb 2025 South Yorkshire (East)
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and treating a patient's fractures.
Action taken summary Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has reviewed its Failsafe Alert for Radiological Findings (Communication Protocol) and plans for its approval and implementation by July
Amy Padley
All Responded
2025-0105 24 Feb 2025 SWANSEA & NEATH PORT TALBOT
SWANSEA BAY UNIVERSITY HEALTH BOARD
Concerns summary Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.
Action taken summary Swansea Bay University Health Board has completed the development of a comprehensive Standard Operating Procedure (SOP) and Care Pathway for individuals with co-occurring mental health and substance u
Pamela Marking
All Responded
2025-0107 24 Feb 2025 Surrey
Surrey and Sussex Healthcare NHS Founda… Department of Health and Social Care NHS England +7 more
Concerns summary Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their competency.
Action taken summary NHS England noted the anaesthesia concerns were outside its remit and highlighted the ongoing Leng Review for Physician Associate (PA) roles. It referenced existing NHSE guidance on safe PA deployment
Lady Lola Crouch
All Responded
2025-0101 21 Feb 2025 Essex
Mid & South Essex NHS Trust
Concerns summary The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to urgent patient deterioration.
Action taken summary The Trust has established a hospital out-of-hours service in the surgical department and reiterated the Medical Emergency call and NEWS escalation processes to staff. They also state that necessary ch
Ann Cotgrove
All Responded
2025-0103 21 Feb 2025 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Action taken summary The Health Board has developed a case summary presentation which will be shared across services through clinical governance meetings to ensure learning from the case. They are also actively progressin
Paul Dunne
Partially Responded
2025-0104 21 Feb 2025 South London
NHS England Department of Health and Social Care Care Quality Commission +1 more
Concerns summary Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial information sharing between departments.
Action taken summary NHS England has recently updated the Mental Health Liaison Team (MHLT) policy, which now outlines required documentation for MHLTs to transfer to acute trust electronic recording systems to ensure cli
Kenneth Clayton
All Responded
2025-0094 19 Feb 2025 Manchester South
Department of Health and Social Care
Concerns summary Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management protocols.
Action taken summary DHSC outlines national plans for 2025-26 to improve urgent and emergency care, including targets for A&E waiting times, increasing same-day emergency care, and reducing discharge delays. The governmen
Philip Unwin
All Responded
2025-0095 19 Feb 2025 Staffordshire and Stoke on Trent
NHS England Royal Stoke University Hospital
Concerns summary Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for patient-to-nurse ratios.
Action taken summary NHS England reports that Royal Stoke University Hospital has implemented new pathways for Acute Medicine in ED Same Day Emergency Care, introduced a daily ED Huddle and a 'Senior Decision Maker' role,
Margaret Rodgers
All Responded
2025-0096 19 Feb 2025 Surrey
Surrey and Sussex Healthcare NHS Trust
Concerns summary Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely ill patients.
Carl Eastman
All Responded
2025-0093 17 Feb 2025 Inner North London
Royal Free London NHS Foundation Trust
Concerns summary There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, indicating potential skills deficits.
Action taken summary Royal Free London NHS Foundation Trust has updated its policy to remove the requirement for consultant radiologist review before requesting CT scans, and clarified this to staff. They have also review
Brigitte Favre
All Responded
2025-0639 12 Feb 2025 Suffolk
Suffolk and North East Essex Integrated… West Suffolk Hospital
Concerns summary A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking adverse outcomes.
Action taken summary West Suffolk NHS Foundation Trust has implemented a new Oncology discharge planning tool, launched in February 2026, to standardise communication and inform discharge decision-making. They are also ex
Nicholas J’Dourou
All Responded
2025-0081 11 Feb 2025 Inner London North
Royal College of Psychiatrists
Concerns summary A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards raises concerns about insufficient monitoring.
Action taken summary The Royal College of Psychiatrists has provided advice on cross-titration of medication through existing publications and supports the use of the Maudsley Prescribing Guidelines. For video observation
John Tompkins
All Responded
2025-0082 11 Feb 2025 Inner London North
Royal Free Hospital
Concerns summary The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Action taken summary Royal Free Hospital has conducted a comprehensive systems-based review into Mr Tompkins' death and committed to several future actions. These include developing a formal escalation pathway for MDT dis