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

Filter:

PFD Reports

2,487 results

Esther Jones

Historic (No Identified Response)

2014-0296 2 Jul 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.

John Adams

Historic (No Identified Response)

2014-0293 1 Jul 2014 Brighton & Hove

National Research Ethics Service National Patient Safety Agency Brighton and Sussex University Hospitals

Concerns summary No specific concerns or systemic failures were detailed in the provided text.

Dayani Chauhan-Ahmed

2014-0287 30 Jun 2014 Leicester City & South Leicestershire

University Hospitals of Leicester NHS T…

Concerns summary Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.

Ian Reid

2014-0288 30 Jun 2014 Cumbria (North & West)

Department of Health and Social Care

Jessica Bond

Historic (No Identified Response)

2014-0297 30 Jun 2014 Essex

Southend University Hospital

Concerns summary Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.

Sadik Miah

Historic (No Identified Response)

2014-0290 26 Jun 2014 London (Inner South)

South London and Maudsley NHS Trust

Concerns summary Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.

Marion Turner

Historic (No Identified Response)

2014-0300 25 Jun 2014 Essex

North Essex Partnership NHS Foundation …

Concerns summary A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to a significant and dangerous delay in response.

Ralph Goslin

2014-0282 25 Jun 2014 London Inner (North)

University College London Hospitals NHS…

Concerns summary An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.

Peter Hinchliffe

Historic (No Identified Response)

2014-0284 25 Jun 2014 South Yorkshire (East)

Sheffield Teaching Hospitals NHS Founda… Department of Health and Social Care NHS England +1 more

Concerns summary Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing risk.

Peter Farebrother

Historic (No Identified Response)

2014-0274 20 Jun 2014 Shropshire, Telford & Wrekin

South Stafford and Shropshire Healthcar…

Concerns summary Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.

Else Harvey-Samuel

Historic (No Identified Response)

2014-0278 20 Jun 2014 Suffolk

West Suffolk Hospital

Concerns summary Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.

Redmond Johnson

Historic (No Identified Response)

2014-0279 20 Jun 2014 Suffolk

Ministry of Justice NHS England

Concerns summary Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.

Samuel Openshaw

Historic (No Identified Response)

2014-0280 20 Jun 2014 Suffolk

East Anglia Team Coronary Heart Disease Review’s Clinica… Congenital Heart Services Clinical Refe… +1 more

Concerns summary Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.

Sol Hadhasseh

Historic (No Identified Response)

2014-0272 17 Jun 2014 Norfolk

Coventry and Warwickshire Partnership N…

Concerns summary A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic flaw in patient transfer procedures between Trusts.

Mrs Care

Historic (No Identified Response)

2014-0273 16 Jun 2014 Cornwall

Royal Cornwall Hospital Truro

Concerns summary Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.

Alun Sheppard

2014-0268 13 Jun 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.

Bridget Cahill

2014-0266 11 Jun 2014 Black Country

National Institute for Health and Clini…

Concerns summary A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, and drug accumulation in long-term therapy.

William Beckwith

2014-0258 9 Jun 2014 Derby & Derbyshire

Chesterfield Royal Hospital

Concerns summary A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.

John Cook

2014-0578 9 Jun 2014 Oxfordshire

Concerns summary Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.

Audrey Daws

Historic (No Identified Response)

2014-0318 9 Jun 2014 Plymouth, Torbay & South Devon

Plymouth Hospitals NHS Trust

Concerns summary Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for the patient's condition.

James McArdle

2014-0264 8 Jun 2014 Wirral

Arrow Park Hospital NHS Trust

Concerns summary The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.

James Boylan

Partially Responded

2014-0253 6 Jun 2014 Cumbria (South & East)

Care Quality Commission NHS England Department of Health and Social Care +2 more

Concerns summary Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.

Katie Davies

2014-0255 6 Jun 2014 Manchester (West)

Department of Health and Social Care

Concerns summary Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed appropriate care.

Frances Bell

Historic (No Identified Response)

2014-0299 6 Jun 2014 Essex

Southend Hospital

Concerns summary The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.

Thomas Maher

2014-0252 5 Jun 2014 Manchester (South)

Central Manchester University Hospitals…

Concerns summary Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.