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).

Response Status
Responded 1,781 No Response 16 Historic 613 Pending 32
AI Classification
Action Taken 57%
Action Planned 24%
Noted 13%
Disputed 6%
Based on 1,612 classified responses
Reports by Quarter
PFD Reports
2,487 results
Refat Hussain
All Responded
2014-0061 12 Feb 2014 London Inner (West)
Harmoni HS
Concerns summary Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Keith Martin
Historic (No Identified Response)
2014-0055 5 Feb 2014 Surrey
St Peter’s and Ashford Hospitals
Concerns summary Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.
Scarlett Sinclair
Historic (No Identified Response)
2014-0059 3 Feb 2014 Avon
Oxford University Hospitals NHS Trust
Concerns summary The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an unstable condition.
Ryan Chapman
Historic (No Identified Response)
2014-0048 31 Jan 2014 West Sussex
Sussex Partnership NHS Trust
Concerns summary Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
William Kent
Historic (No Identified Response)
2014-0056 31 Jan 2014 Surrey
Medicines and Healthcare products Regul… Guest Medical St Peter’s and Ashford Hospitals
Concerns summary Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.
Leslie Pates
Partially Responded
2014-0043 30 Jan 2014 Manchester (South)
Tameside Metropolitan Borough Council Tameside NHS Foundation Trust
Concerns summary A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and no pressure-relieving mattress.
Action taken summary Tameside Hospital is developing a checklist and ensuring documented discussions with patients and families regarding discharge plans to improve communication. They are also providing training to new s
Umul Audu
All Responded
2014-0038 27 Jan 2014 London Inner (North)
University College London Hospitals NHS…
Concerns summary The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
Action taken summary University College London Hospitals NHS Foundation Trust disputes the need to introduce transport heaters, stating their current standard measures for preventing hypothermia are adequate and in line w
Pamela Bailey
Historic (No Identified Response)
2014-0040 27 Jan 2014 South Yorkshire (West)
Sheffield Trust
Concerns summary Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.
Lucy Goulding
Partially Responded
2014-0034 24 Jan 2014 West Sussex
Western Hospitals NHS Foundation Trust Department of Health and Social Care Royal College of Paediatrics and Child …
Concerns summary There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.
Action taken summary The Trust has strengthened consultant involvement in all paediatric handovers and introduced a baton bleep system for attending physicians. They have reinforced critical care experience through staff
Bertha Cray
All Responded
2014-0037 24 Jan 2014 London Inner (North)
Concerns summary Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Action taken summary Barts Health NHS Trust has ceased the practice of using double-sided 'nil-by-mouth' signs at bedsides, confirming it was not standard practice. New signs have been issued with the same instruction on
Desrae Tucker
Historic (No Identified Response)
2014-0032 23 Jan 2014 Gwent
Aneurin Bevan Health Board
Concerns summary Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
Christine Nutbeam
Historic (No Identified Response)
2014-0025 21 Jan 2014 Berkshire
St Peter’s Hospital Wexham Park Hospital
Concerns summary Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent vomiting, contributing to surgical risks.
John Malone
Historic (No Identified Response)
2014-0026 21 Jan 2014 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Mone White
All Responded
2014-0031 21 Jan 2014 London (North)
Northwick Park Hospital Department of Health and Social Care
Concerns summary There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Action taken summary The Department of Health acknowledges the concern but states that developing a national flag system for patient care advice is a matter for local NHS Trusts to ensure existing information is accessed
Wayne Broad
Partially Responded
2014-0020 17 Jan 2014 London (North)
G4S Department of Health and Social Care Serco +1 more
Concerns summary There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees also need alignment with best practice.
Action taken summary The Department of Health clarifies that local arrangements exist for substance misuse liaison in police custody, and that providing specialist nurses in hospitals for substance misuse is a local resou
Craig White
Historic (No Identified Response)
2014-0017 14 Jan 2014 South Lincolnshire
Intensive Care Society Phoenix Partnership United Lincolnshire Hospitals NHS Trust +4 more
Concerns summary Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.
Barbara White
Historic (No Identified Response)
2014-0015 13 Jan 2014 Manchester (South)
Tameside General Hospital
Concerns summary Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
James Withers
Historic (No Identified Response)
2014-0004 7 Jan 2014 Manchester (South)
Tameside Hospital NHS Foundation Trust
Concerns summary Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.
Andrew John Fallon
Historic (No Identified Response)
2014-0005 7 Jan 2014 Manchester (South)
Stockton NHS Foundation Trust
Concerns summary Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Grace Mary Bates
All Responded
2014-0007 7 Jan 2014 London (North)
Department of Health and Social Care Barnet and Chase Farm Hospitals NHS Tru…
Concerns summary The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Action taken summary Barnet and Chase Farm Hospitals NHS Trust has approved a business case for the appointment of at least one full-time specialist diabetic nurse to provide improved cover across the calendar week, and t
Chloe Grace Flavell
Historic (No Identified Response)
2014-0003 6 Jan 2014 Avon
Weston Area Health NHS Trust
Concerns summary The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Daniel Williams
All Responded
2014-0009 6 Jan 2014 South Yorkshire (East)
Rotherham, Doncaster and South Humber N…
Concerns summary Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Action taken summary The Trust has completed 'personal safe care' training for all inpatient staff, altered handover practice, and developed a Standard Operating Procedure for room searches. They have also included a sear
Keith Fleming
Historic (No Identified Response)
2014-0008 3 Jan 2014 Gateshead & South Tyneside
North of England Commissioning Report Trinity Medical Centre Newcastle upon Tyne Hospitals NHS Found… +1 more
Concerns summary The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
Kate Louise Pierce
All Responded
2013-0363 20 Dec 2013 North Wales (East & Central)
General Medical Council
Concerns summary A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.
Action taken summary The General Medical Council acknowledges the concerns but states no action is proposed as their previous investigation was closed due to the five-year rule and they have received no further complaints
Leo Deady
Partially Responded
2013-0369 19 Dec 2013 London (Inner South)
Department of Health and Social Care Royal College of Obstetricians and Gyna…
Concerns summary A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.
Action taken summary The Department of Health, following consultation with the RCOG and review of existing research, concludes there is no benefit to developing a national system of routine late-pregnancy scanning. Howeve