Table 1. Patient-safety-related adult deaths in NHS acute hospital settings: analysis of areas of systemic service failure.

Area of Service Failure	Incident Type	Number of Incidents	Percent of Incidents
Mismanagement of deterioration	Failure to act on or recognise deterioration	462	23%
	Failure to give ordered treatment/support in a timely way	130	6%
	Failure to observe	113	6%
	All mismanagement of deterioration	705	35%
Failure of prevention	Inpatient falls	206	10%
	Healthcare-associated infections	202	10%
	Pressure sores/decubitus ulcers	7	<1%
	Suicides	28	1%
	VTE/pulmonary embolus	87	4%
	All failure of prevention	530	26%
Deficient checking and oversight	Medication error	60	3%
	Misinterpretation or mishandling of test results	34	2%
	Unexpected per-operative death (immediately/within 24 hours)	124	6%
	All deficient checking and oversight	218	11%
Dysfunctional patient flow	Inappropriate discharge	78	4%
	Poor/inadequate handover	94	5%
	Unavailability of intensive treatment unit beds	25	1%
	All dysfunctional patient flow	197	10%
Equipment-related errors	Necessary equipment failed or faulty	16	<1%
	Necessary equipment misused or misread by practitioner	79	4%
	Necessary equipment not available	22	1%
	All equipment-related errors	117	6%
Other		243	12%
Total		2,010	100%

Covers a 17-mo period from 1 June 2010 to 31 October 2012, during which reports of deaths were mandatory.