Case summaries

These short, anonymised stories show the profound impact that failures in public services can have on the lives of individuals and their families.

Please note we have not published any new case summaries on this page since 2015. In April 2021 we began publishing our casework decision statements and investigation reports on our decisions portal.

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Failings led to nerve damage following a biopsy

Summary 1105 | September 2015

Mrs R complained that a biopsy was not done correctly. She also complained that the risks of the procedure were not properly explained to her.

Trust gave good clinical care to cancer patient, but poor record keeping left family with unanswered questions

Summary 1104 | September 2015

Mr P complained that his wife was not given appropriate treatment following breast cancer in 2009. The cancer returned in 2014 and spread to her lungs. Mrs P died and Mr P felt if his wife had been given appropriate treatment in 2009, and if the cancer had been diagnosed sooner in 2014, his wife may have survived or had lived longer.

Practice did not properly monitor prescription of a controlled drug

Summary 1103 | September 2015

Mr J was over-prescribed a controlled drug by his GP Practice. When the Practice was made aware of this, the GP declined to issue another prescription on that day. Mr J complained that he suffered withdrawal symptoms as a result.

GP practice gave wrong advice on how to escalate a complaint about it

Summary 1102 | September 2015

Mrs A complained about the GP Practice's failure to diagnose and treat her urinary tract infection (UTI) in a reasonable time, and about the attitude of her GP. She also complained about the accuracy of her medical records, about the Practice's complaint handling and its failure to learn from her complaint.

An avoidable deep vein thrombosis, complications from a bunion operation and a question of consenting to risk

Summary 1101 | September 2015

Ms P lived alone and was housebound and unable to drive for a year after a routine bunion operation led to a deep vein thrombosis (DVT), and the need for further operations.

Failings in nursing care and delayed diagnosis

Summary 1100 | September 2015

Mrs F experienced poor standards in some aspects of her nursing care. A clinical diagnosis was delayed because facts were not thoroughly considered.

Poor complaint handling contributed to concerns that something had gone wrong

Summary 1099 | September 2015

A trust delayed responding to a complainant's concerns and gave mixed messages about whether an investigation was ongoing or not. This led to fears of a cover up.

Trust mismanaged warfarin medication

Summary 1098 | September 2015

Mr R complained that mismanagement of his warfarin medication had resulted in him suffering two strokes.

District nurses failed to provide reasonable care and support

Summary 1097 | September 2015

When Mr V was in the final days of his life, the Trust's district nurses failed to provide reasonable care and support to him and his wife.

No failings found in care of premature baby

Summary 1096 | September 2015

Ms C raised concerns about the care and treatment given to her baby, J, who was born prematurely.

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