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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Health and social care organisation did not appropriately plan care and failed to respond to a deterioration in a man's mental health

Summary 935 | March 2015

Mr B's grandmother, Mrs A, complained that the health and social care organisation did not do enough to identify Mr B's needs or respond appropriately when there were signs of his mental health beginning to deteriorate.

Trust failed to provide appropriate care, treatment and nutritional support to woman with learning disabilities

Summary 934 | March 2015

Mrs G complained that the Trust did not give her daughter, Miss N, appropriate care and treatment during her hospital stay in 2012. She also complained about inadequate communication by clinical staff and a failure to consider Miss N's mental capacity. Mrs G said failings in these aspects of care led to Miss N's death.

Failings in mental health assessment

Summary 933 | March 2015

Mr Q complained about his assessment and discharge from hospital in winter 2013, where he had been admitted after attempting to take his own life. He complained that the Trusts concluded that he was treated appropriately without sufficient evidence to support this view.

Clinical care of an older man was appropriate

Summary 932 | March 2015

Mrs M complained that failings in her husband's care and treatment resulted in his death.

Hospital staff made multiple failings in assessing, investigating and monitoring a woman's condition

Summary 931 | March 2015

Mrs J's Family complained that during her final stay in hospital, Trust staff did monitor Mrs J's food and drink intake. There was poor communication between Trust staff and as a result, no clear diagnosis of Mrs J's condition was ever reached before she died.

Clinical care of an older man was appropriate but he was not given important information about his condition

Summary 930 | March 2015

Mrs T complained that failings in her husband's care and treatment over a number of years resulted in his death.

Practice failed to properly consider patient's requests for adjustments under the Equality Act

Summary 929 | March 2015

The Practice did not consider Mr D's requests for adjustments in line with the Equality Act 2010 and its communication about parts of this was poor, which had an emotional impact on him.

Son was unhappy about NHS decision not to fund father's care

Summary 928 | March 2015

Mr A said the Clinical Commissioning Group (CCG) refused to carry out a retrospective review of the entitlement of his late father, Mr E, to NHS continuing care between early spring 2004 and the end of 2008. He was concerned that this left his Family financially disadvantaged because they had to fund the care themselves.

Doctor failed to give pain relief to man approaching end of life and to tell him or his family that he might die soon

Summary 927 | March 2015

Mrs Q complained that a doctor who visited Mr Q at home did not give him pain–relief or refer him to hospital, although the doctor appreciated that Mr Q was nearing the end of his life.

Trust failed to act properly after finding blood in patient's stools

Summary 926 | March 2015

Mrs T and her husband, were unhappy with the standard of care her mother, Mrs M, received because the Trust did not act on what was found until after the weekend.

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