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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A GP Practice failed to discuss the implications of stopping medication for a dying patient

Summary 915 | March 2015

Mrs W asked the Trust and the Practice to investigate the actions of the GP in stopping her husband Mr W's tinzaparin (medication to prevent blood clots) injections when he was dying, and the actions of the district nurse following her husband's death.

Patient put at risk of blood–borne diseases by Practice nurse

Summary 914 | March 2015

A Practice nurse injected Ms K with a used needle while giving her the influenza vaccine. As a result, Ms K had to have tests and treatment for potential blood–borne diseases.

Delay in diagnosis of breast cancer

Summary 913 | March 2015

Trust did not carry out a needle biopsy when symptoms indicated possible disease, and it took a long time for doctors to diagnose breast cancer.

Care funding case closed before agreed deadline

Summary 912 | March 2015

A primary care trust (PCT) made an unreasonable decision to close a request for a review of historic continuing care funding.

Poor communication with patient during premature birth

Summary 911 | March 2015

Failings by doctors in communication with Mrs E during premature labour contributed to her uncertainty and distress during the birth of her baby son, who subsequently died.

Hospital fully acknowledged failures in care

Summary 910 | March 2015

Ms L, who was in her seventies, was dissatisfied with how her diabetes was managed during a hospital admission and the fact that the discharge summary was incorrect. She also complained about the attitude of one of the nurses.

Failure to provide a fully funded care package

Summary 909 | March 2015

Mr H complained that not all elements of his son R's care plan were being funded by the NHS. He also complained that R was denied access to housing he had previously been nominated for, after he was found eligible for NHS continuing healthcare funding.

Failure to put in place a clear plan for a man coming to the end of his life caused avoidable distress

Summary 908 | March 2015

Ms F complained that a clear care plan was not put in place for her father, Mr F, although his death was expected. She complained that, as a result, there was confusion and her father's illness was treated inappropriately.

Surgeon did not get fully informed consent for hip replacement

Summary 907 | March 2015

When Mr P developed problems after his hip replacement, he was unprepared because the surgeon had not fully explained the risks of the surgery beforehand.

Practice GP adequately assessed patient's condition but did not make sure she could get to a hospital

Summary 906 | March 2015

Mrs P complained that the Practice failed to recognise the severity of her condition and did not assess her properly during a consultation. Mrs P felt her life was put at risk as a result because she was not transferred to hospital as an emergency patient.

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