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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Hospital did not give woman prescribed medication

Summary 905 | March 2015

Mrs C was in her eighties and had several medical conditions. When she went into hospital, staff did not prescribe her usual medications and did not rectify this for 36 hours. Mrs C died soon after.

Poor care during birth prevented new mother enjoying first months with her baby

Summary 904 | March 2015

Mrs F complained that when she was a patient on the Trust's maternity ward, staff gave her an injection into her buttock through the birth pool water. She said that this led to her developing an abscess.

No delay in Practice's bowel cancer diagnosis but it gave misleading information after review

Summary 903 | March 2015

Mrs K complained that the Practice failed to diagnose her mother Mrs J's bowel cancer early enough to avoid emergency surgery. The Practice carried out a significant event review after Mrs K complained, but it then failed to address areas identified as needing improvement.

CCG did not explain its decision not to fund surgery

Summary 902 | March 2015

Mrs G submitted an individual request for funding for surgery that would not normally be funded by her local clinical commissioning group (CCG).

Missed opportunity to identify decay in a child's tooth meant it had to be extracted

Summary 901 | March 2015

Mr and Mrs T complained that poor dental care and treatment between spring 2009 and summer 2013 meant that their daughter, Miss T, had to have an adult tooth taken out because of decay. Mr and Mrs T said that Miss T endured three months of pain until the tooth was extracted.

Missed opportunity to diagnose infantile spasms

Summary 900 | March 2015

In 2009 Mr and Mrs A took B, their six–month–old child, to the Practice because he was having possible seizures.

GP acted appropriately when patient was diagnosed with rare lung condition

Summary 899 | March 2015

Mrs C felt that the GP Practice did not manage her husband's chest complaints and severe joint pain properly. She felt that clinicians should have reached a diagnosis of pulmonary fibrosis sooner and treated it.

Although a child's mental health care and treatment were overall of a good standard, some care was unhelpful

Summary 898 | March 2015

Mr H complained about the care and treatment the Trust gave L, his daughter. Mr H complained that L's treatment was inappropriate and because of this, she suffered trauma and became withdrawn. Mr H also complained about the way the Trust handled his complaint.

Doctor failed to make adequate record of examination

Summary 897 | March 2015

Mrs D complained that two doctors failed to diagnose a fracture in a bone surrounding her hip replacement.

Practice's anticoagulation service failed to identify patient with complex conditions

Summary 896 | March 2015

Mr S complained that his GP Practice did not manage his warfarin medication appropriately. He felt he should have been referred to hospital earlier.