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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. 

 

Type
Type
Health cases only
Trust gave overdose of insulin twice
Summary 894 |
Mrs J went into hospital with shortness of breath and a cough. She had heart failure. Nurses gave Mrs J more insulin than she needed and did not report this as an incident. They then gave her too much insulin again.
Failings in care and treatment did not increase loss of vision
Summary 892 |
Mr Y complained that when he went to the A&E department at the Trust's hospital with a shadow in his right eye, staff sent him away without a proper examination or treatment. A review at another trust found problems in the blood supply to the optic nerve.
Poor communication by Trust
Summary 886 |
Ms T complained that her mental health team left her confused when it poorly communicated to her about what support was in place for her after she was discharged. She was also unsure how the Trust would deliver mental health care, during a time of extensive changes to these services.