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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Freelance income reimbursed after Trust error

Summary 895 | March 2015

The Trust reimbursed Mr G over £4,000 for loss of freelance income after a seven–month delay in informing him of scan result.

Trust gave overdose of insulin twice

Summary 894 | March 2015

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 out–of–hours GP care for Alzheimer's patient after he attacked his wife

Summary 893 | March 2015

Mr B, who had Alzheimer's disease, lived with his wife of many years. In a display of very uncharacteristic behaviour, he physically attacked and verbally abused her, and she was forced to leave home for her own safety.

Failings in care and treatment did not increase loss of vision

Summary 892 | March 2015

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.

Cardiac care appropriate but Trust staff did not document an adverse reaction to an enema

Summary 891 | March 2015

Ms L complained that her mother's significant heart problems were overlooked when the Trust planned to carry out ovarian cyst surgery. She was also concerned that her mother had an enema even though an earlier one had caused an adverse reaction.

Hospital failed to identify or act on woman's dementia needs while in hospital; social services failed to assess her mental capacity

Summary 890 | March 2015

Ms J complained that her grandmother who was in her nineties had poor care after she went into hospital with breathing difficulties. She also complained social services failed to give her grandmother the support she needed.

Trust's poor communication and Council's failure to make appropriate sick leave arrangements led to anxiety and distress

Summary 889 | March 2015

Mrs A complained that her father, Mr B, suffered heart failure because he was not given enough of his medication. She said that her father's discharge from hospital after his readmission was delayed because of faults by the Council.

Trust failed to treat a suspected stroke

Summary 888 | March 2015

Mrs F complained that staff missed opportunities to identify a stroke when she went to a minor injuries unit in early 2014.

Delays in diagnosis compromised patient's chances of a better outcome from surgery

Summary 887 | March 2015

Mrs P's hernia was not correctly diagnosed for over three weeks. Surgery was eventually carried out, but Mrs P did not recover from this and died in autumn 2013.

Poor communication by Trust

Summary 886 | March 2015

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.