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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Poor midwifery care meant woman delivered baby herself

Summary 845 | February 2015

Miss J says she should not have been discharged home from the maternity unit and although she delivered her baby safely at home herself, she did not receive appropriate midwifery care for the third stage of labour.

Concerns around the support provided to a new mother after birth

Summary 844 | February 2015

Mrs B was distressed that the Trust failed to provide breast feeding support shortly after her baby's birth, and there were errors in her medical records.

Patient not given enough information before pain treatment, and an inadequate consent process

Summary 843 | February 2015

Miss L complained about a pain relief procedure. She was unhappy about the information she received, the consent process, the pain relief, and the needles used during the procedure which she said were bent due to the force used.

Poor nursing documentation in patient's records

Summary 842 | February 2015

Mr W complained about the care and treatment his late mother received while she was an inpatient at the Trust. He also said that his complaint was handled dismissively and not all the issues were addressed.

A mental health trust failed to adequately assess a patient and did not handle a subsequent complaint appropriately. An acute trust also failed to handle the complaint appropriately

Summary 841 | February 2015

Mr N complained that the Mental Health Trust failed to adequately assess his step–son's mental health before discharging him, and the Acute Trust failed to consider if he needed additional support. Shortly after leaving hospital, his step–son, Mr Y, committed suicide.

Patient unable to get support hosiery in the colour she was used to

Summary 840 | February 2015

Mrs J's choice of colour for her compression stockings was limited when the management of her condition changed from hospital to GP.

Dental Practice failed to record consent for removing a bridge

Summary 839 | February 2015

Mrs G was upset that her bridge had been removed, and the Practice's response to her complaint was poor.

Dental Practice did not appropriately discuss patient's medical condition before treating her

Summary 838 | February 2015

The Dental Practice and dentist did not follow established good practice in discussing patient's blood disorder when planning treatment, and tests had to be done as an emergency.

GP Practice failed to appropriately monitor patient who was on a potentially fatal drug

Summary 837 | February 2015

Although Ms J was prescribed a dangerous drug to control her rheumatic condition, her GP failed to monitor her or take appropriate action. When she complained, the local Area Team took a long time to deal with her complaint.

Trust failed to fully recognise the impact of its poor communication

Summary 836 | February 2015

Ms H complained about the care and treatment she received when her fibroids were removed. She said she was unprepared for the procedure, the complications, and the significant scar on her abdomen. She also said that the Trust dealt with her complaint poorly.