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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Trust's investigation into complaint failed to address key issues

Summary 704 | January 2015

When Miss T complained to the Trust about her mother's care, its response failed to address her key concerns and also the main incident she had complained about.

Avoidable death of a man with learning disabilities after failings in care and treatment

Summary 703 | January 2015

Mrs H and Mrs M complained about the care and treatment of their brother, Mr P, in summer 2012.

Poor communication by doctors meant that a young woman's parents did not realise that she was going to die

Summary 702 | January 2015

Miss T's family complained that the care and treatment their daughter received for a brain tumour contributed to her death. They also said that poor communication by staff at the Trust added to their distress.

The Trust did not properly assess Mr H's suitability to donate his kidney to his wife

Summary 701 | January 2015

Mr and Mrs H complained that Mr H was not retested in 2007 to see if he was a suitable live kidney donor. They were also unhappy with the way their complaint was handled.

Trust put right its failings in care and treatment

Summary 700 | January 2015

Ms F complained about the care her late grandmother received, and about the fact that the family could not be with her when she died because staff had recorded only one contact number for the family.

Pharmacy gave mother wrong medicine for child

Summary 699 | January 2015

Mrs F was given the wrong medication for her young son. The medication was not suitable for children.

Trust should have carried out further tests that might have shown man's cancer earlier

Summary 698 | December 2014

Mrs G, together with her son, complained about the care that her husband received from the Trust's pain management team when he developed new symptoms. They also said he should have had another MRI scan.

Hospital did not act on patient's written wishes

Summary 697 | December 2014

Mrs and Mr C complained that the Trust had not been aware of, and did not act on, Mrs C's advance directive (a document that set out her wishes about her treatment) and that communication with the family had been poor. They felt the Trust did not recognise the impact its actions had had on them, and its service improvements had not done enough to stop the mistakes happening again.

Misdiagnosis prevented appropriate care

Summary 696 | December 2014

Mr P's daughter–in–law, Mrs L, complained that Mr P's diagnosis was unclear, his treatment was inadequate and communication from Trust staff was poor. The Trust acknowledged only minor communication failings and maintained that Mr P's care and treatment was appropriate.

Practice did not manage new patient's pain medication prescription

Summary 695 | December 2014

Ms C's GP Practice did not follow guidance and established good practice on swift referral to help her get specialist medication. Ms C suffered uncertainty and ongoing pain.