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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42-week wait for knee replacement surgery

Summary 1055 | August 2015

Mrs F was on a waiting list for a knee replacement. But instead of having her surgery within 18 weeks, as set out in the NHS Constitution, Mrs F waited for 42 weeks for her operation and was in pain during this time.

Surgeon operated on breast unnecessarily

Summary 1054 | August 2015

Ms A expected to have an operation to remove a cluster of painful cysts from her breast, but the surgeon did a different, unnecessary operation.

Poor nursing care in the community

Summary 1053 | August 2015

District nurses failed to treat an ulcer on an older woman's leg, or notice that she had developed another one on her other leg.

Decision to discharge patient may have contributed to his death

Summary 1052 | August 2015

The Trust discharged Mr H after he went to A&E with chest pain, and he died two days later. His son complained to the Trust but was not happy with its response.

Gender reassignment operation delayed because of poor communication

Summary 1051 | August 2015

Poor communication between surgeons led to delay of several months for transgender patient's operation, causing him additional anxiety.

Dental practice failed to refer patient for unresolved bad breath

Summary 1050 | August 2015

Mr J had to pay for private treatment because the Dental Practice failed to adequately assess or treat a wisdom tooth that was causing him bad breath.

Unreasonable withdrawal of treatment

Summary 1049 | August 2015

Mr V's treatment was stopped when the Trust said funding was withdrawn.

GP practice missed opportunity to prevent patient from having a fatal pulmonary embolism

Summary 1048 | August 2015

When Mrs H, in her early fifties, saw her GPs with pain and swelling in her leg, they failed to carry out sufficient investigations to identify or rule out a deep vein thrombosis (DVT). Mrs H died of a pulmonary embolism (a blood clot in the lung) shortly afterwards.

Trust failed to act on another Trust's diagnosis of possible pancreatic cancer

Summary 1047 | August 2015

Mrs W complained that her husband died because the Trust failed to treat his suspected pancreatic cancer despite another Trust's diagnosis. Mrs W also complained about how the Trust handled her complaint.

Earlier diagnosis and treatment could have decreased patient's chances of developing painful ulcers

Summary 1046 | July 2015

Mrs T complained that the Trust delayed giving her late mother, Mrs K, the correct medical attention and failed to manage her pain.

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