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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Ambulance should have taken frail, sick, older woman to hospital

Summary 574 | November 2014

A paramedic decided to leave a frail woman in her eighties alone at home with inadequate support although she was suffering with diarrhoea.

Pregnant woman suffered avoidable distress because of poor explanation

Summary 573 | November 2014

When Ms F was pregnant, routine blood tests showed that she had caught a virus that could have caused her baby to be born with serious disabilities.

Delays in diagnosing spreading cancer

Summary 572 | November 2014

When Mr R developed a lump on his hip, staff at the Trust wrongly diagnosed it as an abscess. The Trust treated it with antibiotics instead of investigating further and correctly diagnosing it as spreading cancer.

Inadequate hospital care for patient with dementia

Summary 571 | November 2014

Mr S experienced delays and failings in nursing care during a short stay in hospital.

Patient's heart rate dropped before cardiac arrest

Summary 570 | November 2014

Mrs B went into hospital and when her heart rate dropped, the Trust did not take appropriate action. Ward staff did not have details of her regular medication, so her Parkinson's medicine was delayed.

Trust did not make adequate follow–up plans for man with heart condition who later died

Summary 569 | November 2014

Mr W had a history of endocarditis and went to the hospital's A&E department twice in one month. When staff discharged him on the second occasion, they told him to go to his GP for follow–up tests. This did not happen and he later died.

Woman took excessively high dose of medication for three months after GP failed to check prescriptions

Summary 568 | November 2014

Ms G's GP Practice prescribed too high a dose of a blood thinning medication. The Pharmacy dispensed the dose when it should have done more to check it was correct. This put Mrs G's health at risk for three months.

Summary 567 | November 2014

Ms J was unhappy with her care and said the Trust did not address her concerns. It also mislaid her clinical records.

Further assessment was needed to determine health care funding

Summary 566 | November 2014

Miss T complained that the Clinical Commissioning Group did not properly review her mother's eligibility for continuing healthcare funding.

Nurses did not consider the needs of learning disabled patient in hospital

Summary 565 | November 2014

Mr F's mother complained about his care and treatment during an admission to hospital.