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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Wheelchair service delayed giving a woman a suitable wheelchair

Summary 534 | October 2014

A wheelchair service took 38 weeks to provide a suitable wheelchair for Mrs M, who has brittle bone disease, after an independent assessment found that her existing wheelchair was no longer fit for purpose.

Trust let down former inpatient of mental health unit

Summary 533 | October 2014

A widow complained that her late husband was not given adequate care after he was discharged from a mental health unit.

Serious breaches in established standards and practice in mental health ward

Summary 532 | October 2014

Mr M complained about his inpatient experience on a ward at the Trust's hospital in late 2012. He said the Trust did not give him information about his rights under the Mental Health Act; failed to take accurate and complete nursing records; threatened and used force to administer medication without getting his consent; denied him comfort and warmth; and deprived him of sleep. He also complained that he was detained against his will for some time.

Failings in care and treatment of a paralysed man in his eighties did not contribute to a stroke, but caused distress to his family

Summary 531 | October 2014

Mrs J complained about the care and treatment her father, Mr L, had in spring 2013.

Nursing failure caused serious injustice

Summary 530 | October 2014

Mrs Q complained on behalf of her sister, Mrs L, about the care and treatment she received at the Trust. As a result of failings by the Trust, Mrs L lost a significant degree of independence and required much greater support from Mrs Q.

GP practice did not follow correct procedures when it removed patient from its list

Summary 529 | October 2014

Mr T complained that his GP Practice removed him from its list unfairly. He was also unhappy about how NHS England dealt with his complaint.

Trust did not manage pain after an operation

Summary 528 | October 2014

Mr A complained about the pain he suffered after a brain operation, and about how the Trust cared for him. He was also unhappy about how it handled his complaint.

New mother died after transfer delay

Summary 527 | October 2014

During her pregnancy, Mrs D had good care from her GP Practice and trust. However, she became ill after the birth of her child. Senior clinicians did not get involved in her care and did not refer her to a specialist unit quickly enough. Although the care and treatment she received at the specialist unit were in line with established good practice, she had a cardiac arrest and died.

Practice ignored complaint

Summary 526 | October 2014

Mr T's GP Practice sent his employer some of his medical records and took too long to deal with his complaint about this.

GP practice wrongly kept patient's name on its mental health register

Summary 525 | October 2014

A GP practice inappropriately included Mr A's details on registers for mental illness. It did not communicate fairly and transparently with him when he queried this.