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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Dental practice did not explain why it removed a patient from its list

Summary 514 | October 2014

A dental practice did not follow its own procedures when it dealt with a situation that led to a breakdown in its relationship with Mr Z. It compounded this failing with poor complaint handling.

Trust gave mental health patient too much medication too quickly

Summary 513 | October 2014

Mrs P complained that Trust staff gave her mother, Mrs N, too much antipsychotic medication and this made her almost comatose and caused her to fall, fracturing her spine. Doctors then delayed diagnosing the fracture, leaving Mrs N in pain. The Trust's response to Mrs P's complaint did not acknowledge the poor care provided.

A&E staff failed to notice a cannula was inserted incorrectly

Summary 512 | October 2014

Mrs B's father, Mr E, was incorrectly discharged from hospital and returned the following day as an emergency. Staff failed to recognise that a cannula had been incorrectly placed, and Mr E lost blood when it was removed. Mrs B said the Trust did not acknowledge its failures in care.

Family had no choice but to put vulnerable man with dementia in private care over Christmas

Summary 511 | October 2014

Mr Q was in his seventies and had dementia. He lived at home with his wife, Mrs Q. On Christmas Eve he had several falls and an ambulance took him to A&E.

Honeymoon disrupted by painful tooth after poor treatment

Summary 510 | October 2014

When Mr J's dentist replaced a temporary filling, he did not remove all of the earlier dressing. This became infected, and Mr J had to interrupt his honeymoon to get treatment.

Trust delayed progressing IVF treatment within the 18–week pathway

Summary 509 | October 2014

When Mrs B was referred for fertility treatment, the Trust unreasonably delayed this. It also failed to tell her about the progress of her appeal for extra funding when she turned 40 and became ineligible for NHS funded treatment.

Woman distressed by Trust's poor complaint handling

Summary 508 | October 2014

Ms D had several complaints about her gynaecological surgery. She said she did not have enough information before and after the surgery, that she did not know how her arm was injured, and a nurse did not apologise when she did not give good care. Ms D also complained that the Trust took too long over her complaint and did not give her proper explanations or an appropriate remedy.

Delay in arranging meeting to discuss complaint about delay

Summary 507 | October 2014

Mr J went to A&E because he was suffering chest pains. He had to wait six hours before he saw a doctor.

GP practice's removal policy was wrong

Summary 506 | October 2014

When a GP practice removed a man from its patient list, it did not act in line with its contract.

Although a trust gave satisfactory care, its response to a complaint was delayed and inaccurate

Summary 505 | October 2014

Mrs M complained that her son (Mr M) was not fit for discharge when the Trust sent him home from hospital. Mrs M also complained that there were inaccuracies in the Trust's response to her complaint, and delays in complaint handling.