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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Two trusts failed to properly assess the mental capacity of an older man with mental health problems

Summary 414 | September 2014

Mr S, who had been diagnosed with mental health problems, had treatment from one trust and longterm supportive care from another. However, neither trust assessed his ability to consent. This meant his daughter thought his condition could have been improved.

Trust did not provide adequate care and treatment for an older person

Summary 413 | September 2014

Mr V complained that the Trust did not provide adequate care and treatment for his mother, Mrs V, which contributed to her deterioration.

Failure to investigate symptoms delayed diagnosis of a spinal tumour

Summary 412 | September 2014

A neurologist discharged Mrs F without sending her for a scan that would have shown that she had a tumour.

Trust delayed when it diagnosed cancer

Summary 411 | September 2014

Long delays in diagnosing Mr Y's cancer meant that he did not get palliative care that might have improved the quality of the last few months of his life.

Trust did not resolve a woman's chronic shoulder pain although it carried out two operations

Summary 410 | September 2014

Ms A eventually had three operations in twelve months to treat chronic shoulder pain. Each operation was needed because the previous ones had not stopped the pain.

Failings found in care given to terminallyill patient

Summary 409 | September 2014

Mr H complained about the care given to his mother who was terminally ill.

Failings in care at the end of an older patient's life

Summary 408 | September 2014

Mr B's son complained that doctors and nurses did not tell him how seriously ill his father was; did not give his father proper nutrition; left medication by his bedside which he should have been given; and took no action when his father's denture went missing.

GP practice took a patient off its list without giving him a written warning, and handled his complaint about this poorly

Summary 407 | September 2014

A GP practice used a zero tolerance policy to remove a patient without prior written warning, which was against its contract.

Out–of–hours service failed to spot that a patient needed to go to hospital immediately

Summary 406 | September 2014

Mrs R complained that a GP from an out–of–hours service failed to diagnose a serious spinal condition and advised her to wait until her GP practice opened in the morning.

GP failed to properly assess patient who died soon afterwards

Summary 405 | September 2014

Mr C's GP made an incorrect diagnosis, but there was not enough evidence for the GP to reach a firm conclusion.