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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Poor care given to patient prone to constipation

Summary 404 | September 2014

Mrs C's family were concerned that failings in her treatment may have led to her death.

Man with heart problems was discharged from hospital after tests, but died before his operation

Summary 403 | September 2014

Ms H complained that her father, Mr H, should not have been discharged from the Trust because he was not well enough. It then took too long for him to get an appointment at another hospital, and he died before his heart operation could take place.

Trust's poor care delayed terminal cancer diagnosis

Summary 402 | August 2014

Ms V had a previous history of cancer and her GP referred her to hospital for tests. But these were delayed, which meant it took longer than it should have done to diagnose her cancer.

Baby not given best chance to survive

Summary 401 | August 2014

Failure to adequately assess a pregnant woman with vaginal bleeding meant that her baby was not given the best chance, however small, of survival.

GP practice failed to investigate symptoms of diabetes in a 15–month–old baby

Summary 400 | August 2014

A GP practice treated Baby V for asthma, but did not investigate his diabetes symptoms. This led to clinical complications that needed an emergency admission to hospital.

Failings by Trust meant that a patient was denied his wish to die at home

Summary 399 | August 2014

Mrs M complained about the Trust's care and treatment of her husband in 2012. In particular, she complained that the Trust did not honour Mr M's wish to die at home.

Trust did not explain the implications of terminal genetically inherited illness to patient and her family

Summary 398 | August 2014

Trust failed to recognise poor communication with a patient and her family, which meant they sought the information from another Trust.

Trust put right problems with complaint handling but not with chest pain procedures

Summary 397 | August 2014

Mrs S complained to the Trust about inadequate care when she went to a minor injuries unit with chest pain and palpitations.

Failure of Trust to convert referral to 'urgent' led to delays in diagnosing and treating liver cancer

Summary 396 | August 2014

Mr B should have had his GP referral converted to an urgent referral in line with guidance.

Trust failed to explain care pathway for patient with heart problems

Summary 395 | August 2014

When Mrs A developed a serious heart condition, the Trust failed to explain to her why it needed to carry out tests and observations first to assess whether she was suitable for heart surgery that carried a significant risk.

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