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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Was major surgery the only option?

Summary 364 | August 2014

Mrs A complained about a Trust's decision to operate on her rather than consider alternative therapies and its failure to explain how her wound would heal after her discharge from hospital.

Trust did not try hard enough to contact a woman whose husband had just died

Summary 363 | August 2014

The Trust failed to communicate appropriately with Mrs B on the morning of her husband's death. She found out her husband had died when she rang the ward.

Mrs A died unexpectedly, only a few minutes before her husband arrived

Summary 362 | August 2014

Mrs A was terminally ill. Her deterioration and death were relatively unexpected and highlighted failings in the care of patients at the end of their life.

Inadequate management of pain after operation

Summary 361 | July 2014

A surgeon did not give enough pain relief or discuss the full implications of a procedure with patient.

Trust provided poor care for fractured ankle

Summary 360 | July 2014

Ms T fractured her ankle. She had poor care from the hospital, which caused further pain and led to an unremedied injustice.

Delay confirming diagnosis meant that family will never know if a young woman might have lived longer or had better quality of life

Summary 359 | July 2014

Miss D complained that in 2005 an NHS Trust failed to diagnose her daughter, Miss E, with a condition that is a rare complication of measles. The condition is progressive and terminal. She also complained that another trust failed to diagnose the condition between 2005 and 2008.

Poor cardiology care led to postoperative death and poor complaint handling

Summary 358 | July 2014

Mrs D complained about the care and treatment her late husband, Mr JD, received from the Trust in spring and early summer 2013. She complained about preoperative advice, that staff did not carry out an operation properly, her husband was discharged too soon and the Trust's complaint handling was poor.

Complaint about antidepressant prescribing in pregnancy and support after miscarriage

Summary 357 | July 2014

Mrs F complained about how the practice managed her antidepressant medication during her pregnancy. She was also unhappy about the support she received following her miscarriage. She felt that this contributed to her mental breakdown.

Failure to adequately assess a mole

Summary 356 | July 2014

The GP practice did not assess Mr L's mole adequately in 2010 and did not refer him to hospital with suspected cancer. His daughter, Mrs N, was distressed because she believed that her father was not adequately assessed or referred when he should have been. The inadequate handling of her complaint by the practice and the Trust caused her further unhappiness.

Unusual birth complication not identified

Summary 355 | July 2014

Midwives did not identify shoulder dystocia during Mrs A's labour, and there was a delay between the baby's head and his body being delivered. The Trust handled Mr and Mrs A's complaint poorly.