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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Stroke patient received poor care

Summary 354 | July 2014

Mr H complained about the care and treatment given to his late father, Mr R. He was particularly concerned about nursing care, too few scans, a fall and poor record keeping.

Trust delayed giving Parkinson's medication

Summary 353 | July 2014

Mr P complained that the Trust did not provide his mother's Mrs P's, Parkinson's disease medication soon enough.

Poor communication led to unnecessary treatment

Summary 352 | July 2014

Mrs N was refused funding for a surgical procedure. She was advised, wrongly, that she would need a psychological assessment to get the funding.

Poor communication about end of life care

Summary 351 | July 2014

A family was left upset and distressed when their father died after being put on the Liverpool care pathway, which had not been explained to them fully.

Poor care delayed postoperative healing of wound

Summary 350 | July 2014

After a minor operation, Mr B's wound became infected. Failings in his postoperative care meant that the wound took longer to heal than it would have otherwise.

Mistakes between two organisations delayed ambulance

Summary 349 | July 2014

Mrs W complained that mistakes by an ambulance service and NHS Direct delayed an ambulance for her fatherinlaw who was in severe pain at home.

Failure to arrange face-to-face review demonstrated serious error in clinical judgment

Summary 348 | July 2014

A GP's failure to appropriately assess a patient's condition and failure to adhere to practice protocols and professional standards meant that a patient did not get a face–to–face medical review.

Trust discharged outpatient without recent clinical review

Summary 347 | July 2014

Mrs F had annual reviews at the Trust. The Trust's decision to discharge her ten months after her last review was not in line with good practice.

GP practice failed to follow its triage protocol

Summary 346 | July 2014

Reception staff did not find out that a patient was suffering from chest pains when he wanted to book an appointment with his GP.

Communication problems between GP practice and pharmacy

Summary 345 | July 2014

Mrs B's husband, Mr B, complained about the care and treatment she received from her GP practice towards the end of her life.

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