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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Patient suffering miscarriage was kept in A&E

Summary 334 | July 2014

Ms E was in A&E for over two hours without seeing a doctor, and staff did not treat her severe pain.

GP failed to refer patient to specialist for on-going symptoms

Summary 333 | July 2014

Mr F saw his GP several times with symptoms including passing stones in his urine. His GP did not refer him to a specialist until two years after his first visit. He was diagnosed with bladder cancer and later died.

GP failed to take relevant factors into account when prescribing

Summary 332 | July 2014

Mr W, who was in his seventies, complained that his GP did not prescribe enough glucose test strips or painkillers and would not prescribe vitamin D at all.

Trust did not adequately describe proposed surgery or assess its impact on woman with mental health problems

Summary 331 | July 2014

Miss C was denied the opportunity to fully consent to surgery and lost faith in the Trust's ability to manage the treatment of her bladder and pelvic problems.

Patient's death was avoidable

Summary 330 | July 2014

Mr N complained to us that Trust staff did not investigate his wife, Mrs N's, symptoms and this delayed any treatment. As a consequence, Mrs N developed sepsis and died one month after Trust doctors first saw her.

Failings in care and communication did not cause death of woman in her late seventies

Summary 329 | July 2014

Mrs F had chronic obstructive pulmonary disease, a condition that causes breathing difficulties. She was on long–term oxygen therapy at home. In winter 2012 she went into hospital with increased shortness of breath and rapid heartbeat.

Dental practice failed to give patient opportunity to make informed choice about treatment

Summary 328 | July 2014

Mrs J said that the information the practice gave her left her unaware of the treatment options available. As a result, she said, she paid for private dental work that could have been given as NHS treatment. Mrs J wanted a financial remedy, an apology and an improvement in the service provided by the practice.

Trust delayed arranging surgery

Summary 327 | July 2014

Mrs G went onto a waiting list for bowel surgery in winter 2011. She was still waiting when she was admitted as an emergency in autumn 2012.

Appropriate investigations for cardiac symptoms let down by poor communication with patient

Summary 326 | July 2014

Ms B complained that her symptoms were not taken seriously during a twelve–day hospital admission for apparent cardiac symptoms.

GP practice missed chance to diagnose fatal heart condition

Summary 325 | July 2014

Ms L complained that the GP practice failed to investigate her father, Mr M's, symptoms adequately, especially his breathlessness. Instead, GPs treated Mr M for anxiety, so his underlying heart condition, which contributed to his death in spring 2012, was not treated. Ms L believed that Mr M died prematurely, and this caused the family distress.

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