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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Mental health trust admitted to failings, but did not put enough in place to address shortcomings

Summary 243 | June 2014

Mrs C complained that she had not been able to access support when she had a mental health crisis and her key worker was on leave. The Trust carried out an internal investigation that was robust and acknowledged its failings. However, it did not fully implement its own recommendations.

GP practice provided reasonable care but inappropriately removed patient from its list

Summary 242 | June 2014

Mr J complained about a failure to diagnose deep vein thrombosis (DVT). He also complained that the Practice considered he was aggressive when he asked for a repeat prescription, and removed him from its list.

Poor nursing care resulted in inadequate pressure area management for terminally ill patient

Summary 241 | June 2014

Mr C had been diagnosed with lung cancer with spinal and liver metastases. After undergoing spinal radiotherapy in spring 2013, Mr C was transferred to Aintree University Hospital.

GP did not make sufficiently detailed notes about consultations or make appropriate referrals

Summary 240 | June 2014

When Mrs A asked her GP to refer her daughter, B, for paediatric and mental health care, the GP did not make suitable referrals, or keep detailed notes. The GP's actions contributed to the delays Mrs A experienced in accessing suitable help for B.

Busy A&E department did not clinically review man with signs of sepsis within a reasonable time

Summary 239 | June 2014

Mr L complained that staff at A&E failed to treat him with sufficient urgency during his admission.

Hospital wrongly discharged vulnerable 84–year–old patient to empty house

Summary 238 | June 2014

Mrs R complained that her late mother, Mrs F, was inappropriately discharged from hospital to an empty house, in a confused state, with no medication and with a catheter still in place.

Hospital trust made reasonable diagnosis

Summary 237 | June 2014

Mr C wanted the Trust to make changes to his medical records about his diagnosis.

Patient was concerned that his deteriorating health was caused by his recent anaesthesia

Summary 236 | June 2014

Mr B felt that he was given too much or the wrong kind of anaesthesia, but we did not find this was the case.

Trust could not have prevented sad loss of unborn twin, but should have apologised for mistake

Summary 235 | June 2014

Mrs R was pregnant with twins. She complained about the care and treatment she received the day before she had an emergency caesarean section. One child, E, was live–born but the other, V, was sadly stillborn.

Patient could not speak to practice on the phone

Summary 234 | June 2014

Mr E complained on behalf of himself and his mother, saying they both have serious health problems but could never get through to the Practice on the phone to get an appointment.

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