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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Lack of clarity about loss of jewellery

Summary 213 | June 2014

Mrs A's husband died in hospital shortly after an emergency admission. She complained that his rings went missing.

Patient should have been prescribed stronger antibiotics and transferred to an acute hospital sooner

Summary 212 | June 2014

An older man was treated with antibiotics and kept in a rehabilitation hospital when he should have been recognised as very unwell and transferred to an acute setting.

Failings in nursing care, although medical and surgical care was in line with established good practice

Summary 211 | June 2014

Mrs H said she was left with some pain despite a programme of treatment including medication and spinal surgery. She was also unhappy about nursing care she had received while in hospital.

Patient's injuries were not properly explained

Summary 210 | June 2014

Mrs C was admitted to hospital with an existing wound to her leg. Her daughter complained that by the time she was discharged she had a pressure sore ulcer and a further injury to her left leg caused by a hot drink.

Failure to carry out root canal treatment

Summary 209 | June 2014

Mr Q wanted root canal treatment, begun overseas, to be completed in the UK.

Ambulance trust's conflicting complaint responses caused grieving wife added distress

Summary 208 | June 2014

Mrs W complained about the actions of a paramedic who attended to her husband a few days before he died. In response, the Trust provided information that was both conflicting and confusing.

Hospital changed patient's medication without informing GP, and failed to provide appropriate nutrition

Summary 207 | June 2014

Mrs F complained that the hospital changed her father's diuretic medication without telling his GP. Mrs F also complained about other problems.

Patient not warned about risk of scarring

Summary 206 | June 2014

Mr D complained about failings in the two minor surgical procedures that he underwent at the Practice and about its complaint handling.

Trust agreed to assess psychological needs and to improve clinical documentation

Summary 205 | June 2014

Ms Y had bipolar disorder. Her mother complained that she was put at risk by being allowed to leave the ward and that she had been denied clinical psychology support.

GP practice failed to provide adequate palliative care for older patient

Summary 204 | June 2014

Mrs C was suffering from a melanoma for which she had had radiotherapy. She was also suffering from vascular dementia, which was progressing quickly. Mrs C lived at home and her family and a carer were very involved in her day–to–day care.

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