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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Trust failed to diagnose husband's fractured hip

Summary 203 | June 2014

Mrs B complained to us that the Trust failed to diagnose Mr B's hip fracture. By the time the Trust identified the fracture, he needed a hip replacement instead of a repair.

Patient unable to access support from maternity unit when she arrived in established labour

Summary 202 | June 2014

The Trust told Mrs K that she was not in established labour. It turned her away and gave her the impression she could not return for several hours. She gave birth at home with no medical help.

Inpatient care on a ward

Summary 201 | June 2014

Ms E's mother was admitted to the ward in the final stages of illness to build up fluids and weight.

Improvements in the provision of mouth care needed

Summary 200 | June 2014

Mrs K's husband was admitted to hospital with a suspected stroke.

No evidence GP delay made condition worse

Summary 199 | June 2014

Mrs D visited her doctor with concerns about her circulation.

Deaf patient denied access to BSL interpreter at GP practice

Summary 198 | June 2014

A Deaf patient did not have access to a British Sign Language (BSL) interpreter for GP appointments for three years because of a dispute over funding.

GP failed to refer woman to dermatologist after changes to moles

Summary 197 | June 2014

When Ms B noted changes to moles on her face, her GP did not make a note of that part of the consultation, and did not refer her back to her dermatologist. Ms B later had surgery for the moles.

Trust failed to admit patient to stroke unit after he arrived at A&E

Summary 196 | June 2014

Mrs R complained about her husband's care and treatment when he went to A&E in the winter of 2012. Mrs R complained that there was an avoidable delay in staff diagnosing that her husband had had a stroke that led to delay in giving him necessary treatment.

Trust failed to adequately assess and treat older patient

Summary 195 | May 2014

Mr A was admitted to hospital following a fall. Staff failed to adequately assess him and delayed giving him appropriate antibiotics.

Poor communication with patient's family

Summary 194 | May 2014

The Trust did not communicate well with Mr Ys family and did not explain the reasons why a do not attempt resuscitation (DNAR) order was in place.