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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No failings in a diagnosis of conjunctivitis

Summary 183 | May 2014

Mrs L complained that an out–of–hours doctor failed to examine her eye and unreasonably misdiagnosed the cause of her symptoms.

Poor communication led to delay in diagnosing sepsis

Summary 182 | May 2014

Mrs A complained about her father's care and a delay in diagnosing sepsis because of a lack of investigation and poor communication.

Mother gave birth in her car after maternity service errors

Summary 181 | May 2014

Mrs L attended her Trust because her waters had broken. The Trust advised her to return home, which she did. Later that evening, Mrs L gave birth on the way to hospital.

Trust and CCG followed Department of Health guidance

Summary 180 | May 2014

When Miss T's PIP breast implants ruptured, she approached the Trust and the Clinical Commissioning Group (CCG) to request a single mixed NHS/privately–funded procedure to remove and replace them.

Surgeon removed patient's organs unnecessarily

Summary 179 | May 2014

Mrs D had surgery to remove an ovary. The surgeon removed not only the ovary but her uterus, appendix and omentum without her consent or knowledge. After surgery her wound reopened, and the doctors at the hospital did not treat this properly.

Cancer diagnosis delays shortened man's life by six months and caused unnecessary pain and distress

Summary 178 | May 2014

Mr A was too unwell to have chemotherapy that would have given him another six months of life. The Trust was not open and accountable when handling his wife's complaint.

Poor care given to patient with heart condition

Summary 177 | May 2014

Mr F had a hole in his heart and suffered from irregular heartbeats. He was referred to hospital, where he was seen by a doctor who failed to provide appropriate treatment before, sadly, Mr F died.

Poor communication and incorrect information from GP practice and PCT was distressing

Summary 176 | May 2014

We upheld Ms T's complaint about Milton Keynes Primary Care Trust (PCT) because of poor communication. We also partly upheld her complaint about a GP practice.

G4S handled complaint poorly

Summary 175 | May 2014

Mr J, who was detained in prison at the time, had been taking medication for a number of years. The prison GP stopped his medication without any warning, causing Mr J withdrawal symptoms.

No failings identified in clinical care, but failings in complaint handling

Summary 174 | May 2014

The Trust gave Mrs P reasonable information about an operation, but there were failures in its complaint handling.