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 did not have all relevant information when it decided to discharge patient

Summary 163 | May 2014

Mrs B had been under the care of the ear, nose and throat department for several years because of ear problems. She had surgery that appeared to be uneventful but she was then admitted to hospital with an ear infection.

Some failings in response to calls for an ambulance and subsequent complaint handling

Summary 162 | May 2014

Ms J complained about two separate incidents during which there were delays in receiving an ambulance response from the East Midlands Ambulance Service NHS Trust.

Trust failed to properly answer a justified complaint

Summary 161 | May 2014

Following a diagnosis of deep vein thrombosis, Ms E's haemoglobin levels were not monitored and she became so anaemic that she had to undergo a blood transfusion at the Trust.

Poor pain management

Summary 160 | May 2014

Mrs D complained on behalf of her late mother, Mrs T. She complained about pain management and the administration of sedatives. We partly upheld her complaint.

Impact of significant delays between hospital review appointments

Summary 159 | May 2014

Mr A had a history of facial pain and was referred to the maxillofacial (jaws and face) department.

Hospital made mistakes, leaving baby with brain damage

Summary 158 | May 2014

A one-day-old baby suffered permanent brain damage because a nurse and two doctors made serious mistakes during a blood transfusion.

Poor nutritional care given to patient in nursing home

Summary 157 | May 2014

Mr K had a stroke in spring 2009. After his discharge from hospital, he received NHS-funded continuing health care and was discharged to the nursing home. In early summer 2012, his partner Ms L complained about the removal of possessions from Mr K's room and suggested that the change in layout of the room was not in his best interest. Ms L was subsequently told to stop visiting. After she complained about this, Ms L was allowed limited visits but restrictions were imposed and her contact with Mr K was supervised by members of staff.

No evidence that dental hospital received faxed referral letters

Summary 156 | May 2014

Mr L's dentist agreed to refer him to the Trust's dental hospital for treatment. The dentist's records indicated that the dental practice faxed the referral to the Trust in late 2012.

Consultant failed to follow established clinical practice and the GMC's Good Medical Practice

Summary 155 | May 2014

Mrs C complained about the way a consultant psychiatrist conducted an appointment with her daughter.

Care and treatment of patient with complex health needs was reasonable

Summary 154 | May 2014

Mrs D complained to us about the care her mother, Mrs R, received during her stay in a psychiatric unit in spring 2011. She was unhappy with the discharge planning arrangements and the care Mrs R received in the community after her discharge.