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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. 

 

Type
Type
Health cases only
Patient in mental hospital was not adequately assessed in A&E
Summary 152 |
A man who was detained in a high-secure mental hospital was taken to A&E at a general hospital. Staff there failed to adequately assess him and he was discharged. He was brought back later that evening, admitted to intensive care, and died a few weeks later.
Dentist ground tooth too far
Summary 151 |
Mrs A complained about the dental treatment that she received when she was given a crown, particularly that one of her opposing teeth was ground down too far.
Poor management of a patient with a breast lump
Summary 147 |
Mrs P complained that her GP, Dr M, inaccurately diagnosed a lump on her right breast as benign in spring 2013. Unhappy with that diagnosis, Mrs P sought a second opinion from a different GP at the Practice. This led to a hospital referral, which resulted in scans that, in summer 2013, identified breast cancer. Mrs P was concerned that the months between the original assessment and the referral may have been detrimental to her health.
Failings by hospital meant a patient became dehydrated
Summary 144 |
Mrs D's daughter, Mrs W, felt that her mother's admission to hospital had been delayed. She was concerned that her mother's subsequent dehydration in hospital affected her chances of survival.