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 monitor a biopsy properly

Summary 143 | April 2014

Mr C died following a liver biopsy. One of the risks associated with a liver biopsy is bleeding from the biopsy site.

Trust failed to alert district nurses to a risk of pressure sore

Summary 142 | April 2014

Staff were aware that Mrs F had developed a red area of skin on her bottom while she was in hospital. However, they did not tell the district nurses about this when Mrs F was discharged. Less than 24 hours after discharge, this turned into a pressure sore.

Clinical care of older woman was reasonable but there were some failures

Summary 141 | April 2014

Mr H complained that the Trust's clinical care and treatment of his mother were not of the standard that could be expected, and about the Trust's complaint handling.

Poor communication between staff and with patient led to loss of confidence in NHS care

Summary 140 | April 2014

Mrs D was recalled for an assessment in summer 2012. She complained about the clinical management of her diagnosis of breast cancer and her subsequent treatment from summer 2012 until winter 2013.

Patient removal from GP practice list was unreasonable

Summary 139 | April 2014

When a GP practice removed Mr P from its list, it failed to follow its policy and consider other options first.

Trust refused to arrange second opinion for cancer patient

Summary 138 | April 2014

The Trust refused to arrange a second opinion for Mr R after he was diagnosed with 'terminal' cancer and only offered him palliative chemotherapy (treatment to help symptoms rather than cure).

Trust delayed performing a scan that would have detected kidney stones

Summary 137 | April 2014

We upheld this complaint about a delay in diagnosing extremely painful kidney stones.

Poor care and management of a patient with severe abdominal pain

Summary 136 | April 2014

Mrs D complained to us about the treatment her mother, Mrs R, received from the time of her admission until her death shortly after. Mrs D felt that the inadequate care her mother received removed any chance she had of surviving.

Patient's family let down by nurse's actions

Summary 135 | April 2014

A patient and his family were caused significant distress by a nurse's actions, despite good clinical care from Trust.

Trust did not give older patient adequate care

Summary 134 | April 2014

Ms J complained that the Trust wrongly discharged her father when he had a chest infection. She also complained about care and treatment during a later hospital admission. Ms J said the failings led to her father's death.