These short, anonymised stories show the profound impact that failures in public services can have on the lives of individuals and their families.

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1101 case summaries

Failings led to nerve damage following a biopsy
Summary 1105/September 2015

Mrs R complained that a biopsy was not done correctly. She also complained that the risks of the procedure were not properly explained to her.

Trust gave good clinical care to cancer patient, but poor record keeping left family with unanswered questions
Summary 1104/September 2015

Mr P complained that his wife was not given appropriate treatment following breast cancer in 2009. The cancer returned in 2014 and spread to her lungs. Mrs P died and Mr P felt if his wife had been given appropriate treatment in 2009, and if the cancer had been diagnosed sooner in 2014, his wife may have survived or had lived longer.

Practice did not properly monitor prescription of a controlled drug
Summary 1103/September 2015

Mr J was over-prescribed a controlled drug by his GP Practice. When the Practice was made aware of this, the GP declined to issue another prescription on that day. Mr J complained that he suffered withdrawal symptoms as a result.

GP practice gave wrong advice on how to escalate a complaint about it
Summary 1102/September 2015

Mrs A complained about the GP Practice's failure to diagnose and treat her urinary tract infection (UTI) in a reasonable time, and about the attitude of her GP. She also complained about the accuracy of her medical records, about the Practice's complaint handling and its failure to learn from her complaint.

An avoidable deep vein thrombosis, complications from a bunion operation and a question of consenting to risk
Summary 1101/September 2015

Ms P lived alone and was housebound and unable to drive for a year after a routine bunion operation led to a deep vein thrombosis (DVT), and the need for further operations.

Failings in nursing care and delayed diagnosis
Summary 1100/September 2015

Mrs F experienced poor standards in some aspects of her nursing care. A clinical diagnosis was delayed because facts were not thoroughly considered.

Poor complaint handling contributed to concerns that something had gone wrong
Summary 1099/September 2015

A trust delayed responding to a complainant's concerns and gave mixed messages about whether an investigation was ongoing or not. This led to fears of a cover up.

Trust mismanaged warfarin medication
Summary 1098/September 2015

Mr R complained that mismanagement of his warfarin medication had resulted in him suffering two strokes.

District nurses failed to provide reasonable care and support
Summary 1097/September 2015

When Mr V was in the final days of his life, the Trust's district nurses failed to provide reasonable care and support to him and his wife.

No failings found in care of premature baby
Summary 1096/September 2015

Ms C raised concerns about the care and treatment given to her baby, J, who was born prematurely.

Poor nursing care for elderly man and poor communication with his family
Summary 1095/September 2015

Mrs G complained about the care and treatment her late uncle, Mr E, received towards the end of his life, including when part of his leg was amputated.

Patient with mental health problems not involved in discussions about her care
Summary 1094/September 2015

Miss T complained that she was unfairly discharged from mental health services.

Hospital's mistakes did not have significant impact on patient's care
Summary 1093/September 2015

Mrs J fell ill while on holiday and was taken to hospital. She told staff that she had a cyst (a type of tumour that is not usually cancerous) on one of her ovaries, which might be causing the problem.

Trust did not arrange a CT scan after an elderly patient fell in hospital
Summary 1092/September 2015

Mrs L died shortly after a fall in hospital so her daughter, Mrs K, asked us to investigate her complaint.

Woman with broken arm was given no painkillers in A&E
Summary 1091/September 2015

Miss T complained that when she went to A&E with a broken arm, she was not given any pain relief and that doctors failed to notice a wound on her elbow which subsequently became infected. She also complained she was not given pain relief when she went to A&E again the following week.

Ambulance trust staff caused avoidable pain and distress to elderly fall victim
Summary 1090/September 2015

Ambulance trust staff did not adequately assess an elderly man who had fallen, and failed to give him any pain relief. He was later found to have broken his back.

Missed opportunities to diagnose leukaemia sooner
Summary 1089/September 2015

Mr F's son complained about the care his late father received at the Trust. He said the Trust had not diagnosed and treated his father's leukaemia at the earliest opportunity. He said the delay deprived the family of the opportunity to make Mr F's last days more comfortable and they were unaware of how much he was suffering.

Doctors did not treat heart attack patient appropriately
Summary 1088/September 2015

Mr R was admitted to hospital with a heart attack. His partner complained about the treatment that hospital staff gave him.

Lengthy wait for response to complaint about delayed operation
Summary 1087/September 2015

Mrs S complained about the care she received after two operations, and that planned surgery was cancelled twice.

Trust failed to adequately manage child's pain after appendix operation
Summary 1086/September 2015

Mr B complained that his daughter's appendectomy procedure was delayed. He also said that after the operation there had been a delay giving her a catheter, and that her pain was not appropriately managed. Mr B said that the Trust's complaint handling was poor.

Trust failed to follow policy after patient fell out of bed
Summary 1085/September 2015

Mr D's wife complained about the care her husband received after a fall at home. She believed her husband died as a direct result of the poor care he received in hospital. She was extremely distressed by the possibility that his death could have been avoided.

Patient with cancer was inappropriately given a laxative for over a month
Summary 1084/September 2015

Mr H received some poor care and treatment, including being given Senna (a laxative) when he had diarrhoea. His wife complained about poor nursing care and a lack of documentation about the care given.

Faults in nursing, communication and complaint handling
Summary 1083/September 2015

Mrs E complained about a surgical procedure that resulted in a prolonged hospital stay. She also raised concerns about nursing care and the way the Trust communicated with her, as well as its complaint handling.

Shortfalls in Trust's discharge processes
Summary 1082/September 2015

Ms R complained about the care her late mother, Mrs F, received from the Trust before she died. She felt that her mother's death was avoidable.

Failings in care did not change the outcome for a patient with diabetes
Summary 1081/September 2015

Mr P is diabetic. He complained about poor care and treatment during several hospital admissions, which he believed resulted in the need for further amputation surgery.

Doctors could not have predicted that a woman with ovarian cancer would have died as quickly as she did
Summary 1080/September 2015

Ms L complained that her mother, Mrs K, was not diagnosed sooner with ovarian cancer by her GP and doctors, and that subsequent hospital care, including pain relief, was poor. Ms L also complained that doctors overestimated how much time her mother had left to live and consequently did not urge Ms L to return home from her holiday sooner. Ms L said the Trust took too long to answer her complaint.

Failure to provide appropriate care for a cancer patient who suffered a major fit and died
Summary 1079/September 2015

Mr A, who was in his late seventies and in good health, was on holiday abroad with his wife. He developed abdominal pains and they decided to come home.

A Trust failed to give appropriate pressure area care and did not communicate woman's deterioration to her family
Summary 1078/September 2015

Mrs D complained about several aspects of her mother's, care and treatment following surgery to repair a rectal prolapse (when part of the rectum protrudes through the anus). Mrs D said she believed poor care and treatment had led to her mother's avoidable death, and that poor communication denied the family the chance to prepare themselves for her death.

Fatal blood clot could have been prevented
Summary 1077/September 2015

An older woman died of a preventable pulmonary embolism (a blood clot in the artery from the heart to the lungs), but she would have died from a heart attack even if the embolism had not developed.

Patient left in pain after hip operation
Summary 1076/September 2015

Mr F complained about the care and treatment he received after his hip replacement surgery.

Lack of patient observations and poor record keeping
Summary 1075/September 2015

Mrs K complained about the care and treatment given to her daughter, Mrs Y, who died three days after having a caesarean section.

Trust did not meet woman's nutritional needs
Summary 1074/September 2015

Ms Q complained that the Trust did not give her mother, Mrs U, enough food and drink during several hospital admissions; discharged her from hospital when she was unfit; and put her on the Liverpool Care Pathway (a way of managing her care at the end of her life) without telling her family. Ms Q also complained about the way the Trust communicated with her.

Trust diagnosed Alzheimer's disease in reasonable time
Summary 1073/August 2015

The time taken to assess, diagnose and give medication to a patient with Alzheimer's disease was appropriate and delays could not be attributed to Trust.

GP practice gave poor standard of blood-thinning treatment
Summary 1072/August 2015

Staff took too long to get the dose of a blood-thinning medicine right, and should have discussed Mrs R's care with senior staff.

Dentist gave inappropriate treatment at patient's request
Summary 1071/August 2015

Mr J insisted on a certain kind of temporary treatment for his tooth and the dentist went ahead with it, although she should have refused to do this and treated Mr J correctly.

Trust did not communicate well with carer, which caused unnecessary distress
Summary 1070/August 2015

There were failings in the way nursing staff communicated with a stroke patient's carer, and they did not give her appropriate information about her rights.

13-hour wait in A&E before transfer to medical unit
Summary 1069/August 2015

Hospital took too long to transfer patient from A&E to the acute medical unit. Staff then moved him to a ward but didn't tell his family.

Failure to follow Mental Health Act Code of Practice
Summary 1068/August 2015

Doctors did not assess whether Mr B had the capacity to make decisions for himself, so he did not have information about taking a drug with side effects.

Poor nursing care for a disabled man
Summary 1067/August 2015

Staff did not carry out required assessments and risk planning, and senior nursing staff failed to identify serious incidents on two occasions.

Trust did not follow guidance for investigating hip pain
Summary 1066/August 2015

Trust failed to follow guidance for one aspect of its care and treatment of a lady who fell and sustained fractures to her wrist and pelvis.

Hospital unfairly detained man under the Mental Capacity Act
Summary 1065/August 2015

A hospital held Mr M for 24 hours until a psychiatrist could see him, when it should have assessed him immediately.

Nursing home did not tell son about his mother's discharge from hospital
Summary 1064/August 2015

Mrs W was discharged back to a nursing home after being in hospital but staff at the home did not tell her son until about four hours after she had arrived. She died soon afterwards.

Dental practice did not tell patient why it stopped treating him
Summary 1063/August 2015

Mr F wanted a specialist procedure done at the Dental Surgery but the dentists said it could not be done. The Surgery eventually decided to stop treating him, but did not tell him why.

Missed opportunities to treat two-year-old child
Summary 1062/August 2015

Doctors missed several opportunities to treat child before his cardiac arrest and gave him the wrong dose of a controlled antibiotic.

Poor root canal treatment caused pain
Summary 1061/August 2015

Mr D said his Dental Practice inadequately completed a root canal procedure and did not give him antibiotics for an infection. He said that he lost two teeth because of this.

Possible missed opportunity to prevent suicide
Summary 1060/August 2015

Miss J was admitted to the Trust following her third suicide attempt. But the Trust failed to manage the risks to her health appropriately, and Miss J took her own life a few days later.

Hospital missed opportunities to save man's sight
Summary 1059/August 2015

Mr G went to the Trust's emergency Eye Clinic with complications after an eye operation. He had treatment but lost the sight in his eye and is now registered as severely sight impaired.

Patient's blood clot missed in A&E
Summary 1058/August 2015

The Trust should have done further tests to check for a blood clot in Mrs N's lung before discharging her.

Trust failed to take action when it suspected sepsis
Summary 1057/August 2015

Staff suspected Mrs P had sepsis but did not diagnose and treat this until she went to intensive care.

Specialist cancer care may have helped with pain
Summary 1056/August 2015

Miss J thought her mother was dying, and so felt her hospital treatment was unnecessary and that she should have been given palliative care.