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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Despite minor shortcomings, hospital and ambulance service provided reasonable response to complaint

Summary 42 | March 2014

Mr L went into urinary retention after a biopsy procedure. He called an ambulance and was taken to A&E. He complained about various aspects of the care he received from the ambulance service and the hospital.

Dentist failed to check that the medicine she prescribed was appropriate

Summary 41 | March 2014

A dentist prescribed medicine to Mrs A that could have affected other medicines she took. Mrs A made a number of complaints that the Practice did not respond to fully in writing.

NHS trust did not reassess older woman and so missed opportunity to give treatment

Summary 40 | March 2014

Mrs A complained that the Trust did not provide adequate care and treatment for her mother, Mrs B, after she was admitted to hospital with diarrhoea and vomiting. She also complained that the Trust did not keep adequate records of her mother's care, communicate appropriately with the family or handle her complaint properly.

Trust failed to properly record and monitor the sodium it gave patient

Summary 39 | March 2014

Ms Q received sodium as part of her liver disease treatment but a lack of proper records meant the amount she received and how quickly is unknown. Her mother, Mrs U, complained on her behalf.

GP practice failed to investigate breathlessness in man with heart and kidney problems

Summary 38 | March 2014

Mr B had health problems including kidney disease, high blood pressure and heart failure. He could not go out without help. His family complained that poor GP care and treatment led to Mr B's deterioration and death.

GP over-prescribed morphine, probably causing a seizure

Summary 37 | March 2014

Ms C suffered from back pain on and off for several years. Her GP prescribed morphine to lessen the pain.

GP's actions led to death of man in late 50s

Summary 36 | March 2014

A GP did not spot a life-threatening condition that led to the patient's death a few hours later.

GP failed to thoroughly assess patient with ulcer

Summary 35 | March 2014

Mr A saw a GP after having severe stomach pain. The GP failed to thoroughly assess him or consider a stomach ulcer as a possible cause for his pain.

Trust did not assess patient's circumstances before discharging him from hospital

Summary 34 | March 2014

Mr B suffered from heart failure and several other chronic illnesses. He was admitted to hospital after experiencing shortness of breath. He was discharged the next day, but was readmitted that same evening, and died the following day.

Failings in care did not lead to patient's death

Summary 33 | March 2014

Mrs R's daughter, Mrs S, complained that her mother should have been cared for in an acute hospital rather than a community hospital and that she received poor care which resulted in her death.