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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Long delay in a GP's referral

Summary 32 | March 2014

Mr B visited his GP because of his headaches. His GP said that he would refer Mr B to a neurologist for further investigation of his symptoms but there was a long delay in making the referral.

Woman needed more surgery after Trust failed in care after operation

Summary 31 | March 2014

After a hysterectomy, staff took out Mrs A's catheter without considering the significance of 'pink urine', as recorded in the notes. This resulted in a bladder injury that needed additional surgery to repair.

Trust missed several chances to diagnose fatal condition

Summary 30 | March 2014

A trust misdiagnosed a patient as having a blood clot when he actually had an aortic dissection (a tear in the blood vessel from the heart to the body). This resulted in his death.

NHS trust failed to record care planning and delayed addressing the complaint

Summary 29 | March 2014

Mr B died in hospital. The Trust could not reassure his family that the care he received was good because some records were sparse. The Trust's complaint handling was also poor.

Failure to spot sepsis led to missed opportunity to treat patient

Summary 28 | March 2014

Mr F complained about the death of his mother after a hysterectomy. He said that the hospital had not given appropriate postoperative care and that her death was avoidable.

NHS trust failed to provide adequate care for an older person

Summary 27 | March 2014

Mrs L had a history of high blood pressure, asthma, chronic constipation and bowel obstruction. She did not get the right care when she went into hospital.

Cancer should have been diagnosed sooner

Summary 26 | March 2014

Mr K's GPs and NHS trust treated him for a common hip problem for several months before the condition was found to be a rare cancer.

Ambulance trust denied woman transport

Summary 25 | March 2014

Mrs L, who has difficulty walking, complained she was unfairly denied patient transport for her physiotherapy appointment despite getting transport regularly in the past.

Older man left frustrated and out of pocket in continuing healthcare assessment (CHC) claim

Summary 24 | February 2014

When Mr R made a retrospective CHC claim for NHS funding for his wife, he was told to pay for copies of her records.

Error by HM Courts & Tribunals Service delayed eviction of tenant

Summary 23 | March 2014

A couple were forced to wait longer than necessary for an unwanted tenant to leave their property.