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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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.