Inadequate Recognition of Treatment Harm
Failure to adequately recognize and categorize the severity of adverse impacts from specific medical treatments.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
64match
#1 - 11th Report – Cosmetic procedures
The PIP implant scandal exposed failures that continue to affect women more than a decade later. Official assurances that PIP implants pose no health risks appear to be based on limited long-term research and underplay the mental health impacts on women of having a substandard product inside them. Many women report enduring physical and psychological harm, compounded by...
Matched on
terms: harm, inadequate
PFD report
61match
Sultana Choudhury
The coroner identified a failure to diagnose an ongoing renal haemorrhage despite clear clinical indicators and the administration of VTE prophylaxis while the patient had a patent bleed. Additionally, inadequate monitoring during admission allowed the patient's condition to deteriorate preventably.
Matched on
terms: inadequate
PFD report
57match
Peter Jeffrey
The coroner noted that after DVT was ruled out, no alternative effective diagnosis or treatment was considered. Additionally, no culture or swab was taken from an infected blister, and intravenous antibiotics were not considered.
Matched on
terms: treatment
PFD report
57match
Pauline Taylor
The coroner raised concerns about the fire hazard of emollient creams with low paraffin content, citing inadequate warnings on packaging and insufficient awareness of these risks. Locala also did not update risk assessments after significant patient changes.
Matched on
terms: inadequate
PFD report
57match
Brian Jackson
The coroner noted concerns that the widely used CAM-ICU diagnostic tool may not consistently recognise all forms of delirium, particularly 'hypo symptoms' or paranoia. This could lead to sub-optimal diagnosis and treatment for patients across the country.
Matched on
terms: treatment
PHSO casework decision
56match
P-003008 - Milton Keynes University Hospital NHS Foundation Trust
Mrs T complained the Trust didn't address cancer treatment side effects, continuing harmful medication, which led to permanent Parkinsonism and other complex health issues. She sought an investigation and financial remedy.
Matched on
terms: harm, treatment
LGO / SPSO decision
55match
201606304 - A Medical Practice in the Lothian NHS Board area
Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his son (Mr A). He said that a GP had prescribed oxycodone (opiate medication) over the phone to Mr A on the morning that he died from a medication overdose. Mr C was also concerned that there had been an...
Matched on
terms: harm, treatment
PHSO casework decision
51match
P-002017 - University Hospitals Birmingham NHS Foundation Trust
Mrs K complained about inadequate non-surgical treatment for wrist fractures, premature cast removal, ineffective physiotherapy, and incorrect recording of her fall details.
Matched on
terms: inadequate, treatment
LGO / SPSO decision
50match
202309740 - Ayrshire and Arran NHS Board
C complained about the care and treatment provided to their late parent (A) by the board. A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course...
Matched on
terms: inadequate, treatment
PFD report
49match
Peter Clive Higson
The coroner raised concerns regarding the detrimental effect of platelet transfusions following stem cell transplants and questioned whether such transfusions might be contraindicated in specific circumstances.
Matched on
classifier match
PFD report
49match
Katie Williams
The coroner identified concerns regarding the administration of a specific medication contributing to serotonin syndrome and death. There is a risk other NHS organisations may not fully appreciate these risks, particularly with complications common in overdose patients.
Matched on
classifier match
PFD report
49match
Brian Beer
The coroner identified a potential risk if current NICE guidelines for prophylactic anti-coagulation after hip fracture surgery do not reflect the latest international learning, specifically regarding optimal duration and the potential for hypercoagulability upon discontinuation in immobile, elderly patients.
Matched on
classifier match
PFD report
49match
Amber Walker
The coroner identifies insufficient discussion of SUDEP risks with epilepsy patients, citing doctors' reluctance, a presumption of prior conversations, and a lack of universal tools. SUDEP also being absent from medical training contributes to gaps in patient awareness.
Matched on
classifier match
PHSO casework decision
48match
P-001376 - Liverpool University Hospitals NHS Foundation Trust
Mr O complained the Trust ruptured his wife's artery, failed to notice internal bleeding, and delayed treatment due to unstaffed theatres, contributing to her death.
Matched on
terms: treatment
Committee recommendation
48match
#11 - 11th Report – Cosmetic procedures
The Government should commission research to better understand the health impacts of breast implants, including their potential impacts on women with pre-existing auto-immune conditions. The research needs to be a mix of clinical research, including on the health impacts of siloxanes, and longitudinal, following a cohort of women over a period of time. Such studies are necessary to...
Matched on
terms: treatment
Committee recommendation
48match
#3 - 11th Report – Cosmetic procedures
Without mandatory participation in the Breast Implant Registry and the regular publication of outcome data, surgeons cannot provide patients with comprehensive risk information. This undermines the principle of informed consent. Many individuals feel inadequately informed before surgery and the absence of a cooling-off period further increases the risk of rushed decisions. As the PIP scandal demonstrates, a lack...
Matched on
terms: inadequate
PHSO casework decision
48match
P-004395 - University Hospitals of Derby and Burton NHS Foundation Trust
Mr B complained about failures in hernia mesh removal, delayed diagnosis/treatment of infection, unnecessary STD tests, misdiagnosis, and psychiatric referral.
Matched on
terms: treatment
PHSO casework decision
47match
P-003788 - Mid Yorkshire Teaching NHS Trust
Ms A complained her son was inappropriately catheterised, suffered delayed UTI/sepsis diagnosis and treatment, and received inadequate physiotherapy, leading to his death.
Matched on
terms: inadequate, treatment
LGO / SPSO decision
47match
201306220 - Highland NHS Board
Mr C complained on behalf of Mr A. Mr C said Mr A suffered from spinal damage which had required an operation but his treatment at Raigmore Hospital had been significantly delayed following his referral as it was unreasonably downgraded from urgent to routine and because the board lacked surgical capacity. Mr C was concerned that Mr A...
Matched on
terms: treatment
LGO / SPSO decision
47match
201602995 - Lothian NHS Board - Acute Division
Mr C complained that his wife (Mrs A) was inappropriately diagnosed as having suffered a miscarriage and that she was not provided with appropriate and timely treatment. Mrs A was in the early stages of pregnancy when she experienced bleeding. During the night, Mr C and Mrs A attended the gynaecology out-of-hours service at the Royal Infirmary of...
Matched on
terms: harm, treatment
PFD report
45match
Susan Poore
Mrs Poore's depression deteriorated after she started antidepressant medication, and her death was not prevented despite the medication carrying a warning of this potential side-effect.
Matched on
classifier match
PFD report
45match
Mrs Care
The coroner noted concerns that extensive bruising sustained by Mrs Care during her hospital stay, which contributed to her death, could not be explained. There was no evidence to determine how the trauma occurred, despite speculation about hoist use.
Matched on
classifier match
PFD report
45match
Barbara Harrison
Concerns were raised regarding physiotherapy that likely contributed to tissue breakdown after surgery, and the unavailability of working fibre optic equipment for intubation during a critical procedure. Nurses also did not promptly identify obvious post-operative swelling.
Matched on
classifier match
PFD report
45match
Lynn Poyser
The coroner raised concerns regarding whether current guidance on co-prescribing ACE inhibitors and Spironolactone sufficiently emphasizes the need for caution, patient monitoring, and a holistic approach, given known risks such as hyperkalaemia.
Matched on
classifier match
PFD report
45match
Thomas Pearson
The coroner noted concerns regarding the continued use of fluticasone in patients like Mr Pearson, where it presented an increased risk of pneumonia without corresponding benefits, and suggested a review of its use.
Matched on
classifier match
PFD report
45match
James Kane
The coroner noted the deceased's death was linked to a drain procedure and that a pre-procedure scan might have reduced this risk. Further consideration of related policy and guidance is needed, despite a lack of local support for changes.
Matched on
classifier match
PFD report
45match
Pamela Hands
The coroner noted a lack of awareness among emergency medicine professionals regarding the risk of respiratory depression when local anaesthetic blocks are administered after opioids. There were no national guidelines for monitoring patients post-procedure to mitigate this risk.
Matched on
classifier match
PFD report
45match
Carl Schmidt
The coroner identified potential neurological damage from chemoradiotherapy provided in a clinical trial and highlighted the need to investigate the mechanism of this injury, whether direct or through the immune system.
Matched on
classifier match
PFD report
45match
Alvin Black
The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing the risk of infection for prisoners; it also notes a missed opportunity to consider anti-coagulation therapy, with the system not picking up on this error.
Matched on
classifier match
PFD report
45match
Marjorie Walker
The coroner noted that DNA CPR protocols were not followed and highlighted significant delays in accessing specialist pain clinics. Concerns were also raised about insufficient monitoring of kidney function when prescribing pain medication, increasing the risk of overdose.
Matched on
classifier match
PFD report
45match
Joshua Asprey
The coroner noted an inconsistency between the Patient Information Leaflet and the British National Formulary regarding suicidal behaviour as a potential side effect of sertraline. This could mean prescribers are unaware of this risk or do not discuss it with patients.
Matched on
classifier match
PFD report
45match
Paz Ogbe-Millar
The coroner heard evidence regarding the appropriate level of observation by Emergency Department staff for mental health patients waiting in the Emergency Department.
Matched on
classifier match
PFD report
45match
Orlando Davis
Midwives and a doctor were unaware of the potential for hyponatremia in birthing women. Additionally, fluid input and output were not accurately recorded during labour, despite encouragement for increased fluid intake.
Matched on
classifier match
PFD report
45match
Mary Pomeroy
The coroner noted that the hospital's investigation incorrectly concluded the incident was unforeseen. The patient involved had a history of aggressive behaviour, and there was a need for enhanced observations which, if implemented, could have prevented the incident.
Matched on
classifier match
PFD report
45match
Raymond Moran
The falls risk assessment was inaccurate and not updated as required, and associated patient documentation was incomplete.
Matched on
classifier match
PHSO casework decision
44match
P-003037 - The Princess Alexandra Hospital NHS Trust
The Trust ignored her concerns about an IV cannula not being properly in place during a CT scan, causing contrast dye leakage and burns. She also received inadequate information about her injury.
Matched on
terms: inadequate
PHSO casework decision
44match
P-004439 - The Princess Alexandra Hospital NHS Trust
A man complained about his mother-in-law's care, citing poor hygiene, inadequate investigation of deterioration, mistaken morphine administration, and unsuitable discharge.
Matched on
terms: inadequate
PHSO casework decision
43match
P-003197 - Berkshire Healthcare NHS Foundation Trust
Mrs A alleged her father received inappropriate heart failure diuretic treatment despite deteriorating, leading to his premature death. She believed alternative care or hospital admission was needed.
Matched on
terms: treatment
PHSO casework decision
43match
P-003310 - Mersey and West Lancashire Teaching Hospitals NHS Trust
Mr E complained clinicians inadequately investigated his father's condition, failed to treat a suspected blood infection, and discharged him inappropriately. He also alleged delays in cardiac testing.
Matched on
terms: inadequate
LGO / SPSO decision
43match
21-017-330a - Rutland House (21 017 330a)
Summary: Mrs B complained to the Ombudsmen that a Care Home provided inadequate care to her son. She complained this led to significant, life-changing consequences for him. We decided not to investigate Mrs B’s complaint. This is because it is unlikely we would reach meaningful, evidence-based findings that the Care Home’s actions caused Mr A a specific injustice.
Matched on
terms: inadequate
LGO / SPSO decision
43match
201405374 - Tayside NHS Board
Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was...
Matched on
terms: treatment
LGO / SPSO decision
43match
201404527 - A Medical Practice in the Lothian NHS Board area
Mrs A had fallen at home and sustained a head injury and suspected fractured hip. She had contacted the medical practice and a GP attended and decided that she required to be taken to hospital. The GP arranged that an ambulance should attend within an hour and left Mrs A with a neighbour to wait for the ambulance....
Matched on
terms: treatment
LGO / SPSO decision
43match
201306304 - Lothian NHS Board
Ms C complained about the care provided to her when she was admitted to the Western General Hospital (the hospital). Ms C, who lives within another board area, was visiting Edinburgh when she became ill with abdominal pain, severe constipation, and vomiting. She attended the A&E department of another hospital in the board's area and was transferred to...
Matched on
terms: treatment
LGO / SPSO decision
42match
202501264 - Grampian NHS Board
C complained about the care and treatment that their spouse (A) received from the board during admissions to Dr Gray’s Hospital (Hospital A) and Aberdeen Royal Infirmary (Hospital B). A was admitted following episodes of vomiting blood and received treatment for gastric varices (enlarged blood vessels in the stomach lining). C complained that the board did not investigate...
Matched on
terms: treatment
CQC action
41match
Fleetwood Hospital
The trust should ensure the number of third- and fourth-degree perineal tears experienced by women are reduced.
Matched on
classifier match
PHSO casework decision
39match
P-004726 - Blackpool Teaching Hospitals NHS Foundation Trust
Miss O complained about inadequate pain management after her hysterectomy, including insufficient pain relief, no morphine driver, and a lack of prompt doctor review, leading to severe pain for hours.
Matched on
terms: inadequate
PHSO casework decision
39match
P-001068 - Portsmouth Hospitals NHS Trust
Mrs L complained that A&E staff failed to share information about a suspected 'old fracture', misdiagnosed her back injury, gave incorrect advice to mobilise, and provided inadequate pain relief.
Matched on
terms: inadequate
PHSO casework decision
39match
P-001076 - University College London Hospitals NHS Foundation Trust
Dr I complained about inadequate postnatal care for his wife and daughter, citing delayed doctor attendance, insufficient pain relief, missed clinical follow-ups, inappropriate antibiotics, and unsafe discharge planning.
Matched on
terms: inadequate
PHSO casework decision
39match
P-001273 - The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
Mrs U complained the Trust failed to diagnose osteomyelitis, provided inadequate wound care, and discharged her mother without sufficient antibiotics or pain relief. She believed these failings contributed to her mother's death.
Matched on
terms: inadequate
PHSO casework decision
39match
P-001892 - Guy's and St Thomas' NHS Foundation Trust
Mr C complained King's College Hospital failed to diagnose his wife's perforated oesophagus. Guy's and St Thomas' then failed to provide timely or appropriate treatment.
Matched on
terms: treatment