Inadequate Recognition of Treatment Harm
Failure to adequately recognize and categorize the severity of adverse impacts from specific medical treatments.
Source spread
Where this theme appears
This theme appears across 7 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
23 PFD reports
17 committee recs
1 PPO rec
1 IMB rec
45 PHSO decisions
78 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(23)
Peter Clive Higson
Concerns: Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Response (Department of Health): The Department of Health refers to a report from NHS Blood and Transplant which indicates that prophylactic platelet transfusion was appropriate in this case, and that the respiratory deterioration likely …
Response (NHS Blood and Transplant): NHS Blood and Transplant concludes that TRALI was unlikely in this case based on SHOT imputibility criteria, recent studies and current guidelines suggest that the benefits of platelet transfusion outweigh …
Responded
Peter Jeffrey
Concerns: Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.
Response (Guys St Thomas NHS Foundation Trust): The Trust reviewed records but states it is unable to respond fully to the concerns due to a lack of clarity regarding the patient's condition in the months before his …
Responded
Susan Poore
Concerns: Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.
Overdue
Mrs Care
Concerns: Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.
Overdue
Barbara Harrison
Concerns: Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.
Overdue
Lynn Poyser
Concerns: Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Overdue
Thomas Pearson
Concerns: A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.
Response (Doncaster and Bassetlaw Hospitals): The response indicates that the respiratory team is well versed with the current state of the evidence and are following appropriate current guidelines and are unable to produce useable local …
Responded
James Kane
Concerns: A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes regarding such procedures.
Response (County Durham and Darlington NHS Trust): County Durham and Darlington NHS Trust will provide all trainees with a copy of the guidance regarding large volume paracentesis, ensure a clear audit trail of patients undergoing paracentesis (including …
Response (Department of Health): The Department of Health consulted NICE and the Royal College of Radiologists and concluded that there is no case for the routine use of ultrasound prior to or during paracentesis, …
Responded
Pauline Taylor
Concerns: Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Response (PAGB): PAGB will provide a written submission to the MHRA by September 30th, 2017 regarding paraffin-containing products and will work with the MHRA, fire brigades, and other stakeholders to ensure clear …
Response (Medicines and Healthcare Products Regulatory Agency): MHRA has liaised with ArjoHuntleigh to confirm risk mitigation factors are appropriate and are working to communicate important healthcare information to healthcare professionals and the public through established alert systems. …
Response (Locala): Locala has shared learning from the case internally, raised awareness about paraffin-containing products in their monthly medicines management report, and is developing a flowchart, documentation, and training for staff to …
Response (NHS England): NHS Improvement notified of the death in 2015 and included actions taken in response to the death in the Patient safety review and response report published in June 2017.
Response (United Kingdom Home Care Association): The UK Homecare Association has provided information to homecare providers including a fact sheet prepared by the London Fire Brigade, an article in their magazine, and an email briefing regarding …
Overdue
Pamela Hands
Concerns: A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.
Response (British Orthopaedic Association): The British Orthopaedic Association (BOA) intends to update its BOAST (BOA Standards for Trauma) document that covers the management of hip fractures to reflect and emphasise the need for appropriate …
Overdue
Carl Schmidt
Concerns: The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.
Response: The University of Birmingham offers condolences and provides background information on its commitment to clinical trials, then addresses specific questions raised by the coroner regarding the medical details of the …
Responded
Alvin Black
Concerns: 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.
Overdue
Brian Jackson
Concerns: Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
Response (National Institute for Health and Care Excellence): NICE acknowledges concerns and will consider them during an update to its guideline on delirium, focusing on risk assessment and diagnosis, including in ICU settings.
Overdue
Marjorie Walker
Concerns: A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.
Response (Greater Manchester Integrated Care): NHS Greater Manchester Integrated Care highlights actions taken including presenting findings to learning forums, introducing electronic white boards in patient areas, completing analgesic dosing audits, distributing a Pharmacy Safe Bulletin …
Response (Department of Health and Social Care): The government plans to spend over £8 billion from 2022-23 to 2024-25 to support elective recovery and reduce waiting times, and the NHS is developing Community Diagnostic Centres. The MHRA …
Responded
Joshua Asprey
Concerns: Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this potential risk with patients.
Response (National Institute for Health and Care Excellence): NICE acknowledges the report but states that responsibility for the BNF content lies with BMJ Group and the Royal Pharmaceutical Society, so they cannot comment on the concerns raised.
Response (British National Formulary Publications): BNF Publications will use communications, including a newsletter and social media, to remind users how to find drug class information within content, including monographs and treatment summaries.
Responded
Sultana Choudhury
Concerns: Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Response (Department of Health and Social Care): The Trust produced a Comprehensive Investigation Report and developed a robust action plan to share learning across the Trust regarding themes relating to continuity, and always ensuring effective communication during …
Responded
Katie Williams
Concerns: The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate these medication interaction risks.
Response (University Hospitals Plymouth NHS Trust): The trust has been in contact with The Faculty of Intensive Care Medicine to assist with sharing information nationally regarding the risks associated with fentanyl. It has also communicated the …
Responded
Paz Ogbe-Millar
Concerns: Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Response (West Hertfordshire Teaching Hospital): The hospital has replaced the previous proforma with an electronic assessment aligned with the current SOP, approved the PSIRP and PSIRF Policy, is implementing an electronic patient record system, is …
Responded
Orlando Davis
Concerns: Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the baby.
Response (NMC): The NMC is carrying out Fitness to Practise investigations, has shared the PFD report with the GMC, and will develop and publish a scenario to inform student midwives and midwives …
Response (NHS Sussex Integrated Care Board): NHS Sussex confirms that University Hospitals Sussex NHS Foundation Trust (UHSx) and East Sussex Healthcare NHS Trust (ESHT) have implemented policies regarding fluid management and hyponatraemia in labour, developed and …
Response (Royal College of Obstetricians and Gynaecologists): The Royal College of Obstetricians and Gynaecologists expresses condolences and outlines its role in supporting maternity services through educational initiatives and clinical guidance. It refers to existing NICE guidelines and …
Response (Department of Health and Social Care): The Department of Health and Social Care highlights the publication of an NHS Resolution report on hyponatremia and notes the rollout of the Brain Injury Reduction Programme across maternity units …
Responded
Brian Beer
Concerns: NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.
Response (National Institute of Health and Care Excellence): NICE acknowledges the coroner's concerns regarding arterial thrombus but clarifies that existing guidance focuses on venous thromboembolism and does not cover arterial prophylaxis. NICE will continue to monitor new evidence …
Responded
Mary Pomeroy
Concerns: A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations for a high-risk patient.
Response (University Hospitals Plymouth NHS Trust): The Trust transitioned to the Patient Safety Incident Response Framework (PSIRF) in June 2024, replacing the Serious Incident Framework. They describe the principles of PSIRF and the process for reviewing …
Responded
Amber Walker
Concerns: Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Response (Department of Health and Social Care): The Department of Health and Social Care references NICE guidance on epilepsy, the Epilepsy Self-Management Programme, and the Clive Treacey Checklist regarding SUDEP risk assessment. They note that medical schools …
Responded
Raymond Moran
Concerns: The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
Response (City of Kingston Upon Hull and the County of the East Riding of Yorkshire): • The Trust accepts that the multifactorial falls assessment and associated documentation were not completed as required by policy. • The Trust accepts the need to reinforce reassessment on transfer …
Responded
Select committee recommendations(17)
#12 —
Recommendation: The Department of Health and Social Care should make primary care workers aware of the potential for a link between autoimmune conditions and breast implants to ensure that women presenting with symptoms following implantation are not dismissed. (Recommendation, Paragraph 47)
Response Pending
#11 —
Recommendation: 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 …
Response Pending
#10 —
Recommendation: Evidence of concentrations of siloxanes in women’s bodies outside of their implants is particularly concerning. The mental health impacts of knowing that chemicals, which are being banned in other uses due to their toxicity, are circulating in your body should …
Response Pending
#9 —
Recommendation: There is growing concern that a number of women are experiencing serious health impacts after receiving breast implants, with many reporting symptom improvements following explantation. While evidence of a definitive link between these symptoms and breast implants has not been …
Response Pending
#8 —
Recommendation: The Government should increase the information available on the approval of medical devices to allow interested parties to see not only what devices are approved but the evidence base underpinning the decisions to approve them. (Recommendation, Paragraph 36)
Response Pending
#7 —
Recommendation: The PIP implant scandal involved substandard implants being given to women for many years without detection. The new post-surveillance regime for breast implants must include regular testing of approved implants to ensure continued compliance with safety standards. (Recommendation, Paragraph 35)
Response Pending
#6 —
Recommendation: A mandatory cooling-off period of at least two weeks should be introduced between the initial consultation and surgery for breast implants, ensuring patients have sufficient time to consider risks and alternatives before making a commitment. (Recommendation, Paragraph 27)
Response Pending
#5 —
Recommendation: We note that the registry is currently overseen by the soon-to-be abolished NHS England. The Government should take steps to ensure that the improvements we call for are not delayed by internal reorganisation. (Recommendation, Paragraph 26)
Response Pending
#4 —
Recommendation: The Government should introduce mandatory recording of breast implant and explant procedures and instances of adverse outcomes in the Breast and Cosmetic Implant Registry by the end of 2026. We welcome the Government’s acknowledgement that the registry requires improvement. The …
Response Pending
#3 —
Recommendation: 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 …
Response Pending
#2 —
Recommendation: While there is a judgement to be made over whether the NHS should offer replacement implants to women affected by the PIP implants scandal, women with PIP implants who wish to have them removed should be able to have that …
Response Pending
#1 —
Recommendation: 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 …
Response Pending
#19 — Establish reducing pain in invasive procedures as a key performance indicator for Women's Health Strategy.
Recommendation: Reducing the pain women experience during invasive procedures should be made a key performance indicator for the Women’s Health Strategy for England. (Paragraph 82) 75 Effect on mental health
Gov response: It is unacceptable that some women have such poor experiences during procedures such as hysteroscopy, intrauterine device (IUD) fitting and cervical screening. Experiences of pain during these sorts of procedures can vary significantly from one …
Response Not Attributed
#17 — Enforce informed consent and halt painful gynaecological procedures lacking adequate pain relief.
Recommendation: The NHS must do more to monitor and enforce protocols governing procedures such hysteroscopy, IUD fitting and cervical screening and ensure that they are underpinned by informed consent and are trauma-informed. A risk assessment that allows a patient to make …
Gov response: It is unacceptable that some women have such poor experiences during procedures such as hysteroscopy, IUD (intrauterine device) fitting and cervical screening. Experiences of pain during these sorts of procedures can vary significantly from one …
Position Not Stated
#16 — NHS fails patients during routine reproductive procedures, neglecting duty of care and pain management.
Recommendation: The NHS is failing many patients who undergo routine reproductive healthcare procedures such as hysteroscopy, IUD fitting and cervical screening. In too many cases, we find that a duty of care from gynaecologists and other medical practitioners is absent. Women …
Gov response: It is unacceptable that some women have such poor experiences during procedures such as hysteroscopy, intrauterine device (IUD) fitting and cervical screening. Experiences of pain during these sorts of procedures can vary significantly from one …
Response Not Attributed
#32 —
Recommendation: Finally, we note that in setting up the vaccine programme the Department provided indemnities to vaccine manufacturers, which gave cover for future claims against producers for any adverse effects of their vaccines. These indemnities may add to the costs of …
Not Addressed
#29 — Require MoJ, HMPPS, NHSE/I to set out work improving prison healthcare and accessibility.
Recommendation: It is concerning that issues relating to healthcare continue to be a contributing factor to deaths in custody. The MoJ, HMPPS and NHSE/I should set out what work they are doing to: • improve communications between staff across all disciplines …
Gov response: We accept this recommendation. A joint HMPPS/NHSE Information Sharing Task & Finish group has produced a delivery plan identifying a number of products to improve practice and confidence amongst prison, probation, and health staff to …
Accepted
PPO death in custody recommendations(1)
PHSO casework decisions(45)
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.
NHS in England
Apr 2022
P-001057 — Manchester University NHS Foundation Trust
Miss A complained she sustained skin damage, including burns and blisters, during shoulder surgery and was not informed about the injury by the Trust.
NHS in England
Partly Upheld
Apr 2021
P-001072 — Manchester University NHS Foundation Trust
Ms A complained her deceased brother’s NG tube was wrongly inserted, causing fluid to enter his lung and contributing to his death. She also alleged poor communication about his cardiac arrest and inconsiderate handling of tissue donation.
NHS in England
Upheld
Jun 2021
P-001087 — University Hospitals Bristol and Weston NHS Foundation Trust
Miss E complained her son developed painful burn-like wounds to his bottom after surgery, causing significant distress to him and his parents.
NHS in England
Upheld
Jul 2021
P-003845 — Salford Royal NHS Foundation Trust
Miss U complained the Trust continued prescribing a strong cream for her skin condition despite side effect concerns, causing her to develop multiple serious health problems.
NHS in England
Sep 2023
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.
NHS in England
Sep 2024
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.
NHS in England
Oct 2024
P-004395 — University Hospitals of Derby and Burton NHS Foundation …
Mr B complained about failures in hernia mesh removal, delayed diagnosis/treatment of infection, unnecessary STD tests, misdiagnosis, and psychiatric referral.
NHS in England
Not Upheld
Dec 2025
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.
NHS in England
Dec 2025
P-004751 — South West Yorkshire Partnership NHS Foundation Trust
Mr C complained that the Trust prescribed him quetiapine which caused side effects and did not listen to his concerns. He also felt pressured to take acamprosate.
NHS in England
Not Upheld
Jan 2026
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.
NHS in England
Partly Upheld
Jan 2026
P-001060 — University Hospital Southampton NHS Foundation Trust
Mrs C complained about her husband's care, citing inappropriate discharge, delayed diagnosis, insufficient pain medication, and slow steroid prescription, leading to brain damage.
NHS in England
Partly Upheld
Apr 2021
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.
NHS in England
Partly Upheld
May 2021
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.
NHS in England
Not Upheld
Jun 2021
P-001084 — Pennine Acute Hospitals NHS Trust
Miss B complained her mother was given midazolam, believing it caused a comatose state and premature death, and medical records were incomplete.
NHS in England
Not Upheld
Jul 2021
P-001267 — Kettering General Hospital NHS Foundation Trust
Miss D complained the Trust administered a Pfizer COVID-19 vaccine as her second dose, despite her first being Astra Zeneca and her informing staff. She suffered severe swelling, prolonged illness, and developed a new condition.
NHS in England
Jan 2022
P-001265 — Croydon Health Services NHS Trust
Ms L complained doctors failed to identify and treat infections and sepsis in her father, leading to an avoidable death. She disputed the Trust's lymphoma diagnosis and suspected a cover-up.
NHS in England
Partly Upheld
Jan 2022
P-001273 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
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.
NHS in England
Jan 2022
P-001346 — The Dudley Group NHS Foundation Trust
Ms Z complained she developed a pulmonary embolism due to Depo-Provera injections provided by the Trust, leading to lifelong medication, distress, and worry about her health.
NHS in England
Mar 2022
P-004560 — Lewisham and Greenwich NHS Trust
A daughter complained about her mother's care across three admissions, including pressure sores, sacral tear from bedpan use, diuretic withdrawal, oxygen mismanagement, hypoxia misdiagnosis, and inappropriate digoxin prescription.
NHS in England
Partly Upheld
Dec 2025
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.
NHS in England
Not Upheld
Mar 2023
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.
NHS in England
Partly Upheld
Jun 2023
P-002428 — A practice in the City of Portsmouth area
Miss A complained a practice in Portsmouth didn't take her eczema seriously, failed to refer her to a specialist, and prescribed a cream she was allergic to.
NHS in England
Jan 2024
P-002988 — A practice in the Walsall area
Mrs O complained the Practice discontinued her husband's blood clot medication, leading to a fatal stroke. She also alleged the Trust delayed diagnosis and risked kidney function during scans.
NHS in England
Sep 2024
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.
NHS in England
Not Upheld
Dec 2024
P-003181 — A practice in the Newham area
Mr B complained staff failed to monitor his father, who pulled out his oxygen tube, leading to low oxygen, infections, pain, and potentially hastening his death.
NHS in England
Dec 2024
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.
NHS in England
Not Upheld
Jan 2025
P-003268 — Portsmouth Hospitals University NHS Trust
Mrs A complained doctors did not properly investigate her husband's condition, made incorrect diagnoses, and delayed an MRI scan during his last four months, questioning if his death was avoidable.
NHS in England
Not Upheld
Jan 2025
P-003793 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs B complained the Trust failed to treat her husband's gallbladder infection, act on deterioration signs, or identify/treat sepsis, leading to his death.
NHS in England
Partly Upheld
Aug 2025
P-003770 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs C complained the Trust delayed giving her son, D, intravenous antibiotics for a UTI, leading to his rapid deterioration and death, believing this affected his survival chances.
NHS in England
Upheld
Aug 2025
P-004456 — Portsmouth Hospitals University NHS Trust
Ms N complained the Trust failed to identify, record, and treat complications during Mr L's LVP procedure, believing internal bleeding from the procedure caused his death.
NHS in England
Dec 2025
P-001612 — University Hospitals Sussex NHS Foundation Trust
Mrs M complained the Trust failed to monitor and respond to Mr M's constipation, keep him hydrated, and properly investigate his deteriorating condition, contributing to his death.
NHS in England
Partly Upheld
Nov 2022
P-001688 — Leeds Teaching Hospitals NHS Trust
Mrs A complained about the Trust's care for her late husband, Mr U, including poor deterioration management, uncommunicated changes, and end-of-life interventions against wishes.
NHS in England
Nov 2022
P-002441 — Frimley Health NHS Foundation Trust
Ms D complained Trust A wrongly prescribed medication leading to her father's death, and Trust B failed to investigate symptoms or provide adequate hydration/nutrition.
NHS in England
Partly Upheld
Feb 2024
P-002627 — Royal Free London NHS Foundation Trust
Ms B complained the Trust caused her aunt a leg injury, failed to manage pain and nutrition, and did not prevent pressure sores, contributing to her death.
NHS in England
Upheld
May 2024
P-003032 — Surrey and Sussex Healthcare NHS Trust
Mrs A complained she was given the incorrect blood type, had a surgical drain left in her stomach after a C-section, and received an inappropriate voicemail, causing constant pain and job loss.
NHS in England
Oct 2024
P-003057 — Guy's and St Thomas' NHS Foundation Trust
Mr S complained a consultant damaged his nerve during surgery in September 2021, resulting in permanent functional nerve damage to his hand, requiring further surgeries and impacting daily activities.
NHS in England
Oct 2024
P-003017 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs O complained a consultant provided incorrect eye treatment and monitoring in 2021, causing sight loss. In 2022, a different consultant incorrectly used drops, leading to an unnecessary operation and worsened sight.
NHS in England
Oct 2024
P-003095 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mr E complained doctors failed to provide appropriate support after discharge and inadequately treated his mother's significant health problems, including sepsis, dehydration, and delirium, leading to her distress and avoidable death.
NHS in England
Partly Upheld
Oct 2024
P-003765 — Manchester University NHS Foundation Trust
Mrs C complained about her mother's care after bypass surgery, alleging prolonged sedation, incorrect line handling, delayed diagnosis of a necrotic tongue, inadequate blood clot management, and delayed CT scan contributed to her death.
NHS in England
Not Upheld
Aug 2025
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.
NHS in England
Not Upheld
Aug 2025
P-004128 — University College London Hospitals NHS Foundation Trust
Prof. A complained the Trust failed to adequately monitor his brother's skin for necrotising fasciitis, perform timely debridement, or monitor for infection spread post-surgery.
NHS in England
Partly Upheld
Oct 2025
P-001719 — University Hospitals Birmingham NHS Foundation Trust
Mrs A complained staff refused to treat an abscess, misdiagnosed it multiple times, and failed to treat gangrene, ultimately leading to her leg amputation.
NHS in England
Jan 2023
P-002948 — Surrey and Sussex Healthcare NHS Trust
Miss U complained the Trust performed an inappropriate assessment of her cousin, Mrs I, and wrongly discharged her with pneumonia, leading to her deterioration and eventual death.
NHS in England
Partly Upheld
Sep 2024
P-003328 — Leicestershire Partnership NHS Trust
Miss A complained Leicestershire Partnership NHS Trust failed to provide appropriate physiotherapy and skin care for her sister, Mrs C, leading to a worsening pressure sore and her death.
NHS in England
Not Upheld
Feb 2025
LGO / SPSO decisions(78)
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 …
LGO (Local Government & …
Health
Nov 2022
201406639 — Forth Valley NHS Board
Mr C complained that the prison health centre failed to provide appropriate treatment for the injury to his knee. After injuring his knee, Mr C attended the health centre and was prescribed pain medication. Mr C saw the doctor again a few days later because of the pain in his …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2015
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 …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2015
201404527 — A Medical Practice in the Lothian NHS Board …
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 …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2015
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 …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2015
NIPSO-19185 — South Eastern Health and Social Care Trust
The Ombudsman has partially upheld a complaint about the care and treatment of man while he was an in-patient in the Lagan Valley Hospital in 2017.
NIPSO (NI Public Service…
Health & Social Care
Jul 2022
NIPSO-19019 — Western Health and Social Care Trust
An investigation into complaints about the end of life care received by a man in the South West Acute Hospital has found that he was treated appropriately by medical staff.
NIPSO (NI Public Service…
Health & Social Care
Jul 2022
NIPSO-201917306 — Belfast Health and Social Care Trust
A woman complained that hospital delays contributed to her mother’s early death. We found a number of failings in her care and treatment.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Feb 2024
PSOW-202202124 — Cardiff and Vale University Health Board
Ms X complained that the Health Board had failed to respond to her complaint about the care provided to her during her pregnancy and labour, which she made to it in December 2021. In considering the complaint, the Ombudsman was concerned that the Health Board had not yet provided Ms …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202202017 — Betsi Cadwaladr University Health Board
Ms X complained about the medical care provided to her mother during the time she was admitted to hospital. She felt that the hospital failed to provide her mother with an acceptable or even a safe level of care and wanted a personal face-to-face apology from staff involved. The Ombudsman …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202200953 — Betsi Cadwaladr University Health Board
Ms A complained that in May 2021 she was not informed about the risk of losing her baby following a 13-week scan. She also complained about the lack of monitoring and internal communication between departments. Other issues complained about included the insensitively of a staff member when discussing an autopsy, …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202102573 — Betsi Cadwaladr University Health Board
Miss X complained that Betsi Cadwaladr University Health Board failed to make a diagnosis, and/or communicate a diagnosis, of endometriosis (a condition where tissue similar to the lining of the womb grows in other places such as the ovaries), either internally, or to Miss X, within a reasonable and appropriate …
PSOW (Public Services Om…
Health
Upheld
Jul 2022
PSOW-202308559 — Betsi Cadwaladr University Health Board
Mrs L complained whether, following the removal of her husband’s cancerous melanoma in 2020, he received appropriate follow-up care and whether he should have had further scans in 2022 when national guidance changed. The Ombudsman’s investigation found that after the removal of the cancerous melanoma in 2020, Mrs L’s husband’s …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
PSOW-202400450 — Swansea Bay University Health Board
Dr C complained about the care and treatment provided to his wife, Dr E. Specifically, Dr C was concerned about whether appropriate cardiological tests were carried out when Dr E attended hospital in July 2023. The investigation found that appropriate levels of care were delivered to Dr E. When Dr …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
PSOW-202406252 — Cardiff and Vale University Health Board
Mrs X complained that Cardiff and Vale University Health Board failed to publish specific public guidance about the best care pathway and treatment approach for children with Cystic Fibrosis suffering with significant urinary incontinence. Mrs X said her child had been left to suffer for 18 months without a referral …
PSOW (Public Services Om…
Health
Dec 2024
PSOW-202406267 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to respond to his complaint submitted 6 months ago regarding excessive waiting times for his mother’s elective orthopaedic surgery for total hip replacement. The Ombudsman concluded that the Health Board had failed to respond to Mrs X’s complaint in line …
PSOW (Public Services Om…
Health
Dec 2024
PSOW-202406512 — Hywel Dda University Health Board
Miss X complained that Hywel Dda University Health Board had failed to respond to her complaint in line with its internal complaint process regarding Miss X being incorrectly told she had a stroke. The Ombudsman concluded that the Council had failed to respond to the complaint in line with its …
PSOW (Public Services Om…
Health
Dec 2024
PSOW-202406627 — Aneurin Bevan University Health Board
Mrs X complained that Anuerin Bevan Health Board failed to identify the cause of her debilitating back pain following several scans. Mrs X said she had to pay privately to establish that the Health Board had overlooked a herniated disc in her spine. The Ombudsman concluded that the Health Board …
PSOW (Public Services Om…
Health
Dec 2024
PSOW-202307359 — Cwm Taf Morgannwg University Health Board
Mr X complained about the standard of treatment provided to him by Cwm Taf Morgannwg University Health Board in relation to his orthopaedic pain. Specifically, the Ombudsman’s investigation considered whether the tests and investigations carried out into his left hip and foot pain during hospital admissions in July and August …
PSOW (Public Services Om…
Health
Not Upheld
Jan 2025
PSOW-202406934 — Betsi Cadwaladr University Health Board
Ms B complained about care and treatment provided by Betsi Calwaladr University Health Board in relation to screening received prior to being diagnosed with breast cancer. She said that the Health Board investigated her concerns before she was able to submit a formal complaint. The Ombudsman said that the Health …
PSOW (Public Services Om…
Health
Jan 2025
201405452 — Grampian NHS Board
Mrs C was unable to eat or drink without being sick in the early weeks of her pregnancy, and she complained that a midwife should have taken a urine sample for testing to look into this problem. Mrs C also felt unwell in the weeks following her return home after …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2015
201401774 — Lothian NHS Board
Mr C complained about the medical treatment he had received in prison and, in particular, about delays he had faced in getting medication. We took independent advice from one of our medical advisers, who is an experienced GP. Although there was no evidence that there was a three-week delay in …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2015
201401646 — Tayside NHS Board
Mr C complained that the board unreasonably advised the Scottish Prison Service (SPS) that it was safe for him to be subject to metal detecting equipment, although he has an implantable cardioverter defibrillator (ICD) (a device that regulates irregular heart rhythms). Mr C also complained about the board’s handling of …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2015
201400695 — Forth Valley NHS Board
Mr C complained that the board’s prison health centre doctor unreasonably stopped his pain medication for a long-term knee injury, on the basis of alleged intelligence that Mr C misused another pain relief medication he had previously been prescribed. Mr C was concerned that the doctors at the health centre …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2015
201400410 — Lanarkshire NHS Board
Mr C complained to the board about the care and treatment that his wife (Mrs A) received. Mrs A was being investigated for lung disease when an error in interpreting a scan referral in December 2011 resulted in a delay in the diagnosis of lung cancer. Mrs A underwent surgery …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2015
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 …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2015
201607122 — Tayside NHS Board
Mr C complained that, following a collapse in the street where he vomited blood, his son (Mr A) was taken to Ninewells Hospital where he was discharged after treatment for a head injury. Later that day Mr A was again found collapsed in the street and he was again taken …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201606980 — A Medical Practice in the Tayside NHS Board …
Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his wife (Mrs A). He said that Mrs A had been seen by two GPs at the practice within three days with complaints of severe abdominal pain and dehydration, and that she …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201606735 — A Medical Practice in the Forth Valley NHS …
Mr C complained that the practice failed to appropriately manage pulmonary fibrosis (a lung condition) in his late mother (Mrs A). The condition was first identified in a scan carried out five years prior to Mrs A's death and she regularly attended the practice over the intervening years with symptoms …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201606304 — A Medical Practice in the Lothian NHS Board …
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 …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201604927 — Tayside NHS Board
Mr C complained that the prison health centre unreasonably decided to discontinue his medication when he failed a medication check. Mr C said the prison health centre failed to take account of the fact that he had reported to them that he was being bullied for his medication. The prison …
SPSO (Scottish Public Se…
Health
May 2017
201604427 — Tayside NHS Board
Mr C underwent an operation at Ninewells Hospital to remove a skin tag on his penis. He was concerned about the outcome of the operation and the appearance of the resulting scar, and he said that he was left with some disfigurement. Mr C complained that the consultant urological surgeon …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201604403 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained about the care and treatment provided to him at the diabetes clinic at the New Victoria Hospital. Mr C complained that when he was experiencing severe problems with his diabetes there were delays in him being given appointments, and that he was often given phone reviews instead …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201604349 — A Medical Practice in the Forth Valley NHS …
Mr C complained that the practice had failed to act appropriately on his reported symptoms of imbalance. Mr C has diabetes and related diabetic neuropathy (nerve damage). He said that over a long period he had complained to the practice of imbalance and falls but that this had always been …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201604204 — A Medical Practice in the Ayrshire and Arran …
Mrs C complained about the medical practice with regards to the care and treatment provided to her husband (Mr A). Mrs C said that the GP failed to ensure that Mr A's diagnosis of a rare type of cancer was followed up and that had the GP acted differently, Mr …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201603948 — Grampian NHS Board
Mr C made regular visits to his medical practice. He was concerned about symptoms of facial flushing and rash (for which he was seeing a dermatologist at a hospital). After six months, a blood test confirmed that Mr C had diabetes. Mr C complained that the practice failed unreasonably to …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201603555 — A Medical Practice in the Fifie NHS Board …
Mr C complained about the care and treatment he received from his medical practice. Mr C had been admitted to hospital to receive treatment for chronic liver disease. When he was discharged from hospital, the medication he was prescribed was a lower dosage than he had been taking previously. Mr …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201603001 — A Medical Practice in the Grampian NHS Board …
Ms C complained about care and treatment her mother (Mrs A) received from her medical practice. Ms C was concerned that the practice missed opportunities to enable an earlier diagnosis of lung cancer. She felt that an earlier diagnosis could have helped prevent Mrs A's death. Ms C also raised …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
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 …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201602880 — Fife NHS Board
Mrs C underwent a hip-replacement operation at Victoria Hospital. During the operation, a suture (a stitch used to close a cut or wound) used to repair the muscles at the back of her hip caught the edge of her sciatic nerve (a nerve in the lower back area). Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
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). …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2026
202500492 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment provided by the board during a planned caesarean section. C said that complications occurred during the procedure which could have been avoided based on information available from antenatal scans. C also complained about the timing of the procedure, record keeping, delays in arranging …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2026
202408417 — Ayrshire and Arran NHS Board
C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of the nose) after a rugby accident. C complained about the care and treatment provided to A following the procedure. C had all skin sutures and brace, seven days after surgery, …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2026
202400402 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment that they received from the board.Towards the end of their pregnancy, C contacted the Maternity Assessment Unit due to reduced fetal movements. After phone advice and subsequent in-person assessment, they were discharged home. C again reported concerns at 39 weeks and 5 days …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2026
202311004 — A Medical Practice in the Highland Board area
C complained about the care and treatment given to their late spouse (A) by the practice before A died from metastatic renal cancer. C raised concerns that A was misdiagnosed by the practice and that they did not make appropriate referral for further investigation when they should have done. In …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2026
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 …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2026
202306923 — A Medical Practice in the Ayrshire & Arran …
C complained that the practice failed to act reasonably on the symptoms and information provided by C to the practice. The practice acknowledged difficulties in handling the complaint and failed to manage its interactions with a specialist laboratory. C has since transferred to a different practice, and has a diagnosis …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2026
NIPSO-20800 — Belfast Health and Social Care Trust
We found that the Belfast Health and Social Care Trust acted appropriately when stopping a patient's pain relief injections, but asked it to reflect on the best way to manage the issues around patients having treatments withdrawn that, to them, have resulted in benefits.
NIPSO (NI Public Service…
Health & Social Care
Mar 2021
PSOW-202302872 — Hywel Dda University Health Board
Mrs A complained about a delay in the provision of pain relief for her mother, Mrs C, during her wait in an ambulance outside Glangwili General Hospital on 13 March 2022. She also complained about a delay in carrying out her mother’s surgery to her right hip following her admission …
PSOW (Public Services Om…
Health
Upheld
Jul 2024
PSOW-202401324 — Hywel Dda University Health Board
Ms A complained that Hywel Dda University Health Board (“the Health Board”) took too long to respond to her complaint. She also complained about the response to an issue referred to the Health Board by the Medical Examiner. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman …
PSOW (Public Services Om…
Health
Jul 2024