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 10 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
23 PFD reports
17 committee recs
1 CQC action
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: 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.
Response (Department of Health): • NHS Blood and Transplant (NHSBT) investigated the specific platelet transfusions administered to Mr Higson. • NHSBT established that donors were appropriately selected to minimise the risk of transfusion-related acute … (AI summary)
Response (NHS Blood and Transplant): • NHS Blood and Transplant (NHSBT) contacted hospital staff at Frimley Park Hospital to review the case notes related to the specific incident. • NHSBT recommended informing the Medicines and … (AI summary)
Responded
Peter Jeffrey
Concerns: 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.
Response (Guys St Thomas NHS Foundation Trust): • The Trust stated it would remind staff of the importance of following through with referral plans to ensure follow-up appointments are initiated. • The Trust stated it would remind … (AI summary)
Responded
Susan Poore
Concerns: 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.
Overdue
Mrs Care
Concerns: 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.
Overdue
Barbara Harrison
Concerns: 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.
Overdue
Lynn Poyser
Concerns: 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.
Overdue
Thomas Pearson
Concerns: 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.
Response (Doncaster and Bassetlaw Hospitals): • The respiratory team held discussions regarding the use of inhaled corticosteroids in chronic obstructive pulmonary disease. • The team works collaboratively and regularly discusses a variety of clinical topics. … (AI summary)
Responded
James Kane
Concerns: 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.
Response (Department of Health): • The Department of Health consulted the National Institute for Health and Care Clinical Excellence (NICE) regarding the coroner's concern. • The Department of Health consulted the Royal College of … (AI summary)
Response (County Durham and Darlington NHS Trust): • A root cause analysis was undertaken, and national and regional guidelines on paracentesis were reviewed. • The Trust committed to providing trainees with guidance and developing an audit trail … (AI summary)
Responded
Pauline Taylor
Concerns: 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.
Response (PAGB): • PAGB is developing new warning statements for product packaging and patient information leaflets, which will undergo user-testing to ensure clarity. • PAGB will work with the MHRA and other … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA is undertaking an in-depth review of instructions for use and reported adverse incidents, aiming to complete it by the end of 2017 and consider publishing additional safety … (AI summary)
Response (Locala): • Locala disseminated updated guidance on paraffin-containing skin products and their fire risk to all business units and staff. • Training was updated, and risk assessment processes were revised to … (AI summary)
Response (NHS England): • The NHS Patient Safety Team undertook work with the Medicines and Healthcare Regulatory Agency and other organisations regarding the concerns. • Actions taken were detailed in the Patient safety … (AI summary)
Response (United Kingdom Home Care Association): • The United Kingdom Homecare Association published a fact sheet, 'UKHCA Guidance; Emollient Products Guidance for homecare providers,' in January 2018. • The United Kingdom Homecare Association published an article, … (AI summary)
Overdue
Pamela Hands
Concerns: 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.
Response (British Orthopaedic Association): • The British Orthopaedic Association (BOA) has advocated for a multidisciplinary approach to managing patients with femoral neck fractures, including dedicated trauma lists and written standards. • The BOA has … (AI summary)
Overdue
Carl Schmidt
Concerns: 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.
Response: • The University suspended recruitment into Arm 3 of the trial. • The University reviewed the patient's dosage and radiotherapy outlining plans and consulted pathologists. • An emergency meeting of … (AI summary)
Responded
Alvin Black
Overdue
Brian Jackson
Concerns: 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.
Response (National Institute for Health and Care Excellence): • NICE had completed a review of its guideline on delirium. • NICE stated it would update the guideline, focusing on risk assessment and diagnosis of delirium in ICU settings. … (AI summary)
Responded
Marjorie Walker
Concerns: 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.
Response (Greater Manchester Integrated Care): • Electronic whiteboards were introduced in patient areas to improve oversight of patient needs, including DNACPR status, and a trust-wide DNACPR audit was completed. • Analgesic dosing audits were completed, … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care has committed over £8 billion from 2022-23 to 2024-25 to increase elective activity and reduce waiting lists, aiming to eliminate waits of … (AI summary)
Responded
Joshua Asprey
Concerns: 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.
Response (National Institute for Health and Care Excellence): • The respondent stated that responsibility for the content of the British National Formulary (BNF) rests with its publishers. • The respondent indicated that it cannot comment on the concerns … (AI summary)
Response (British National Formulary Publications): • BNF Publications stated it would use a range of communications to remind users how to find drug class information within its content. • This would include a news piece … (AI summary)
Responded
Sultana Choudhury
Concerns: 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.
Response (Department of Health and Social Care): • The Department of Health and Social Care made enquiries with NHS England and the Care Quality Commission. • The Department noted that Barts Health NHS Trust produced a comprehensive … (AI summary)
Responded
Katie Williams
Concerns: 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.
Response (University Hospitals Plymouth NHS Trust): • University Hospitals Plymouth NHS Trust has been in contact with The Faculty of Intensive Care Medicine to assist with sharing relevant information nationally. • The Trust has taken the … (AI summary)
Responded
Paz Ogbe-Millar
Concerns: The coroner heard evidence regarding the appropriate level of observation by Emergency Department staff for mental health patients waiting in the Emergency Department.
Response (West Hertfordshire Teaching Hospital): • The previously used proforma for mental health patients has been replaced by an electronic assessment tool, aligning with the current Standard Operating Procedure. • A Patient Safety Incident Response … (AI summary)
Responded
Orlando Davis
Concerns: 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.
Response (NMC): • The NMC is carrying out Fitness to Practise investigations. • The NMC has shared the PFD report with the General Medical Council. • The NMC will develop and publish … (AI summary)
Response (NHS Sussex Integrated Care Board): • Policies regarding fluid management and hyponatraemia in labour were put in place by University Hospitals Sussex NHS Foundation Trust and East Sussex Healthcare NHS Trust by November 2022. • … (AI summary)
Response (Royal College of Obstetricians and Gynaecologists): • The Royal College of Obstetricians and Gynaecologists stated it would approach NICE to suggest an addendum to the Intrapartum care guideline (NG235) regarding hyponatremia risks, monitoring, and management. • … (AI summary)
Response (Department of Health and Social Care): • The Department noted that NHS Resolution published a report in 2023 on recognising and avoiding maternal and neonatal hyponatremia, which highlighted the importance of accurate fluid balance monitoring. • … (AI summary)
Responded
Brian Beer
Concerns: 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.
Response (National Institute of Health and Care Excellence): • Senior clinical advisers within the patient safety team reviewed the concerns raised. • NICE will continue to monitor new evidence in this area of practice. • The report has … (AI summary)
Responded
Mary Pomeroy
Concerns: 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.
Response (University Hospitals Plymouth NHS Trust): • The Trust transitioned to the Patient Safety Incident Response Framework (PSIRF) in June 2024, ceasing the use of the Serious Incident Framework. • It developed a new policy for … (AI summary)
Responded
Amber Walker
Concerns: 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.
Response (Department of Health and Social Care): • The Department noted that National Institute for Health and Care Excellence (NICE) guidance outlines best practice for discussing SUDEP risk with epilepsy patients and their families. • NHS England's … (AI summary)
Responded
Raymond Moran
Concerns: The falls risk assessment was inaccurate and not updated as required, and associated patient documentation was incomplete.
Response (City of Kingston Upon Hull and the County of the East Riding of Yorkshire): • The Trust conducted immediate post-fall debriefs and multidisciplinary SWARM reviews, which identified specific local learning points. • The Trust reinforced with ward teams the requirement for reassessments upon patient … (AI summary)
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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
NCEPOD recommendations(2)
CQC inspection actions(1)
PPO death in custody recommendations(1)
Independent reviews(4)
Cumberlege Review — Rec 5
Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy.
Health & Social Care
Cumberlege Review — Rec 4
Separate schemes should be set up for each intervention – HPTs, valproate and pelvic mesh – to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim.
Health & Social Care
Cumberlege Review — Rec 3
A new independent Redress Agency for those harmed by medicines and medical devices should be created based on models operating effectively in other countries. The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals.
Health & Social Care
Cumberlege Review — Rec 1
The Government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh.
Health & Social Care
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