Inadequate Recognition of Treatment Harm
Failure to adequately recognize and categorize the severity of adverse impacts from specific medical treatments.
166 items
7 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
64match
#1 - 11th Report – Cosmetic procedures
The PIP implant scandal exposed failures that continue to affect women more than a decade later. Official assurances that PIP implants pose no health risks appear to be based on limited long-term research and underplay the mental health impacts on women of having a substandard product inside them. Many women report enduring physical and psychological harm, compounded by...
Matched on
terms: harm, inadequate
PFD report
61match
Sultana Choudhury
Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Matched on
terms: inadequate
PFD report
61match
Amber Walker
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.
Matched on
terms: inadequate
PFD report
57match
Peter Jeffrey
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.
Matched on
terms: treatment
PFD report
57match
Pauline Taylor
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Matched on
terms: inadequate
PFD report
57match
Brian Jackson
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.
Matched on
terms: treatment
PFD report
57match
Paz Ogbe-Millar
Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Matched on
terms: inadequate
PFD report
57match
Orlando Davis
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.
Matched on
terms: inadequate
PHSO casework decision
56match
P-003008 - Milton Keynes University Hospital NHS Foundation Trust
Mrs T complains about the care and treatment she had from the Trust from April 2014 to November 2021. She says the Trust did not address the side effects of the cancer treatment, it continued to administer harmful medication and did not refer her to a specialist after the family raised concerns.
Matched on
terms: harm, treatment
LGO / SPSO decision
55match
201606304 - A Medical Practice in the Lothian NHS Board area
Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his son (Mr A). He said that a GP had prescribed oxycodone (opiate medication) over the phone to Mr A on the morning that he died from a medication overdose. Mr C was also concerned that there had been an...
Matched on
terms: harm, treatment
LGO / SPSO decision
50match
202309740 - Ayrshire and Arran NHS Board
C complained about the care and treatment provided to their late parent (A) by the board. A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course...
Matched on
terms: inadequate, treatment
PFD report
49match
Joshua Asprey
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.
Matched on
classifier match
PFD report
49match
Katie Williams
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.
Matched on
classifier match
PHSO casework decision
48match
P-001376 - Liverpool University Hospitals NHS Foundation Trust
Mr O complained about the Trust’s treatment of his wife during her admission in February 2021. He says the Trust ruptured his wife's artery while removing an ascitic drain, and failed to notice she was bleeding internally.
Matched on
terms: treatment
Committee recommendation
48match
#11 - 11th Report – Cosmetic procedures
The Government should commission research to better understand the health impacts of breast implants, including their potential impacts on women with pre-existing auto-immune conditions. The research needs to be a mix of clinical research, including on the health impacts of siloxanes, and longitudinal, following a cohort of women over a period of time. Such studies are necessary to...
Matched on
terms: treatment
Committee recommendation
48match
#3 - 11th Report – Cosmetic procedures
Without mandatory participation in the Breast Implant Registry and the regular publication of outcome data, surgeons cannot provide patients with comprehensive risk information. This undermines the principle of informed consent. Many individuals feel inadequately informed before surgery and the absence of a cooling-off period further increases the risk of rushed decisions. As the PIP scandal demonstrates, a lack...
Matched on
terms: inadequate
PHSO casework decision
48match
P-004395 - University Hospitals of Derby and Burton NHS Foundation Trust
Mr B complains about the treatment he has received at the Trust following complications after surgery in May 2022. He complains about the Trust's delay in treating his wound, and the failure to manage the infection in his testicles.
Matched on
terms: treatment
LGO / SPSO decision
47match
201306220 - Highland NHS Board
Mr C complained on behalf of Mr A. Mr C said Mr A suffered from spinal damage which had required an operation but his treatment at Raigmore Hospital had been significantly delayed following his referral as it was unreasonably downgraded from urgent to routine and because the board lacked surgical capacity. Mr C was concerned that Mr A...
Matched on
terms: treatment
LGO / SPSO decision
47match
201602995 - Lothian NHS Board - Acute Division
Mr C complained that his wife (Mrs A) was inappropriately diagnosed as having suffered a miscarriage and that she was not provided with appropriate and timely treatment. Mrs A was in the early stages of pregnancy when she experienced bleeding. During the night, Mr C and Mrs A attended the gynaecology out-of-hours service at the Royal Infirmary of...
Matched on
terms: harm, treatment
PFD report
45match
Peter Clive Higson
Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Matched on
classifier match
PFD report
45match
Susan Poore
Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.
Matched on
classifier match
PFD report
45match
Mrs Care
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.
Matched on
classifier match
PFD report
45match
Barbara Harrison
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.
Matched on
classifier match
PFD report
45match
Lynn Poyser
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.
Matched on
classifier match
PFD report
45match
Thomas Pearson
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.
Matched on
classifier match
PFD report
45match
James Kane
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.
Matched on
classifier match
PFD report
45match
Pamela Hands
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.
Matched on
classifier match
PFD report
45match
Carl Schmidt
The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.
Matched on
classifier match
PFD report
45match
Alvin Black
The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing the risk of infection for prisoners; it also notes a missed opportunity to consider anti-coagulation therapy, with the system not picking up on this error.
Matched on
classifier match
PFD report
45match
Marjorie Walker
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.
Matched on
classifier match
PFD report
45match
Brian Beer
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.
Matched on
classifier match
PFD report
45match
Mary Pomeroy
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.
Matched on
classifier match
PFD report
45match
Raymond Moran
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
Matched on
classifier match
PHSO casework decision
44match
P-004439 - The Princess Alexandra Hospital NHS Trust
Mr P complains the Trust failed to provide appropriate bed care, investigations and treatment and pain medication to his late mother-in-law Mrs K. He also says the Trust unsafely discharged her when it realised it has inappropriately given her, end-of-life medications.
Matched on
terms: treatment
PHSO casework decision
43match
P-001060 - University Hospital Southampton NHS Foundation Trust
Mrs C complained on behalf of her husband, Mr C, about the care and treatment the Trust gave him. Specifically, that it was inappropriate for Mr C to be discharged from A&E when he first attended, that he was not treated quickly enough and only had an MRI scan once Mrs C demanded a second opinion. Mrs C...
Matched on
terms: treatment
PHSO casework decision
43match
P-001068 - Portsmouth Hospitals NHS Trust
Mrs L complains about aspects of treatment provided by Portsmouth Hospital NHS Trust (the Trust) when she attended A&E, following a fall in which she hurt her back. Specifically, Mrs L complains that the A&E registrar concerned did not share with her information, that he believed he found evidence of an ‘old’ fracture. She also says the A&E...
Matched on
terms: treatment
PHSO casework decision
43match
P-001076 - University College London Hospitals NHS Foundation Trust
Dr I complains the Trust provided inadequate post-natal care to his wife and daughter in relation to failures to follow-up clinical results, provision of adequate and timely pain relief. Dr I also tells us that Mrs I was left in pain on the ward and was significantly distressed by the lack of care she received. On returning home...
Matched on
terms: inadequate
PHSO casework decision
43match
P-001265 - Croydon Health Services NHS Trust
Ms L complained about aspects of the care and treatment doctors at the Trust gave to her father between 14 March and 10 April 2019. Specifically, she says doctors failed to identify and treat infections and sepsis.
Matched on
terms: treatment
PHSO casework decision
43match
P-004560 - Lewisham and Greenwich NHS Trust
Ms A complains about the care and treatment the Trust provided to her mother over a number of years. She complains about pressure ulcer care and medical treatment.
Matched on
terms: treatment
PHSO casework decision
43match
P-003197 - Berkshire Healthcare NHS Foundation Trust
Mrs A complains about the treatment the Trust provided to her father in relation to his heart failure.
Matched on
terms: treatment
LGO / SPSO decision
43match
21-017-330a - Rutland House (21 017 330a)
Summary: Mrs B complained to the Ombudsmen that a Care Home provided inadequate care to her son. She complained this led to significant, life-changing consequences for him. We decided not to investigate Mrs B’s complaint. This is because it is unlikely we would reach meaningful, evidence-based findings that the Care Home’s actions caused Mr A a specific injustice.
Matched on
terms: inadequate
LGO / SPSO decision
43match
201405374 - Tayside NHS Board
Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was...
Matched on
terms: treatment
LGO / SPSO decision
43match
201404527 - A Medical Practice in the Lothian NHS Board area
Mrs A had fallen at home and sustained a head injury and suspected fractured hip. She had contacted the medical practice and a GP attended and decided that she required to be taken to hospital. The GP arranged that an ambulance should attend within an hour and left Mrs A with a neighbour to wait for the ambulance....
Matched on
terms: treatment
LGO / SPSO decision
43match
201306304 - Lothian NHS Board
Ms C complained about the care provided to her when she was admitted to the Western General Hospital (the hospital). Ms C, who lives within another board area, was visiting Edinburgh when she became ill with abdominal pain, severe constipation, and vomiting. She attended the A&E department of another hospital in the board's area and was transferred to...
Matched on
terms: treatment
LGO / SPSO decision
42match
202501264 - Grampian NHS Board
C complained about the care and treatment that their spouse (A) received from the board during admissions to Dr Gray’s Hospital (Hospital A) and Aberdeen Royal Infirmary (Hospital B). A was admitted following episodes of vomiting blood and received treatment for gastric varices (enlarged blood vessels in the stomach lining). C complained that the board did not investigate...
Matched on
terms: treatment
PHSO casework decision
39match
P-001273 - The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
Mrs U complained about the Trust’s care and treatment of her late mother's infection. She also raised concerns about the decisions the Trust made regarding painkillers and antibiotics when they discharged her mother.
Matched on
terms: treatment
PHSO casework decision
39match
P-002017 - University Hospitals Birmingham NHS Foundation Trust
Mrs K complains the Trust did not do enough when she fell and fractured her wrist. She says it chose to give her conservative treatment, it took the cast off too soon and the telephone physiotherapy was not helpful.
Matched on
terms: treatment
PHSO casework decision
39match
P-003310 - Mersey and West Lancashire Teaching Hospitals NHS Trust
Mr E complains about several issues relating to how clinicians at a hospital treated his father during two admissions towards the end of his life. He believes they failed to arrange the care and treatment needed and that his father’s death could have been avoided.
Matched on
terms: treatment
PHSO casework decision
39match
P-003793 - Mid Cheshire Hospitals NHS Foundation Trust
Mrs B complains the Trust failed to provide appropriate treatment for her husband’s gallbladder infection. She also complains the Trust failed to prevent her husband’s condition from deteriorating.
Matched on
terms: treatment
PHSO casework decision
39match
P-003770 - Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs C complained about the care and treatment of her adult son when he was admitted to hospital in November 2022. She complains doctors failed to give him antibiotics in a timely way even though he was admitted with a known infection.
Matched on
terms: treatment