Doctors failed to tell a father of seven that he had a terminal illness and gave him false reassurance that he would be all right, an investigation by England’s Health Ombudsman has found. 

William Chapman, known as Syd, died eight months after accidentally discovering his prognosis when his GP, believing hospital doctors had already told him the full scale of his condition, mentioned it during a phone call. 

The Parliamentary and Health Service Ombudsman (PHSO) said that the doctors at the Countess of Chester Hospital showed a worrying lack of accountability and had failed to learn from the mistakes made in Syd’s case. 

Our investigation highlights how quickly trust can be eroded in public services and why NHS and Government leaders need to make sure they build and support a consistent culture of openness and honesty within the NHS. 

Rebecca Hilsenrath KC (Hon), Chief Executive Officer at PHSO, said, 

There are many brilliant and dedicated people working in the challenging circumstances of an NHS under intense pressure. But it is inevitable that sometimes things go wrong. When that happens, it is important that people listen and take learning on board.

 

 “This disturbing case highlights the importance of effective communication and the consequences of getting it wrong. When you hear this kind of diagnosis in this kind in this way, you lose a sense of dignity and the opportunity to make your own decisions about how to live your life. The family’s trauma was compounded by their treatment during the hospital’s internal complaints handling.

 

“Too little accountability and too much defensiveness in the NHS is something we highlighted in our Broken Trust report two years ago. There needs to be a cultural shift starting from the top down to improve patient safety and avoid further harm to patients and their families.

 

“Good communication is critical in health settings. In this case, a patient was misinformed about his health and this led to a breakdown in trust between clinicians and the patient and to prolonged distress for his family.” 

Syd, 58, from Upton, Cheshire, was a grandfather-of-16, had served in the Royal Irish Rangers and ran a cleaning business.  

He went to the hospital in July 2021 with deteriorating shortness of breath and was diagnosed with COVID-19. Syd was referred to the specialist lung department the following month for further tests. 

In September, a junior doctor told Syd that there was nothing to worry about and gave him unfounded reassurance that he would be all right when they did not know this would be the case. 

On 1 November, Syd was seen by a consultant who noted in a letter to his GP that he had pulmonary fibrosis, a type of lung disease that makes it hard to breathe. The consultant did not send Syd the letter or tell him about the diagnosis as they should have. 

Syd found out that he had pulmonary fibrosis, a progressive and terminal illness, when he spoke to his GP in December. Syd died in August 2022.

Syd’s daughter Chantelle, 32, said, 

We feel completely let down by the Trust. My dad thought he was going to get better, because that’s what they led him to believe. Because of that he carried on working even though it was a struggle for him. 

 

“If he had known the truth, he would have given up work and made the most of the time he had left with his family. By the time he was given the information to make that decision he was too poorly to work anyway, he was practically bed-bound. We all lost that time to spend together.

 

“It was such a rollercoaster. This has affected all of us and we’ve all lost our trust in the NHS. A relative offered to pay for my dad to have treatment privately, but he had such faith in the NHS that he turned it down. 

 

“Medical staff have a duty of care to tell patients what is really happening. It was very traumatic for us all to lose him after being told that he would be fine.” 

The Ombudsman found that Syd was given false reassurances about his prognosis which prevented him from making informed decisions about his health and meant he was not prepared when later told that his illness was extremely serious. 

Hospital staff failed to listen to Syd’s family. Consultations were not recorded properly in his medical records, and sometimes not recorded at all.

The Countess of Chester Hospital NHS Foundation Trust took over a year to respond to the family’s complaint. The Trust did not adequately investigate what happened or acknowledge all its failings. This meant Syd’s family had to go through an unnecessarily long and painful process to get the answers they were seeking. 

The Trust also failed to properly acknowledge the impact its failings had on Syd and his family and, most importantly, to learn from what had happened. While the Trust acknowledged that it had provided false reassurance to Syd, it had not taken adequate steps to make sure this does not happen again.

PHSO found no failings with the clinical care given to Syd. 

Rebecca Hilsenrath added, 

We found some poor record keeping which can affect a Trust’s ability to understand the impact of what happened and to take appropriate steps to prevent it from reoccurring.

 

“Poor quality investigations and unacceptable delays in responding to complainants are issues we have highlighted before in the NHS. We routinely see Trusts fail to accept errors or acknowledge the impact, which causes complainants more distress at what is already a difficult time.” 

PHSO recommended the Trust acknowledge its failings and apologise to Syd’s family, make service improvements, improve its record keeping, and pay Syd’s wife £1,200. The Trust has complied.

Read the investigation report.

We launch today a consultation on a proposed own initiative investigation into whether Registered Social Landlords (also known as Housing Associations) and local authorities are appropriately responding to reports and concerns relating to disrepair, with a focus on damp and mould, taking into consideration the needs of vulnerable tenants.

We can launch an investigation into a matter even without receiving a complaint, known as ‘own initiative’ investigations. We can do this if we decide that something may have gone wrong with public services; the issue could have negative impact on a wide group of citizens (particularly if they may be vulnerable or disadvantaged); and it would be in the public interest to investigate.

If needed, any investigation or investigations would identify what social housing providers could do better to ensure that they respond to concerns of vulnerable tenants (including disabled people, older people, young people and children, people on a low income, people from diverse ethnic backgrounds) appropriately and in a timely manner.

The investigation would also share any good practice identified to drive improvement across public services in Wales.

Michelle Morris, the Public Services Ombudsman for Wales, said,

“Poor housing has a serious impact on people’s physical and mental health, yet too many tenants continue to live with disrepair, damp, and mould, causing daily anxiety which affects their wellbeing. In recent years, we have seen a rise in complaints about social housing, with just over 19% of new complaints in 2024-2025 relating to these issues.”

“In response, we published our thematic report, Living in Disrepair, in November last year. The report highlighted key themes and learning from our casework, including examples where vulnerable tenants waited longer than necessary for repair or maintenance work. It also emphasised that the impact of poor housing conditions is even greater for elderly or disabled residents.”

“More recently, we have received further complaints of this nature. During 2024 -2025, we intervened early in 79 cases relating to disrepair or damp and mould. In the past two months, we have issued four Public Interest reports against Cardiff Council, Flintshire County Council, and Trivallis about these issues.”

“This leads us to suspect that similar issues may affect tenants across other social housing providers, and reinforces the need for action to ensure tenants’ concerns are addressed promptly and effectively.”

The consultation will close on 8 December at mid-day.

A homeless Leicester family spent nearly 10 months too long in Bed and Breakfast accommodation, according to the Local Government and Social Care Ombudsman.

Following an investigation into the case, the council has rejected the Ombudsman’s recommendation to pay the family a financial remedy for the injustice they have been caused.

It is the second time this year the council has taken the rare step of refusing to accept one of the Ombudsman’s recommendations.

The family complained to the Ombudsman that Leicester City Council placed them in B&B accommodation in separate rooms because of the family’s size in August 2023. The family were also moved on a number of occasions.

The council eventually found a suitable property for the family in July 2024.

The Ombudsman’s investigation found fault with how the council handled the family’s case, including delays when reviewing their Personalised Housing Plan and not telling the family about their rights to appeal the suitability of accommodation offered.

The council also took too long to decide it owed the family the main housing duty, and for failing to move the family to self-contained accommodation after six weeks of living in the B&B, contrary to the law.

Mrs Amerdeep Clarke, Local Government and Social Care Ombudsman, said:

“The council is not alone in experiencing increasing pressure and demands on its homelessness services. However, it is unique in repeatedly declining to agree to our recommendations to remedy the injustice caused to families impacted by its failings.  We cannot become apathetic to failings simply because we see these repeated across different parts of the country and we will continue to hold councils to their legal obligations.

“By refusing to acknowledge and remedy the injustice caused to the family – including splitting them up across separate rooms – for nearly 10 months, I am concerned Leicester City Council has yet again not fully accepted the personal impact of what has gone wrong.

“We hear the council’s concerns about wider impacts of paying a financial remedy to the family. Our report recognises the service improvements the council has made to address the use of B&B accommodation for homeless families. However, we have been clear that we have only recommend financial remedies for the two complaints brought to us and that these are based on the individual circumstances of each complaint. This is clearly reflected in the different remedies we have made in this and the previous case.

“I urge Leicester City to reflect on this case, and its responses to my office, and to put things right for this family.”

The Local Government and Social Care Ombudsman remedies injustice and shares learning from investigations to help improve public, and adult social care, services. In this case the council has agreed to apologise to the family for what has gone wrong in this case.

However, it has not agreed to pay £3,525 for the injustice of having to live in unsuitable B&B accommodation for 42 weeks longer than they should have done.

In line with the Ombudsman’s powers, the council now must consider the Ombudsman’s report at a full council meeting, or similarly senior decision-making level, and formally respond.