Dudley CCG

2. Mrs O complains about a consultation for her late daughter, Miss L, which occurred on 28 May 2017 at an Urgent Care Centre. She complains that the Advanced Nurse Practitioner (ANP) who reviewed Miss L failed to recognise the seriousness of her condition during the assessment.

3. Mrs O says the actions of the ANP led to Miss L’s death on 28 May 2017. She tells us this has had a significant impact on her and her family. Mrs O says that the family does not feel complete, and this has had a considerable impact on their mental health.

4. As an outcome to her complaint, Mrs O wants the CCG to admit the mistakes made in Miss L’s care. She also seeks service improvements to prevent this happening to any other families.

5. Miss L became unwell after her eight-week injections. On the 28 May 2017, Mrs O took Miss L to the Urgent Care Centre following the advice of 111. Miss L was seen by the ANP who advised Mrs O to take her home and continue to monitor her symptoms. Mrs O was told to bring Miss L back if her symptoms worsened. When Mrs O woke the following morning, Miss L was not breathing. Miss L was taken to hospital, but sadly died shortly afterwards.

6. Mrs O raised her complaint with the CCG in August 2017. The CCG responded on 21 September 2017. It appears that a Local Resolution Meeting took place on 10 October 2017, and a further response was sent by the CCG on 30 October 2017. We have not had sight of any further responses. Mrs O contacted our Office to escalate her complaint in October 2020.

Consultation on 28 May 2017

8. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. Mrs O tells us she became aware of her reason to complain in May 2017. We have taken this as her date of knowledge. This means that Mrs O should have brought her complaint to us by May 2018.

9. We have discussed this with Mrs O to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Mrs O.

10. Mrs O tells us that she was not aware that her complaint could go any further and that she was not informed of how to escalate her concerns. She explains that she contacted her local Member of Parliament (MP), various solicitor’s, and the Care Quality Commission (CQC), but was unable to escalate her complaint. She also says that she contacted the Patient and Liaison Service (PALS), but again could not progress her complaint. Mrs O tells us she only found out about the Parliamentary and Health Service Ombudsman (PHSO) through social media, and this is when she took action to escalate her complaint.

11. In addition to this, Mrs O explains that she was not able to raise her complaint with the CCG, or our Office, sooner as she was caring for her two young sons and was supporting herself and her family through the difficult time after the loss of Miss L. We understand that Mrs O was struggling to deal with these circumstances, and she tells us she was unable to think clearly. Mrs O also explains that she did not have the support or knowledge that she does now to progress her complaint, and so waited until she was in a better frame of mind to do so.

12. We made enquiries with the CCG and the Trust to seek information about Mrs O’s complaint. We contacted the Trust as the Urgent Care Centre is based at one of its hospitals. The Trust confirmed that it had not had any input into this complaint.

13. As we have explained in the background section of this statement, Mrs O raised her complaint in August 2017. The first response from the CCG dated 21 September 2017 advised Mrs O that she could get back in touch if she remained dissatisfied with the response. We are also aware that included with this response was a letter from the Director of Urgent Care. This letter addressed the complaint and advised Mrs O that the CCG and Urgent Care Centre would be happy to meet to discuss her concerns further. This letter signposted Mrs O to our Office and provided the details of how to contact us. We consider this shows that Mrs O was told how to escalate her concerns.

14. We can see that Mrs O received a further letter from the CCG on 30 October 2017. This letter refers to a local resolution meeting which took place on 10 October 2017 with the staff from the Urgent Care Centre. Whilst this letter did not signpost Mrs O to our Office, she had previously been given these details. We also consider that this was an opportunity for Mrs O to ask those present how she could escalate her concerns if she was unsure of how to do so.

15. If Mrs O was unsure of how to progress her complaint, we consider she could have investigated this further. It is reasonable to expect that she could have contacted the CCG to ask how to do so. There is also a wide range of information available to the public through many resources such as our website, advocacy services, and the Citizen’s Advice Bureau.

16. We recognise that Mrs O and her family have been through a significantly distressing time and we have carefully considered the personal difficulties she has experienced. We acknowledge that this would have had an impact on her ability to raise her concerns, but we have identified a few opportunities where Mrs O was able to raise her concerns and could have sought further information about escalating her complaint. The information we have reviewed shows that Mrs O was provided with information about pursuing her concerns further and external help and assistance was available to her through alternative organisations if she felt unable to manage this herself.

17. For this reason, we are unable to put our time limit to one side. We do not consider there is sufficient justification to be able to set aside such a large period of time from the date of knowledge to Mrs O complaining to us.

18. We are sorry that we cannot consider this part of Mrs O’s complaint further on this occasion. Our time limit is a legal requirement. It is not an optional consideration, but a significant part of our decision-making process and one we must take into account when we receive complaints outside of our time limit.

1. We have carefully considered Mrs O’s complaint about Dudley CCG (the CCG). We were sorry to learn of Miss L’s passing, and the circumstances which led Mrs O and her family to raise their concerns. For Mrs O’s concerns about the CCG, we have decided the complaint falls outside of our time limit.