Liverpool Women's NHS Foundation Trust

2. Mrs A complains a doctor at the Trust incorrectly stated in a clinic letter in 2016, that she had undergone excision surgery for endometriosis three times, when she had only undergone it once.

3. Mrs A feels this error in her records has caused a barrier to her receiving the appropriate care and treatment for endometriosis, as those treating her had an inaccurate picture of her medical history. She says this has had an effect on the treatment she received and has caused her enormous stress and upset.

4. Mrs A wants a full apology for lack of care and consideration, her records to be reviewed and corrected. She also wants procedures regarding endometriosis patients and the complaint procedure to be improved, so patients are not misled.

5. On 22 March 2016, Dr O sent the clinic letter to Mrs A that said she had undergone three excision surgeries for endometriosis.

6. In 2019, Mrs A submitted a complaint to the Trust about different concerns and the Trust sent its investigation report on 15 July 2019.

7. In February 2021, Mrs A says her psychologist had recommended she look back over her records and documents to try and come to terms with things, as she had been diagnosed with PTSD and had been receiving therapy for this.

8. She says some wording about previous treatment in the Trust’s investigation response prompted her to look at further documents and this is when she found the letter from 2016. Mrs A saw this had an error about her surgical history. She says this is when things started to fall into place, and she realised this misinformation could have had a negative impact on her care and treatment. She made a complaint to the Trust about this on 9 February 2021.

9. The Trust initially decided there was not enough evidence to open a complaint as its investigation report did not mention three excision surgeries as Mrs A said. Mrs A sent the Trust a copy of the letter from 2016. The Trust also asked for Mrs A’s reasons why she did not bring her complaint to it sooner, as it was out of time. During this time Mrs A also sent a complaint form to us on 16 February, and we advised the complaint was not ready for us. On 2 March 2021, the Trust agreed to investigate on the basis she knew about the letter in 2016 but had not realised the full impact until more recently.

10. On 12 May 2021, Mrs A received the final response from the Trust. On 13 July 2021 we received the final response and other supporting documents from Mrs A, to review the complaint.

Incorrect surgical history in records

12. 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. We have discussed this with Mrs A to understand the reasons why she could not do so. We have also considered what the Trust did.

13. We are sorry to hear about what happened and that Mrs A feels this has had an impact on her care and treatment. We are also sorry to hear how much stress and upset this matter has caused her. We have kept this in mind when considering Mrs A’s complaint to see if there is more we can do to help resolve this.

14. Firstly, we have considered Mrs A’s date of knowledge. Mrs A says her date of knowledge is in February 2021, when she went over her documents following advice from her psychologist. She says this is when she noticed the error about her surgical history. Some wording in the Trust’s investigation report from 2019 prompted her to dig deeper and look at other documents and letters.

15. Mrs A has provided us with a copy of a letter addressed to her, from 2016, showing this error. We think this is the date of knowledge for this issue as Mrs A received a copy of the letter at the time. She would therefore have needed to bring her complaint to us by March 2017. This means Mrs A’s complaint is four years and almost four months out of time.

16. We acknowledge Mrs A says she did not notice the error at the time in 2016, and that she would have corrected the Trust about this had she noticed. We also appreciate why Mrs A did not notice anything that suggested this in the Trust’s investigation report she received in 2019 for some time, due to her mental health difficulties.

17. She got the 2016 letter itself before the Trust’s investigation in 2019. We have therefore focused on that timeframe, 2016 to 2019. We cannot see, and Mrs A has not told us, any reason why she could not have raised her concerns when she received the clinic letter in 2016, or thereafter, until 2019 when she raised a separate complaint to the Trust.

18. We understand why Mrs A may not have thought to challenge this until things fell into place and she realised this error could have had an impact on her care and treatment. Our casework policy (SMG 2.238) is clear that the date of knowledge is when the person could first reasonably know an organisation may have got something wrong, not when they experience the impact of that.

19. We recognise the Trust agreed to look into her complaint when she raised it in 2021, even though it was out of time. We must make our decisions based on our own legislation and policy.

20. We are sorry to hear Mrs A has had difficulty with both her treatment and mental health. Our time limit is a legal requirement and we have considered the reasons Mrs A has provided, particularly for any delay between 2016 and 2019. Unfortunately, not noticing the information in the letter at the time was incorrect is not enough for us to put our time limit to one side. We will therefore not take any further action on this complaint.

21. We hope Mrs A does not think in any way we believe this diminishes the effect the issues in her complaint have had on her. We are sorry there is nothing further we can do, but we have to consider our time limit by law.

1. We have carefully considered Mrs A’s complaint about Liverpool Women’s NHS Foundation Trust (the Trust). We are sorry to hear about her concerns and that she has had difficulty with her treatment and mental health. We consider Mrs A’s date of knowledge to be sooner than she says, and her complaint therefore falls outside of our time limit. Unfortunately, the reasons Mrs A has provided for the delay in bringing her complaint to us are not enough for us to put our time limit to one side.