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North Tees and Hartlepool NHS Foundation Trust

P-001436 · Statement · Decision date: 13 June 2022 · View North Tees and Hartlepool NHS Foundation Trust scorecard
Treatment Record keeping and management Drugs / medication Diagnosis Delayed Recognition of Deterioration Pharmacist missed drug contraindications
Complaint (AI summary)
Mrs L complained the Trust misdiagnosed her stroke as a migraine, prescribed inappropriate medication (Sumatriptan), and failed to consider alternative medication, leading to health deterioration and distress.
Outcome (AI summary)
The ombudsman closed the complaint as it fell outside the time limit for investigation.

Full decision details

The Complaint

2. Mrs L complains the Trust diagnosed a migraine in August 2017 when she had suffered a stroke. The Trust also did not request a copy of her notes of a private appointment in November 2017 which confirmed she had had a stroke.

3. The Trust also prescribed Sumatriptan to Mrs L which should not be taken following a stroke. Mrs L was also prescribed Topiramate, and the Trust failed to consider alternative medication when she told them the medication was severely impacting her ability to carry out daily tasks.

4. As a result, Mrs L says her health has further deteriorated and she cannot carry out day to day activities without difficulties. The prescribed Topiramate made her feel like a zombie and further increased her difficulties in carrying out daily tasks.

5. Mrs L explained she now suffers from a low mood due to the treatment received, she says the Trust did not listen to her or take her views into consideration. Due to feeling dismissed by the Trust she now finds attending hospital appointments very stressful.

6. Mrs L would like an acknowledgement from the Trust stating they were not proactive in asking for consent to access her private neurologist’s records which recorded the stroke diagnosis and a further acknowledgement stating the Trust should not have prescribed Sumatriptan following her stroke.

7. Mrs L would also like an apology and financial remedy.

Background

8. To reach our decision, we considered information sent by Mrs L and her advocate. This includes Mrs L’s complaint form and her account of what happened.

Findings

9. 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 L and her advocate to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Mrs L.

10. Mrs L attended an appointment with a neurologist in November 2017. The neurologist informed Mrs L she had suffered a stroke. Mrs L complained to the Trust about this in June 2018.

11. Mrs L explained she did not complain to the Trust earlier due to ill health resulting in numerous falls, one of which resulted in her breaking her back. Her daughter who could have supported her in making her complaint was also seriously unwell at this time.

12. Mrs L contacted our office in August 2018. During initial checks it was found Mrs L’s complaint had been treated as an informal complaint by the Trust. The Trust advised Mrs L to contact them with her outstanding concerns.

13. Mrs L returned to our office in December 2018. We confirmed the Trust had sent a final response dated 28 November 2018. Mrs L was advised to complete a complaint form so that we could look into her complaint further. We advised Mrs L by email that the complaint form could be posted, completed online, or downloaded and emailed.

14. Mrs L did not contact us again until November 2021. She explained she had contacted the Trust again about her complaint in February 2021 and had also contacted an advocacy service for support. The Trust sent its final response to Mrs L in October 2021.

15. Mrs L explained she thought she needed to complain to the Trust again before completing a complaint form. She says between December 2018 and February 2021 her health was poor, and she struggled with her memory. She said she struggled to complete daily tasks and was only able to continue with her complaint with support from an advocate.

16. We understand Mrs L was suffering from poor health which did have an impact on her daily life. However, Mrs L contacted us in December 2018 and was aware that she had received her final response from the Trust. It is clear from emails we sent to Mrs L that her complaint was ready to be brought to us with details of how to access a complaint form given.

17. Following Mrs L’s contact with the Ombudsman in December 2018 we cannot see a compelling reason for Mrs L not to have continued with the complaints process at that time, therefore we will not be able to take any further action on Mrs L’s complaint.

Our Decision

1. We have carefully considered Mrs L’s complaint about North Tees and Hartlepool NHS Foundation Trust (the Trust). We are sorry to hear about the problems Mrs L describes following her treatment at the Trust and the impact this has had on her life. We have decided the complaint falls outside of our time limit.

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