3. Mr O complains about the care and treatment his wife, Mrs O, received from the Trust between 13 September 2019 and 28 September 2019. Following Mrs O’s operation to her right knee, he says the Trust failed to appropriately monitor and manage her diabetes.
4. As a result, Mr O says his wife developed dangerously high blood sugar levels which contributed to her death. By bringing the complaint to our office, Mr O is seeking an apology and £25,000 compensation.
5. On 13 September 2019, the Trust admitted Mrs O to hospital to undergo surgery to her right knee. Mrs O previously had a successful full knee replacement. She later developed an infection which needed to be cleaned out.
6. On 15 September the flow in Mrs O’s insulin pump was both blocked and running out of insulin. Mrs O contacted her sister to come into hospital and help her fix the insulin pump. An insulin pump is a medical device used for the administration of insulin in the treatment of diabetes. It delivers tiny amounts of insulin into the blood throughout the day and night. This reduces hypoglycaemia (when the blood glucose level is too low) and can improve blood glucose levels.
7. The following day the Trust carried out the surgery to Mrs O’s knee.
8. On 19 September the Trust moved Mrs O to its High Dependency Unit (HDU). The Trust placed her under the care of its medical team to improve diabetic control.
9. On 23 September Mrs O became short of breath and the Trust admitted her to its Adult Intensive Care Unit (ICU) for treatment.
10. A few days later Mrs O suffered a cardiac arrest due to a myocardial infarction. She died later that afternoon. A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle.
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 enough reason to do so. We have discussed this with Mr O to understand the reasons why he could not bring h. We have also considered the time the Trust took to respond to his complaint.
13. In his complaint form to us, Mr O confirms he was immediately unhappy in September 2019. He complained to the Trust in November 2019 and the Trust arranged for a local resolution meeting (LRM) to take place in February 2020. Following the LRM, the Trust transferred Mr O’s case to its clinical governance team so a structured judgement review (SJR) could take place. A second LRM took place one year later in February 2021.
14. Mr O remained unhappy with the outcome of the second LRM. In March 2021, he attended a third meeting at the Trust. Mr O did not approach our office with his complaint until July 2021.
15. We discussed the reasons for the delay with Mr O. He emailed us and explained he did not raise his concerns with us sooner because, after each meeting with the Trust, he would discuss his concerns with his family. Mr O told us he felt ‘forgotten’ and as though the Trust were ‘pushing him aside’.
16. We do not underestimate the difficulties Mr O says he experienced at this time. We appreciate the events he complains about would have been extremely distressing.
17. Mr O went on to explain, the Trust took too long to arrange and complete the SJR. We acknowledge the delay in the Trust arranging a second LRM was out of Mr O’s control. That being said, Mr O told us he remained unhappy throughout 2020 and that the LRM did not resolve his concerns. We consider this would have been an opportunity for Mr O to approach us.
18. Further, in May 2021, Mr O approached a solicitor with his concerns. The solicitor informed him he did not have a case and they could not look at his concerns. We consider this would have been another opportunity for Mr O to approach our office with his concerns. Mr O did not approach us at this time. Instead, he went back to the Trust.
19. We do not underestimate the difficulties Mr O says he experienced. Mr O told us he knew he was unhappy in September 2019. Therefore, we consider it reasonable he could have approached our office with his concerns much sooner.
Summary
20. We appreciate Mr O’s strength of feeling about his complaint and it is clear he feels deeply concerned about the service and care his wife received. We do not wish to diminish the impact he says these events had on him and his family. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reason for it.
1. We have carefully considered Mr O’s complaint about Oxford University Hospitals NHS Foundation Trust (the Trust). The complaint relates to the care and treatment his wife, Mrs O, received.
2. We are very sorry to hear about the circumstances he complains about. We have completed our consideration of Mr O’s complaint and decided the complaint falls outside of our time limit.