Care and treatment
15. 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. We have discussed this with Mr E to understand the reasons why Mrs E could not bring her complaint sooner. We have also considered the time the Trust has taken to respond to Mrs E’s complaint.
16. Mrs E had her operation in May 2012. She had reason to complain in March 2014 when she says she was told by a consultant that her colon had been cut during her operation. Mrs E’s daughter complained to the Trust on her behalf in January 2018. Mrs E complained to us at the end of June 2021. Her complaint is therefore six years and three months out of time. We have carefully considered the reasons provided for the delay in bringing the complaint to the Trust, and in turn to us.
17. Mr E told us the delay was due to Mrs E having more surgery in 2014, 2015, 2017 and 2018, and also because a legal team was looking into the case.
18. We recognise Mrs E and her family were coping with a difficult period in their lives while Mrs E was undergoing further surgery. We can see that her husband and daughter have assisted with her complaint. Therefore, we consider that Mrs E could have complained earlier than she did with help from her family. She could also have sought help from a professional advocacy service if needed. Based on the information provided by Mr E, there also looks to have been time between 2015 and 2017 when Mrs E was not having surgery and she could have complained. We saw no evidence she did this.
19. We have also considered an internal email, dated 16 December 2019, in the Trust’s complaints file stating the file was closed by legal in September 2015. The case was archived as the legal team had received no communication with Mrs E’s solicitors since the medical records were disclosed, and no further action was taken. As the legal file was closed in 2015, we do not consider that this prevented Mrs E from complaining to the Trust before January 2018. In addition, the fact that Mrs E was able to look at taking legal action during this period indicates that she could also have complained to the Trust.
20. We have seen a more recent letter to Mrs E from a solicitor, dated June 2021, advising her that they cannot assist with her legal claim for various reasons. Pursuing legal action at this point does not explain why Mrs E was unable to complain to the Trust before 2018, or to contact us sooner than she did. In any event, we would not generally consider the pursuit of legal action sufficient reason to set aside our time limit.
21. From the Trust’s complaints file, we recognise that there have also been lengthy delays on its part once Mrs E complained. There look to have been delays in arranging complaints meetings and getting the notes reviewed by attending clinicians, and then sent to Mrs E’s daughter, who made the initial complaint to the Trust on Mrs E’s behalf. Some of this delay looks to have been due to the impact of the COVID-19 pandemic. While we acknowledge there were also delays by the Trust, Mrs E was already almost three years outside of our time limit at the point the complaint was raised with the Trust.
22. There also looks to have been a delay before the Trust sent the notes to Mr E in June 2021. Mr E has showed us emails he sent the Trust in February 2020 (the date the meeting took place), and in January, March, and September 2021. Aside from the email sent on the date of the meeting, there is no evidence Mr and Mrs E contacted the Trust until January 2021. Mr and Mrs E were present at the meeting so there was nothing preventing them from chasing the meeting notes sooner than they did.
23. In summary, we recognise that some of the delays in bringing this complaint to us were outside of Mrs E’s control. However, there is a significant delay before Mrs E complained to the Trust. Even without the later delays in the complaint process, her complaint was already substantially outside of our time limit at the point she complained to the Trust. Having considered the length of this delay, and the reasons provided, we do not think there are sufficient grounds for us to set aside the time limit.
Trust’s complaint handling
24. Mrs E says she did not receive satisfactory answers following the complaints meeting in February 2020. She says the Trust’s Governance Support Officer said the Trust would investigate her concerns further and answer her questions following this meeting. She says the Trust did not answer her questions namely:
· Why she was discharged from hospital with her bowel cut
· why she was discharged knowing that faeces were coming out of her surgery wound
· why no follow up appointments were scheduled
· why there were no discharge papers
· why an X-ray was not done sooner
· why she was not told about the colorectal surgeon being present at her operation without her consent
· whether correct procedures were followed before surgery such as cleaning and preparing her abdomen.
25. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
26. Our Principles of Good Administration say organisations should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot.
27. Draft notes of the meeting in the Trust’s complaint file set out further actions to be taken by the Trust:
· finding out what happened regarding Mrs E’s follow up appointment after the first operation.
· checking the discharge summary for Mrs E’s June admission.
· contacting the legal team regarding the legal claim raised.
· querying if the matter was raised as a serious incident.
· sending a medical records access form.
28. The actions set out in the draft notes are different to the actions Mr and Mrs E believed the Trust was going to take. There is no evidence in the notes to indicate that the Trust agreed to reinvestigate those aspects of the complaint. In addition, the notes show that most of the further questions Mrs E wanted answers to were broadly addressed by the consultants during the meeting. The notes explain that no bowel injury was obvious at the time of the surgery, and a CT scan had not reported any damage to the bowel. They explain why the colorectal surgeon was asked to attend the operation and that the Trust felt the gynaecology team’s request for their support was appropriate. The notes also explain what happened during Mrs E’s follow up appointment in August 2020.
29. As we have seen no evidence of any agreement or plan for the Trust to investigate the set of questions Mrs E told us about, we cannot see that the Trust has failed to keep a commitment to her. So, we do not consider there are indications of maladministration (fault) here. We are sorry that what the Trust told Mrs E was not enough to reassure her about what happened during and after her operation.
30. We recognise Mrs E may be disappointed with this decision and we are sorry for any distress it causes. It is our duty to be impartial and transparent in explaining our decision. We hope Mrs E understands the reason for our decision.