University Hospitals Bristol and Weston NHS Foundation Trust

3. Miss A complains the Trust’s poor dental treatment in February 2019 led to Mr A getting sepsis and his later death in May 2020. She says:

• the Trust attempted to inject Mr A’s gums without sedating him first which was wrong as he had dementia and was ‘terrified’ of dentists. She says his reaction meant the Trust decided not to remove his eight ‘bad teeth’ and it prescribed fluoride toothpaste instead • the Trust failed to explain the risks of leaving ‘bad teeth’ in his mouth during the ‘Best Interest Discussion’.

4. Miss A says the poor treatment led to Mr A getting sepsis in November 2019 which caused his face to swell up. She says he was admitted to hospital, the infection was treated, and he also got pneumonia. She says the sepsis and pneumonia left her Mr A ‘frail and weak’ and she says this led to his death. Miss A says watched Mr A ‘suffer’ until he died, which caused her significant distress. She says she also needed grief counselling.

5. By bringing this complaint to us, Miss A would like an apology, service improvements, and financial compensation.

6. In February 2019, Mr A complained about toothache. Miss A arranged for him to see a specialty dentist officer at the Trust. During the consultation, the specialty dentist officer was could not remove eight teeth. They telephoned Miss A and said they would prescribe fluoride toothpaste instead of removing any teeth.

7. In August 2019, the Trust examined Mr A’s teeth again.

8. In November 2019, Mr A became very unwell and was admitted to hospital. He was diagnosed with parotitis which is an inflammation of one or both of the major salivary glands on either side of the face.

9. After being treated, Mr A was discharged from hospital.

10. On 7 June 2021, Miss A contacted a consultant dentist at the Trust to make a complaint about Mr A’s dental care.

11. On 17 September 2021, the Trust sent its final complaint response to Miss A’s concerns and it directed her to the Parliamentary and Health Service Ombudsman (us) if she was still unhappy.

12. On 1 October 2021, Miss A brought her concerns to us.

15. The law explains our role, responsibilities, and the things we must consider as the final step in the complaints process.

16. It says we should not investigate a complaint if it is brought to us more than one year after the affected person first became aware of their reason to complain, unless we consider there is good reason to.

17. Miss A told us Mr A was ‘terrified’ of dentists and he was nervous about attending. We understand Miss A was not at the consultation but the dentist who saw Mr A contacted her by phone to hold a ‘Best Interests Discussion’. During this discussion they explained they had difficulty removing Mr A’s teeth.

18. Miss A told us the dentist ‘persuaded’ her that a prescription of fluoride toothpaste would work better instead, and she should ‘watch and wait’ before doing anything more. She told us that, at the time, she had no reason not to accept this course of action.

19. In November 2019, Mr A became very unwell. He had toothache, and his face had swollen up on the left side and became ‘red hot’. The care home arranged for a doctor to visit him and after examining him, they contacted Miss A and told her he needed ‘urgent hospital attention’.

20. Mr A was admitted to hospital, and he was diagnosed with septic parotitis. Miss A told us one of the possible causes of septic parotitis is decaying teeth.

21. Miss A says Mr A ‘somehow survived’ but he was ‘very frail and thin’ when he was discharged from hospital and she believes this led to his death.

22. Miss A told us she first became aware she had a reason to complain when Mr A died.

23. The law says Miss A needed to make her complaint to us by May 2021 (a year from when she knew something was not right).

24. From the evidence available to us, we can see she first made a formal complaint to the Trust on 7 June 2021.

25. Following the Trust’s investigation and final response, Miss A came to us on 1 October 2021.

26. We asked Miss A why she did not raise her concerns with us sooner than she did.

27. She told us that in the months after Mr A’s death she was grieving and had ‘developed depression’ which ‘took over’ her emotions. She also told us Mr A had died during the ‘height of the pandemic’ and the Trust’s website said its complaints were put on hold. She further told us our website said there was a delay in the handling of complaints within the NHS.

28. Miss A told us that because of this, she wanted to wait until the pandemic had ‘died down’ before raising her concerns.

29. We recognise Mr A’s death caused her significant distress. We also recognise this led to her experiencing depression and needing grief counselling. We know this was a difficult time for Miss A.

30. We also accept we paused our casework from March to July 2020 because of the pressures on the NHS.

31. However, from July 2020 we began accepting new complaints which gave Miss A the opportunity to contact us with her concerns. Our website was also updated at the time to reflect this change. We cannot see that she attempted to contact us either before or after the pause on casework was lifted.

32. We also realise the Trust put its complaints on hold during the height of the pandemic. We have considered if this is reason for us to put our time limit to one side.

33. The Trust’s quarterly ‘Complaints Report’ says after firstly pausing its progression of complaints due to the pressures of the pandemic, its service had ‘fully restarted’ with ‘all complaints that had been put on holding during the COVID-19 outbreak now either under investigation or resolved’.

34. This report tells us by the beginning of July 2020, any complainants whose enquiries had been put on hold had been contacted and their enquiries progressed. It also tells us that despite the pandemic and the Trust’s decision to ‘pause’ its progression of complaints, complainants could still raise their concerns with the Trust.

35. While we recognise Miss A wanted to wait for the pandemic to ‘die down’ before raising her concerns, we have seen no reason why she could not have raised her concerns sooner (because the Trust was accepting complaints, just not progressing them).

36. Having considered all the information provided and available to us, we do not consider Miss A’s reasons for delay in bringing her complaint to us are strong enough to set aside our one-year time limit.

37. We appreciate the impact the issues she has raised have had on her, and we recognise she may not have felt able to pursue a complaint while she was grieving.

38. However, as explained above, we can see Miss A first complained to the Trust 13 months after Mr A died and she came to us 17 months after his death. For the reasons given, we cannot put our time limit to one side and investigate the complaint.

1. We have carefully considered Miss A’s concerns about the treatment and care University Hospitals Bristol and Weston NHS Foundation Trust (the Trust) gave to her father, Mr A. She told us the Trust’s poor dental treatment in February 2019 led to him getting sepsis and his later death. We recognise how distressing these issues have been for her.

2. After carefully considering the evidence available to us, we have decided Miss A’s complaint falls outside of our one-year time limit, and we are not able to set the limit to one side in this case. We explain the reasons for our decision below.