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University Hospitals of North Midlands NHS Trust

P-001648 · Statement · Decision date: 18 October 2022 · View University Hospitals of North Midlands NHS Trust scorecard
Complaint (AI summary)
The complainant alleged the Trust incorrectly administered a fentanyl patch, leaving her mother without pain relief and causing distress, alongside poor record-keeping.
Outcome (AI summary)
The ombudsman closed the complaint because it fell outside their time limit, and they decided not to waive this rule.

Full decision details

The Complaint

3. Mrs N complains the Trust incorrectly gave a fentanyl (a strong painkiller) patch to her mother, Mrs V, on 20 March 2020. She is also concerned about the Trust’s record keeping in relation to this and says it also skipped and delayed other medication.

4. Mrs N says Mrs V was left without pain relief from 20 to 22 March 2020. She says when the issue was identified by her sister, the Trust had to give morphine (a strong painkiller) which was harmful for Mrs V. Mrs N says the experience was frustrating for her family and caused Mrs V distress which she was not able to communicate.

5. Mrs N wants the Trust to change its procedures to prevent others, particularly vulnerable patients, having a similar experience. She is also seeking financial compensation.

Background

6. Mrs V’s family had been applying fentanyl patches to her skin when she was at home. The patch has a plastic backing which must be peeled off before the patch is stuck to the skin. The painkiller is contained within the patch and is absorbed through the skin slowly and continuously while the patch is in place.

7. The Trust admitted Mrs V to hospital in late February 2020. It changed her fentanyl patch while she was an inpatient. The Trust applied a patch on 20 March but did not do this correctly. The Trust changed the patch when one of Mrs V’s daughters (Mrs N’s sister) identified the issue on 22 March.

8. Mrs V’s family made the decision to take her home the next day. The Trust’s palliative care team gave her morphine to help manage her pain. She sadly died in late March 2020.

9. Mrs N complained to the Trust on 19 June 2020. The Trust’s response is dated 29 September. Mrs N was unhappy with the Trust’s response and explained why when she wrote to it on 13 November.

10. The Trust contacted Mrs N by telephone on 18 November 2020 and wrote to her to confirm the key points it was going to investigate. The Trust’s final response is dated 22 June 2021. Mrs N first contacted us on 8 November 2021. We received her complaint form and supporting documents shortly after.

Findings

13. Before we can look into the concerns someone has raised, we have to check their complaint passes our primary tests. These are set out in the law that covers our work.

14. 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. We have discussed this with Mrs N to understand the reasons why she could not come to us sooner. We have also considered the time the Trust took to respond to her complaint.

15. Mrs N is complaining about the care Mrs V received during her hospital admission in 2020. Her key concern is about the patch applied by the Trust on 20 March 2020. She says her sister raised concerns on 22 March which resulted in the Trust recording the incident on Datix (a risk management information system).

16. The family made a formal complaint on 19 June 2020, approximately three months later. We consider the three months it took to make the first complaint is not too much time as the family had been grieving after Mrs V’s death. Mrs N’s sister told us she had to take six months off work due to the impact of her bereavement. We understand how difficult this must have been for the family.

17. The Trust’s first complaint response is dated 29 September 2020. This means it took the Trust just over three months to respond. We do not consider this a significant period of time because the NHS Complaints Regulations say organisations should respond within six months.

18. Mrs N returned to the Trust to raise outstanding concerns in mid-November 2020. This was approximately six weeks after getting the response. Given Mrs N has described having to discuss the response with her family, we consider six weeks was a reasonable period of time to review and reflect on it.

19. The Trust’s final response is dated 22 June 2021. This means it took just over seven months to respond to the follow-up correspondence. This is longer than the six month period set out in the NHS Complaints Regulations, so there is evidence of a potential relatively short delay on the Trust’s part.

20. The Trust’s complaint handling accounts for approximately ten and a half months in total. As we have explained, most of this is reasonable.

21. The final response directs Mrs N to come to us and mentioned ‘it is important you make your complaint as soon as you receive our [the Trust’s] final response as there are time limits for the Ombudsman to look into complaints’. Mrs N contacted us about four and a half months after getting the final response. This could be considered to be an unexplained delay.

22. We appreciate Mrs N needed to liaise with her family and lockdown restrictions made this more difficult. By the time the Trust sent its final response, restrictions on social contact between households had been eased. Most legal limits on social contact were then removed on 19 July and there were no further restrictions until December. Mrs N had already contacted us by that point.

23. Considering this information, our view is there was a delay here. Had Mrs N approached us right after getting the final response, her complaint would have been approximately three months outside of our time limit. We would have been more likely to use our discretion then or soon after and put our time limit to one side.

24. Instead, when Mrs N brought her complaint to us in early November 2021, it was about seven and a half months outside of our time limit.

25. The gaps in the timeline linked to Mrs N progressing her complaint account for about seven months. Of this, the delay is linked to the four-and-a-half-month period between Mrs N getting the Trust’s final response and contacting us. After considering the timeline, we cannot justify using our discretion and putting our time limit to one side.

26. Unfortunately, this means we are unable to look into Mrs N’s concerns in the way she and her family wanted us to. We would like to offer our condolences for their loss and thank them for bringing their complaint to us.

Our Decision

1. We have carefully considered Mrs N’s complaint about University Hospitals of North Midlands NHS Trust (the Trust). We recognise how important this complaint is to Mrs N and her family. We were sorry to hear of her concerns about the care her mother, Mrs V, received before she passed away.

2. The complaint falls outside of our time limit. Having considered the timeline and Mrs N’s reasons for the delay, we have decided we cannot put our time limit aside to consider it further. We have explained our reasoning in this decision statement.

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