University Hospitals of Derby and Burton NHS Foundation Trust

4. Mrs V complains about the treatment of Mr R during A&E and hospital admissions at the Trust between 9 September 2018 and 4 March 2019, after a fall at home. Mr R sadly died in April 2019.

She says on 9 September 2018 the Trust: • did not discuss Mr R’s care plan with a neurosurgeon despite deterioration in GCS score (measures a person’s responsiveness) and progressive neurological symptoms • did not follow the correct procedure for ordering, conducting and reporting the findings of a CT scan (a test which is used to look inside the body), despite Mr R presenting with high risk factors for head injury • failed to appropriately manage Mr R’s mobility, pressuring the family to stand him up and failing to immobilise him despite his injuries • failed to manage Mr R’s pain levels and blood sugar levels • took over nine hours to dress a head injury that later became infected • took 60 hours to diagnose Mr R’s condition which needed surgical treatment.

5. Mrs V also says while under the care of the Trust in February and March 2019, Mr R suffered with pressure sores, which he did not have on admission.

6. Mrs V says Mr R experienced ‘immense’ pain, loss of mobility in his arms and legs, and anger and frustration with what he felt was the poor care that he received. Further, she says her mother, Mrs R, experienced stress, trauma and psychological pain due to Mr R’s experience. She now experiences low mood, loneliness and isolation.

7. Mrs V is seeking an ‘honest independent investigation’ of her complaint. She would also like an apology and service improvements. Finally, she is seeking financial compensation.

8. Mr R had a fall at home on 9 September 2018. He injured his head and neck and was taken by ambulance to the Trust.

9. A doctor examined Mr R and immobilised him using a collar and board. The doctor ordered a CT scan. The Trust decided to keep him in hospital as an inpatient.

10. On 12 September the Trust diagnosed Mr R with a cervical flexion injury (fracture of the spine) with a shallow posterior epidural haematoma (blood clot) with cord compression (when the spinal cord is compressed) at C6/7 (vertebrae bones in the spine).

11. On 15 September Mr Wright had a surgical procedure to fix his injuries. He was discharged in February 2019. On discharge, the Trust and Mrs V noted he had developed a grade two pressure sore.

12. Mr R had further treatment from the Trust in March 2019. On 4 March, his medical records show he had developed a grade three pressure sore to his right buttock. This needed treatment until his death.

13. Mrs V submitted her first complaint to the Trust on 9 September 2019. It agreed to investigate it and shared its serious incident report on 12 March 2020. Mrs V was unhappy with the findings, so raised a second complaint on 27 June. The Trust sent its second response letter on 23 September.

14. Mrs V was still unhappy with the Trust’s response. She sent a third complaint letter in November 2020 and her complaint was sent to NHS Resolutions. On 26 January, NHS Resolutions confirmed it had considered her claim for financial compensation and offered a settlement payment. In April 2021, Mrs V rejected the offer, as she wanted the Trust to carry out a further investigation of her complaint before making its decision.

15. Mrs V’s family instructed a solicitor ‘for help and advice’ in September 2021. In April 2022, NHS Resolutions confirmed it had instructed a panel of solicitors to investigate her complaint further. She approached us in June 2022 as she felt she had ‘run out of options’ for escalating her complaint.

Care and treatment

18. 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 V to understand the reasons why she could not come to us in time. We have also considered the time the Trust took to respond to her complaint.

19. We accept Mrs V would have had full knowledge of how unhappy she was when Mr R died. For her complaint to be in time, she would have needed to approach us no later than April 2020. We did not receive her complaint until 1 June 2022, so her complaint is approximately two years and two months out of time.

20. We asked Mrs V to explain the reasons for her delay.

21. Mrs V waited until 9 September 2019 to complain to the Trust. This is five months after Mr B’s death. She explained during this time, she was grieving and needed to speak to a family friend who has a medical background for advice.

22. We are very sorry to hear of the distress and grief Mrs V experienced after Mr B’s death. We recognise this must not have been an easy time for her.

23. To better understand her circumstances, we considered what, if anything, changed in September 2020, which then meant Mrs V felt strong enough and able to engage with the Trust’s complaints process.

24. Mrs V has not explained what changed to allow her to complain to the Trust after five months, nor is there any evidence of this within her complaint form. Without this clear explanation, it is difficult for us to be able to say that she could not have complained earlier.

25. It is important to note Mrs V independently complained to the Trust and to us about her complaint. While she may have wanted to get advice from a family friend, she could have asked her questions and raised issues with the Trust sooner. For these reasons, we cannot say that Mrs V’s desire to get information and support from different people stopped her from bringing her complaint to the Trust.

26. Mrs V got the Trust’s serious incident report on 20 April 2020. She then took two months to respond with further questions. She explained the reason for the delay was because ‘she does not have any medical knowledge’ and had to carry out her own research and speak to a family friend for advice before responding.

27. We appreciate how important Mrs V’s complaint is to her. We can see she wanted to feel reassured she understood the findings of the Trust’s report before raising a second complaint.

28. Importantly, the Trust offered to explain and answer any further questions when it sent Mrs V a copy of the report in March 2020. That said, it seems it would have been equally reasonable to expect Mrs V to approach the Trust more quickly with these outstanding questions, rather than do her own research.

29. It is also important to recognise as Mrs V was unhappy with the outcome of the investigation, she could have made enquiries about how to escalate her complaint or brought her complaint to us at this point. We consider this is a reasonable missed opportunity where she could have potentially escalated her complaint.

30. The Trust sent a second response on 23 September 2020. Mrs V remained unhappy with the outcome and sent a third complaint letter on 9 November. Mrs V stated she ‘did not think this was a long time to write something so emotional’ and that, as with the delay before, she was doing her own research.

31. We understand that the content of the complaint is extremely emotional for Mrs V. We do not doubt that reading the Trust’s responses would have been upsetting for her.

32. We have seen evidence to show the Trust offered to meet with Mrs V in person to explain its findings in more detail. This seems to be another reasonable opportunity where Mrs V could have engaged with the Trust more quickly, rather than doing further independent research. As outlined above, Mrs V could have also asked the Trust how to escalate her complaint or referred her complaint to us for an independent investigation.

33. Mrs V’s complaint was next considered by NHS Resolutions. On 26 January 2021, it confirmed it had completed its investigation and offered a settlement payment. Importantly, in its response, NHS Resolutions explained it would not deal with any of Mrs V’s outstanding complaints and its response was purely a ‘response to your claim for compensation’.

34. Mrs Davies V to reject the compensation offer. In her chronology, she told us this was because she wanted the Trust to investigate her complaint about the pressure sores again to answer some outstanding concerns.

35. At this stage, Mrs V had already had three responses to her complaint including a serious incident report. We consider she had reasonably exhausted the complaints process. We consider this was a missed opportunity, where she could have asked the Trust to direct her on how to escalate her complaint for an independent investigation as she was unhappy with the findings. Or, she could have approached us directly with her concerns. NHS Resolutions made it clear it was only considering her claim for financial compensation and this would not have stopped her from making enquiries with us.

36. In September 2021, Mrs V told us her sister instructed a solicitor on behalf of the family ‘for advice and support’ about their complaint. This shows Mrs V’s family were still unhappy with the Trust’s responses to their concerns. Sadly, we consider Mrs V could have equally approached us at this time and got advice about getting an independent investigation.

37. Mrs V made her complaint in writing to us on 1 June 2022. She told us the reason she brought her complaint to us was because she was not sure how to progress her complaint and ‘felt out of options’. We are sorry to hear Mrs V felt frustrated and anxious and she was not getting the answers she needed.

38. As outlined above, we have identified several opportunities where Mrs V could have reasonably made enquiries about how to escalate her complaint and approach our office. It is unclear why Mrs V waited so long to refer her complaint to us. Without this, it is difficult for us to say she could not have approached us earlier with her concerns. For all these reasons, we have decided not to set the time limit to one side.

1. We have carefully considered Mrs V’s complaint about University Hospitals of Derby and Burton NHS Foundation Trust (the Trust). We are sorry to hear she is unhappy with the care her father, Mr R, had after he had a fall on 9 September 2018. We are also very sorry to hear of the deep distress and significant impact Mr R’s death has had on her and her family.

2. Sadly, Mrs V’s complaint falls outside of our one-year time limit. Having carefully reviewed her circumstances, we consider she could have reasonably approached us with her complaint sooner. That said, we have not seen a good reason to set our time limit to one side and we have decided not to consider this complaint further.

3. In making this decision, we recognise Mrs V has experienced significant grief and deep distress since Mr R’s death. We do not wish to diminish in anyway how difficult this experience has and continues to be for her.