10. 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 do so.
11. We have carefully considered whether there are good reasons to set aside the time limit in this case. We have considered all the explanations Miss I gave for why she did not complain to us sooner. We have also considered the time the Trust took to handle Miss I’s complaint.
12. Miss I’s complaint form says she first became aware of the problem on the day Mrs E died in October 2018. We have thought about this and agree Miss I would have been aware of all the concerns about care and treatment by that date. Based on this date of knowledge, she would have had to approach our office in October 2019 for the complaint about the care to be made in time.
13. Our records show we received Miss I’s complaint form on 29 October 2021, so the complaint was approximately two years outside the time limit.
14. Miss I also complains about the Trust not conducting a post-mortem on Mrs E. We understand Miss I would have become aware of this concern later than the issues with the care. We have also considered whether we can set aside the time limit for this part of the complaint.
15. Miss I has not stated a specific date of knowledge for when she was aware of the Trust’s reasons for not carrying out a post-mortem. There is evidence suggesting the post-mortem issue was raised during the Trust’s local resolution meeting (LRM) with the family before August 2019.
16. We understand Miss I and her family became aware by August 2019 at the latest of the Trust’s reasons for not carrying out Mrs E’s post-mortem. We have taken August 2019 as the date of awareness for the post-mortem concerns because we think Miss I would have been fully aware of the reasons for this complaint by that time.
17. The post-mortem complaint would have needed to be with us by August 2020 to be within the time limit. As Miss I came to us in October 2021, the post mortem concerns are one year outside the time limit. This means most issues in Miss I’s complaint are two years outside the time limit, and one issue is one year outside the limit. We have considered all the relevant circumstances and evidence for the time-limit test, and we have taken the different dates of knowledge into account.
Reasons for the delays
18. Miss I told us one of the reasons she did not complain to us sooner was that the Trust did not inform her of the one-year time limit. In the complaint correspondence, there is no evidence of the Trust informing Miss I of our time limit.
19. We can see the Trust signposted Miss I to us and provided our office’s contact details for Miss I to complain to. We have taken into account that Miss I did not get information from the Trust about our time limit. We have also taken into account there is some onus on complainants to contact us and find out the next steps for pursuing a complaint. Overall, we do not consider this explanation to be a strong reason to set aside our time limit.
20. Miss I also told us it was very difficult to go through the information regarding Mrs E’s death. When we clarified Miss I’s complaint, she added she and her family needed time to grieve Mrs E’s death without repeatedly going over the records. She explained the circumstances of Mrs E’s death caused much shock and stress.
21. She said this included the meetings with the hospital staff, who admitted on the local resolution recording that they had prescribed, stopped and readministered the wrong medication. The family did not feel anything had been achieved by going through the stress of these meetings and felt an apology was insufficient.
22. We appreciate the time immediately following Mrs E’s death was extremely distressing to the family, and we do not underestimate or dismiss the pain and stress they experienced.
23. Looking at the complaint history, we can see the family complained to the Trust on 1 November 2018. This was soon after Mrs E’s death. We have also seen there was an LRM and the Trust sent written responses to the family’s complaint. This is evidence the family were discussing the difficult information with the Trust at that time.
24. While we acknowledge going through the information was difficult, we cannot say Miss I was unable to pursue the complaint with us earlier than she did, because the family were already in communication with the Trust soon after Mrs E’s death. The delay in contacting us is very significant, and we do not consider this explanation to be a strong reason for the delay.
25. Miss I told us another reason for the delay was that her mother was ill and worked through the pandemic. Miss I explained her mother has had mental health issues for many years, and these issues were triggered again after Mrs E’s death.
26. Miss I explained that, during the pandemic, her mother worked in a care home which was very understaffed. This added to the traumatic experience and brought back difficult memories for her. Miss I found it difficult to confirm what her mother witnessed when Mrs E died. She explained that, as her mother has dyslexia, Miss I needed to deal with any written complaints.
27. We recognise the distress caused by the pandemic. We are sorry to learn Miss I’s mother had mental health issues which were further aggravated by Mrs E’s death and the strain of the pandemic.
28. We have seen the Trust addressed Miss I in its response letters and consider this evidence of her communication with the Trust. As such, during this period we recognise Miss I’s mother was already dealing with the Trust and so could have complained to us earlier. For this reason, we do not think this explanation is a strong reason to set aside our time limit.
29. Miss I said she needed to deal with the complaints as her mother is dyslexic. It is possible for a complaint to be made by a personal representative. While our records show Miss I rather than her mother raised the complaint to us, the delay in contacting us was significant. We do not consider this to be sufficient justification for the long delay.
30. Miss I also told us that she lost another grandmother to cancer in November 2017, the year before Mrs E died. Her mother had also nursed that grandmother at home, making this a traumatic experience. In the same year, Miss I says she had emergency spinal surgery in January 2017, leaving her with a disability and loss of employment.
31. Miss I explained her recovery was not easy and it took a long time to get back to normal. The recovery was still ongoing after Mrs E’s death. She adds she had been living elsewhere that year and returned to her mother’s area for family support in October 2019. Moving further contributed to this stress.
32. We do not minimise the difficulties Miss I experienced in 2017 due to her surgery and her grandmother’s death. Given the main effects of these circumstances were prior to Mrs E’s death in 2018, we find this should not have stopped Miss I from raising a complaint sooner and within the time limit.
Time local resolution took
33. We also considered the time the Trust took to respond to the complaints, and we find their responses were timely.
34. Miss I first complained to the Trust on 1 November 2018. On 27 August 2019, the Trust’s correspondence briefly covers the LRM held with Miss I and her family and the concerns about Mrs E’s care and treatment. This part of the complaints process took approximately nine months.
35. On 3 October 2019, the Trust issued a final response to the family. This final response letter also said Miss I’s mother had been in contact with the Trust’s complaints coordinator on 4 September 2019. This part of the complaints process took approximately one month.
36. Based on the above dates, it took approximately ten months in total for the family to complete the complaints process with the Trust. We do not consider this a strong reason to set aside the time limit. The complaints process finished in October 2019, but Miss I did not complain to us until October 2021, more than two years later.
37. We find it unreasonable to set aside the time limit, as the Trust’s responses would not have had a significant effect on when Miss I could come to us. We consider she had sufficient time to bring her complaint to us significantly sooner than she did.
Conclusion
38. Overall, we do not think Miss I’s reasons justify the extent of the delays. We have considered her explanations and the time the Trust’s complaints process took, but we have not seen good reasons to set aside the time limit.
39. It is important we act according to the law, and we regret this decision may further upset Miss I and her family. We thank Miss I for bringing her complaint to us and trust our statement has clearly explained the reasons why we will not consider this case further.