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Whittington Health NHS Trust

P-001737 · Statement · Decision date: 6 January 2023 · View Whittington Health NHS Trust scorecard
Choice and Consent Death, mortuary and post-mortem arrangements Treatment Care and discharge planning Care plan failures Patient dignity and privacy Inadequate Pre-Operative Risk Assessment
Complaint (AI summary)
Mr Y complained about a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order, a safeguarding referral, and inappropriate mortuary care for his mother. He alleged these issues caused distress and prevented necessary treatment.
Outcome (AI summary)
The ombudsman closed the complaint because it was submitted outside the specified time limit. No further action was taken on the substance of the complaint.

Full decision details

The Complaint

2. Mr Y complains about the care the Hospital Trust and the Ambulance Trust gave his mother, Mrs R, in February 2020. Specifically, he complains about:

• the decision of the Hospital Trust to place a do not attempt cardiopulmonary resuscitation (DNACPR) order on his mother’s records following her admission to hospital on 2 February 2020, meaning if her heart or breathing stopped the healthcare team would not try to restart it • the safeguarding referral made by the Ambulance Trust after it took his mother from her home to hospital on 2 February 2020, and • how the mortuary at the Hospital Trust cared for his mother’s body following her death in February 2020.

3. Mr Y says the DNACPR order prevented his mother receiving the treatment she needed, and the safeguarding referral led to a coroner’s inquest (an inquiry into the circumstances surrounding a death), which was very distressing for him. He says the care in the mortuary was inappropriate and has left him feeling bereft.

4. Mr Y has asked us to investigate his complaint and wants the two Trusts to pay him financial compensation.

Background

5. An ambulance took Mrs R to hospital on 2 February 2020. Her condition did not improve and she sadly died in hospital later that month.

Findings

7. The law says a complaint should be brought to us within a year of the person becoming aware of the problem. This is referred to as the ‘date of knowledge’. We cannot consider complaints brought to us more than one year after the date of knowledge unless we can see there was an exceptional circumstance which prevented the person from doing so.

8. Mr Y says he became aware of the need to complain when the coroner’s inquest into his mother’s death was concluded in June 2020. Although his mother died several months before this date, we accept June 2020 as the date of knowledge. To meet our time limit, Mr Y needed to formally bring his complaint to us by June 2021.

Complaint to the Hospital Trust about the DNACPR decision

9. Mr Y says he initially looked into pursuing his complaint through legal channels with the help of a solicitor but the solicitors he contacted declined to take his complaint forward. He says he contacted the advocacy agency and, after discussing his concerns, decided to pursue his complaints one at a time, starting with his complaint to the Hospital Trust about the DNACPR decision.

10. With the help of the advocacy agency Mr Y made his first complaint to the Hospital Trust about the DNACPR decision on 17 July 2020 and he received the Hospital Trust’s response to the complaint in October 2020. Mr Y says he did not pursue this complaint further after this response and decided to take time to discuss his concerns with his advocate. Mr Y says he then decided to make his second complaint – this time, to the Ambulance Trust about the safeguarding referral made by the paramedics after they attended to his mother on 2 February 2020.

11. Mr Y says he did not contact the Hospital Trust again until 5 August 2021, when he decided to make his third complaint. This was a separate complaint about the Hospital Trust's mortuary care between February and April 2020.

12. Mr Y brought his complaint about the DNACPR decision to us on 4 March 2022, 17 months after the response from the Hospital Trust and 21 months after the date of knowledge, which is significantly outside our time limit. We accept the distressing nature of the complaint and the impact this incident has had on Mr Y. We have carefully considered the information he and the advocacy agency have given us about the Hospital Trust’s complaint handling processes.

13. Having considered all the information, we think it would have been possible for Mr Y to pursue this complaint with the Hospital Trust further or bring it to us sooner after the Hospital Trust’s response in October 2020.

14. We have not seen any evidence to suggest there was a significant barrier preventing Mr Y from pursuing this complaint with the Hospital Trust or formally bringing this complaint to us within our time limit. For this reason, we have decided not to consider this complaint further.

Complaint to the Ambulance Trust about the safeguarding referral

15. Mr Y says after he received the Hospital Trust’s response to his first complaint in October 2020, he took time to discuss his concerns with his advocate. He says he then decided to complain to the Ambulance Trust about the safeguarding referral the paramedics made after attending to his mother on 2 February 2020. He sent his complaint to the Ambulance Trust on 22 April 2021.

16. Mr Y says he received the response from the Ambulance Trust in July 2021 and he did not pursue it further. Mr Y says he then decided to make a third complaint – this time, to the Hospital Trust about the mortuary care it provided between February and April 2020.

17. Mr Y brought his complaint about the safeguarding referral to us on 4 March 2022, eight months after the response from the Ambulance Trust and 21 months after the date of knowledge, which is significantly outside our time limit. We have carefully considered the information he and the advocacy agency provided to us about the Ambulance Trust’s complaint handling process.

18. Having considered all the information, we think it would have been possible for Mr Y to pursue this complaint with the Ambulance Trust sooner after the date of knowledge and possibly at the same time as his first complaint to the Hospital Trust. We also think Mr Y could have brought this complaint to us sooner after the Ambulance Trust response in July 2021. We think it would have been possible for Mr Y to formally bring this complaint to us in line with our time limit if it had not been for these two delays.

19. We have not seen any evidence to suggest there was a significant barrier preventing Mr Y pursuing this complaint with the Ambulance Trust sooner than 22 April 2021 or formally bringing it to us within our time limit. For this reason, we have decided not to consider this complaint further.

Complaint to the Hospital Trust about mortuary care

20. Mr Y says originally he did not want to make a complaint to the Hospital Trust about the mortuary care, but he reconsidered and decided to put this complaint to the Hospital Trust on 25 August 2021. The Hospital Trust responded to this complaint on 26 October 2021 and Mr Y says he did not pursue it further with the Hospital Trust after he received its response.

21. Mr Y brought this complaint about the mortuary care to us on 4 March 2022, five months after the response from the Hospital Trust and 21 months after the date of knowledge, which is significantly outside our time limit.

22. We have carefully considered the information Mr Y and the advocacy agency provided to us regarding the Hospital Trust’s complaint handling processes. Mr Y says he decided to pursue his complaints one at a time and only decided to proceed with the complaint about the mortuary care after he had received the Ambulance Trust’s response to his complaint about the safeguarding referral.

23. Having considered all the information, we think it would have been possible for Mr Y to pursue this complaint with the Hospital Trust sooner after the date of knowledge and at the same time as his first complaint to the Hospital Trust. We also think Mr Y could have brought this complaint to us sooner after the Hospital Trust response in October 2021. We think it would have been possible for Mr Y to formally bring this complaint to us in line with our time limit if it had not been for these two delays.

24. We have not seen any evidence to suggest there was a significant barrier preventing Mr Y from pursuing this complaint with the Hospital Trust sooner than 22 April 2021 or formally bringing it to us within our time limit. For this reason, we have decided not to consider this complaint further.

Summary

25. Having considered all the information available to us, we have seen no evidence which would allow us to extend our time limit and investigate the points of complaint.

26. We accept the information provided by Mr Y and his advocate about the Trusts’ complaint handling processes and the approach they took when pursuing his complaint. We also accept how distressing this incident has been for him and the profound impact the death of his mother has had on him.

27. It seems the decision to pursue each point of complaint one at a time has pushed each complaint outside our time limit. It seems the decision not to pursue any single complaint further with the Trusts nor to bring any of the complaints to us sooner after each of the Trusts’ responses has also pushed each complaint outside our time limit. We have not seen any evidence to suggest it was not possible for Mr Y to send his complaints at the same time nor to bring them to us in line with our time limit.

28. For this reason, we have decided not to consider Mr Y’s complaint further. We accept the seriousness of the complaint and the impact this has had on Mr Y. We hope this statement helps him to understand our decision and we would like to offer our condolences on his loss.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr Y’s complaint about Whittington Health NHS Trust (the Hospital Trust) and London Ambulance Service NHS Trust (the Ambulance Trust) and have decided the complaint is outside our time limit.

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