University Hospitals of North Midlands NHS Trust

4. Mr A complains, between 30 March and 16 September 2020, the Practice did not correctly examine his mother, order relevant tests in a timely manner or refer his mother to the Trust quickly. He also says the Practice incorrectly told him his mother did not have anything severely wrong with her.

5. Mr A says his mother felt abandoned and let down, and the Practice missed obvious signs of lymphoma (a cancer of the lymphatic system which helps protect us from infection and disease), which may have been treatable if identified earlier.

6. Mr A also complains about the care his mother received on a Trust hospital ward between 31 August and 9 September 2020. Specifically, he says the Trust:

• did not document or treat Mrs A’s speech and mental health issues • told him his mother was fine when she was clearly not, and • wrongly discharged her on 5 September.

7. Mr A says the Trust did not address his mother’s mental health and speech needs, and neglected her. He says when he spoke to her, she was often crying and she lost all her spirit and resolve.

8. He says when she came out of hospital she was completely incoherent. He also says the inaccurate information and hospital discharge caused the whole family significant distress and worry.

9. Mr A wants the Practice and the Trust to accept their mistakes, apologise and make service improvements.

10. In early 2020, following a chest infection, Mrs A spent around three weeks in hospital over two stays. Prior to these admissions, in 2018, Mrs A had a double lung transplant and, in 2019, she developed an issue with her kidneys because of the medication she needed to take to support the transplant.

11. By 30 March 2020, Mrs A was having regular falls. She contacted the Practice which suspected she had had a stroke. The Practice decided it was not in Mrs A’s best interests to send her to hospital because of the COVID-19 pandemic.

12. Over the next six months, Mrs A continued to have frequent contact with the Practice and her health continued to worsen. She also had several emergency hospital admissions.

13. By 16 September 2020, Mr A was so concerned about the care his mother was receiving he contacted Healthwatch (an organisation providing support for health and social care issues to members of the public). Following its advice, he raised his concerns with the Practice.

14. A GP visited Mrs A at home that day, made minor changes to her medication and referred her to outpatient services at the Trust. Mr A says he was told there was nothing severely wrong with his mother.

15. On 18 September 2020, Mrs A was readmitted to hospital, where she sadly died in early October.

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 do so.

19. First, we have considered the time it took the organisation to respond to the complaint.

20. Mr A received responses to his complaints from both organisations within five months (30 June 2021). The time they took to complete their complaint handling was not excessive, so does not provide an obvious reason for the delay in Mr A coming to us.

21. After receiving the responses from the organisations, Mr A contacted us by phone on 28 October 2021. This was over 12 months since Mrs A had died. This is the latest possible date we consider Mr A was aware of the issues he is complaining about.

22. Next, we have discussed the delay with Mr A to understand the reasons why he could not bring his complaint to us sooner.

23. We do not have full details of Mr A’s call to us but we noted he had a complaint about an unknown organisation. He had not yet sent us a written complaint, which is necessary for us to consider it. Mr A does not remember the date or details of that call, but he does remember speaking to us on the phone.

24. We did not receive the complaint in writing for another four months. That means the complaint was brought to us around five months outside our time limit.

25. Mr H tells us it was very distressing writing down what had happened and reliving the events. He tells us he could not ask for support from others as he feels sharing the complaint with other family members would be a burden to them. He also tells us he had to take a break from discussing the complaint for a while for his own mental health.

26. Mr H tells us he took a lot of time off work during his mother's illness to help care for her. He says when she died it was very difficult for him to return to work. He tells us he could not return to normal and he had never experienced this feeling before.

27. Mr A tells us it was very difficult to deal with the pressures of needing to return to work when he was not ready.

28. We are very sorry to hear about how Mr A was affected by his mother’s death and the complaint process. We recognise the events have clearly been very distressing for him and we appreciate the complaint was an additional strain at that difficult time. We have not seen any evidence these circumstances entirely prevented him from progressing the complaint.

29. We understand it can be difficult for people close to an event to ask for help. If Mr A needed support with the complaint, he could have contacted the Patient Advice and Liaison Service (PALS) or another independent advice service such as Healthwatch. He tells us he had done this before.

30. We appreciate that when Mr A received the organisations’ responses to his complaint after several months had passed, it may have been difficult for him to revisit these events.

31. Given Mr A felt able to revisit the complaint and contact us in October 2021, we have not seen sufficient justification for the extent of the delay (several more months) in sending the complaint to us, despite other events at that time.

32. Mr H tells us he did not realise there was a timeframe to come to us.

33. The responses from both organisations say, ‘It is important that you make the complaint as soon as you receive our final response as there are time limits for the Ombudsman to look into complaints.’

34. While this does not specify the exact time limit, it is clear there is a time limit, so Mr A should have complained to us quickly. As set out above, he waited seven months.

35. Finally, Mr H tells us, when he did decide to come to us, he sent his complaint using the online form, but he did not hear anything from us. He says, after sending the form, he phoned us and we told him to email us, so that is what he did. He says he could not remember when he sent the online form, but he thinks he phoned us a couple of weeks after that.

36. We are sorry to hear Mr A initially had problems sending us his complaint. We do not have a record of his online form or the further call. It is possible we did not take personal details or record the details of the call on his case if we considered his enquiry to be general in nature.

37. We have considered if receiving this complaint two weeks sooner would have made a difference to our decision. Given the delay was several months, if we had received Mr A’s complaint a couple of weeks earlier, we would not have changed our overall decision.

38. Overall, we have not seen any evidence Mr A’s reasons justify the time he took in bringing his complaint to us.

39. We are very sorry to hear about Mr A’s experience. It is clear it has been a very difficult period for him and we thank him for sharing the details of his complaint. It is important we consider and act within the law and we are sorry for any further upset our decision may cause.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr A’s complaint about the care and treatment his mother, Mrs A, received from a practice in the Staffordshire area (the Practice) and from University Hospitals of North Midlands NHS Trust (the Trust). We are sorry to hear Mr A has reasons to complain.

2. In this case, the complaint has been brought to us outside our time limit. We have considered the reasons for this delay and decided they do not provide sufficient justification for us to extend our time limit to consider the complaint further.

3. We recognise this is not the decision Mr A was hoping for. We hope this statement clearly explains our reasons.