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East Suffolk and North Essex NHS Foundation Trust

P-001795 · Statement · Decision date: 27 February 2023 · View East Suffolk and North Essex NHS Foundation Trust scorecard
Complaint (AI summary)
Mr F complained the Practice missed signs of his wife's brain tumour and the Trust delayed radiotherapy and chemotherapy, potentially affecting her chances of survival.
Outcome (AI summary)
Complaint closed. The complaint fell outside the ombudsman's time limit, and no good reason was found to set this aside, so no further action was taken.

Full decision details

The Complaint

4. Mr F complains the Practice missed signs Mrs F had a serious underlying condition and did not take appropriate action when she contacted it between 3 February and 15 June 2020. Mrs F went to the hospital on 16 June, where doctors diagnosed a brain tumour.

5. After Mrs F’s cancer diagnosis, Mr F complains the Trust:

• delayed arranging a review to consider radiotherapy in July 2020 • decided not to provide radiotherapy in August 2020, and • did not arrange chemotherapy in April 2021 after it decided this could prolong Mrs F’s life.

6. Mrs F sadly died from cancer in June 2021. Mr F thinks the tumour could have been found sooner and now wonders whether this, and the Trust’s care, affected his wife’s chances of survival. Mr F is raising these concerns to ensure no one else has the same experience in the future, and so the Practice and Trust can improve.

Background

7. Mrs F contacted the Practice a number of times with concerns about symptoms such as weakness, numbness and pain between 3 February and 15 June 2020. During this time, the Practice referred her for some tests. She also saw a physiotherapist and an osteopath.

8. After seeing the osteopath on 15 June, Mrs F tried to speak to someone at the Practice. The Practice did not return her calls, so on 16 June she went to the emergency department at the Trust. This led to further tests, which showed she had a brain tumour.

9. Mrs F had brain surgery at another NHS trust in July 2020, which then discharged her into the care of the cancer team at the Trust. The Trust did not recommend radiotherapy at first, but after her cancer returned, she had this at another NHS trust in November 2020 and January 2021.

10. After a scan in March 2021, the Trust told Mrs F on 13 April they could not cure her cancer, but she might live longer with the help of chemotherapy to control the cancer. A scan on 21 April confirmed the cancer had grown. The Trust said it would not offer chemotherapy at this stage, but would get further opinions from the doctors at the other NHS trust involved in Mrs F’s care.

11. During this time, Mrs F had seizures which required admissions to hospital in October 2020, February 2021 and April 2021. Mrs F’s condition got much worse in June, when she sadly died.

Findings

13. The law says a person needs to make their complaint to us within a year of becoming aware of the problem they wish to complain about.

14. The complaints about the Practice and the Trust concern different issues which happened at different times. We considered our time limits for each organisation separately.

The Practice

15. Mr F and his wife became fully aware of their concerns on 16 June 2020. It is likely they were developing concerns about the adequacy of Mrs F’s care since February 2020 because her condition was not improving. On 16 June, Mr and Mrs F decided to go to the Trust’s emergency department and learned about the brain tumour.

16. We received Mr F’s complaint about the Practice on 28 June 2022. This means the complaint reached us one year and 13 days past our time limit.

17. We cannot investigate complaints brought to us outside our time limit unless we think there is a good reason to. We first considered the time it took the Practice to respond to Mr F’s complaint.

18. Mr F complained to the Practice on 28 October 2021. It provided its first response on 13 December 2021, just under seven weeks after receiving the complaint.

19. Mr F posted a follow-up complaint letter to the Practice on 29 January 2022, but when he received no reply, he hand-delivered another copy of the letter on 31 March. It appears the Practice had not received the posted copy of the letter. It provided its final complaint response on 30 May 2022, just over eight weeks later.

20. In total, it took the Practice 15 weeks to provide two complaint responses. These timescales were prompt, and well within the six months the NHS Complaints Regulations require.

21. We do not consider the time it took the Practice to respond to the complaints presents a good enough reason to set aside the time limit.

22. We next considered Mr F’s explanation for the delay in the complaint reaching us.

23. The main period of delay is the time between the events and Mr F’s complaint to the Practice. Mr F complained to the Practice 16 months after he became aware of the problem, and 20 weeks after his wife’s death.

24. Mr F says he did not complain sooner because he was dealing with Mrs F’s illness, which he described as a ‘living nightmare’. After Mrs F sadly died, he was then dealing with his and his family’s grief. We recognise this was a difficult time for him.

25. Mr F also says delays due to COVID-19 and problems with the crematorium meant it took six weeks to arrange his wife’s funeral. He says he could not complain during this time because these problems added even more stress to his situation.

26. Mr F explains it then took a while to decide to complain because he knew it would be a long process, and he was not sure it was the right thing to do for his own well-being. He also says he was not aware there were time limits to complain.

27. Once Mr F decided he wanted to make a complaint, he contacted the Care Quality Commission (CQC) in September 2021. The CQC told him about the NHS complaints process, and he contacted us for advice. He then complained to the Practice the next month.

28. After Mrs F’s diagnosis, we accept she and Mr F faced a difficult year due to her treatment and regular hospital visits. We are not convinced, though, that Mrs F’s illness prevented her or her husband from complaining about the Practice at any time during the year before she sadly died.

29. We recognise there were times during this year when Mr and Mrs F could have found making a complaint difficult, and understand for them complaining was less important than Mrs F’s care. There were periods, though, in between radiotherapy treatments, surgeries and hospital visits when Mrs F or her husband could have complained, possibly with the help of an advocacy service, if needed. We have not seen a good enough reason here to put the time limit aside.

30. We accept Mr F’s reasons for not complaining straight away after his wife’s death while he was waiting for the funeral to be arranged. It would have understandably been very difficult to manage a complaint in this six-week period.

31. It was then a further 14 weeks until he complained to the Practice. We understand he was at first hesitant about complaining, and he wanted to think about whether this was the best course of action for him. By doing so, his complaint unfortunately became further out of time.

32. We appreciate Mr F’s comment he did not know about our time limit, but this is not a reason for us to set it aside. Our time limits are published on our website. We are also a publicly funded organisation, and because there are time limits to what we can look into we must carefully examine any periods of delay.

33. We have considered all of Mr F’s reasons, and we are not convinced there is a good enough reason to set aside our time limit. His account makes clear this was a difficult period of time for him. It is our view the reasons he has given do not justify the length of the one year and 13 day delay in the complaint reaching us.

The Trust

34. We received Mr F’s complaint about the Trust on 28 June 2022. Mr F became aware of his three main concerns at different times. We have set each out below.

35. Mr F became aware of his concerns about the delayed review on 10 August 2020. This issue reached us ten months past our time limit.

36. Mr F learned the Trust would not offer radiotherapy on 11 August. This issue also reached us ten months outside our time limit.

37. Mr F says he did not realise this was such a big issue until later when Mrs F’s cancer returned. Mrs F went on to have radiotherapy in November 2020. While Mr F may only later have realised the full impact of not having radiotherapy treatment sooner, he knew about the Trust’s decision not to offer radiotherapy as early as 11 August 2020.

38. Finally, Mr F became aware the Trust would not provide chemotherapy on around 22 April 2021. No chemotherapy had been arranged since the 13 April appointment. When Mr F asked the Trust on 22 April if his wife would be having chemotherapy, the Trust said it was writing to another NHS trust to see if it could offer any treatment first. This issue reached us just over two months past our time limit.

39. We cannot investigate complaints brought to us outside our time limit unless we think there is a good reason to. We first considered the time it took the Trust to respond to the complaint.

40. Mr F complained to the Trust on 29 March 2022. The Trust responded eight weeks later on 25 May. This was prompt, and well within the six months the NHS Complaints Regulations require. So, this does not present a good reason to set aside the time limit.

41. The main period of delay is the time between the events and Mr F’s complaint to the Trust on 29 March 2022, which was:

• 19 months after he became aware of the issues in August 2020 • 11 months after he became aware of the issues in April 2020, and • nine months after Mrs F’s death.

42. We next considered Mr F’s explanation for these delays. His reasons are the same as those set out above for his complaint about the Practice.

43. We understand Mr and Mrs F faced a difficult period of time after her diagnosis. We appreciate how devastating it was for them both to learn she had cancer, and to later learn there was no cure.

44. However, as stated above, we have not seen anything to reasonably account for the length of the delay in making the complaint to the Trust. Mr and Mrs F understandably made her care at the time the priority, but in doing so they delayed the complaint.

45. While we accept Mr F’s reasons for not complaining straight away after his wife’s death, he did not complain to the Trust for nine months. He knew as early as September 2021 about the complaints process, and in October 2021 was able to complain to the Practice.

46. We have seen no good reason for the further five-month delay before he complained to the Trust in March 2022. He could have complained to both organisations at the same time, and we have not seen anything to show it would not have been practical to do this.

47. As explained above, not knowing about our time limit is not a good enough reason for us to set aside the time limit. The law sets out we must carefully consider the reasons for delays in a case reaching us. We have done this, and there is not a good enough reason to set aside our time limit here.

48. In summary, Mr F’s complaint has reached us out of time. We have carefully considered his reasons for the delay, but we have not seen a good enough reason to set aside our time limit on this occasion. So, we will take no further action.

49. We recognise how important this complaint is to Mr F, and understand this is not the outcome he hoped for. Although our decision may be disappointing, we hope he can be certain we have carefully considered his explanations of delays, and hope we have explained the reasons for our decision clearly.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr F’s complaint about a practice in the Essex area (the Practice) and East Suffolk and North Essex NHS Foundation Trust (the Trust). We are sorry to hear Mr F’s concerns about the care his wife, Mrs F, received before she died.

2. Mr F’s complaint falls outside our time limit, and we have decided there is no good reason for us to set this aside. This means we cannot consider the complaint further.

3. We recognise how deeply Mr F has been affected by his wife’s death. We do not underestimate how difficult this time has been for him. Although we are unable to look into his concerns further, we thank him for taking the time to raise them with us.

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