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A practice in the Leeds area

P-001803 · Statement · Decision date: 27 February 2023
Diagnosis Treatment Treatment Diagnosis Delayed Recognition of Deterioration
Complaint (AI summary)
Mrs A complained the GP and Trust failed to provide urgent cancer referrals, diagnose, and treat her mother's cancer, and did not perform a genetic blood test.
Outcome (AI summary)
Complaint closed. The ombudsman declined to investigate further as the complaint was brought outside its time limit with no good reason to set it aside.

Full decision details

The Complaint

4. Mrs A says when her mother, Mrs U, went to her GP between October 2019 and January 2020 with her symptoms, the GP failed to do urgent cancer referrals.

5. Mrs A says between October 2019 and January 2020 the Trust failed to pick up, diagnose and treat her mother’s cancer and did not run a blood test for her mother to see whether the cancer was genetic.

6. Mrs A says she was shocked to see her mother in pain and the actions of the GP and the Trust made her feel helpless.

7. Mrs A says the Trust should have done a blood test to see whether the cancer was genetic. It did not and this has left Mrs A unsure whether one day she may develop this cancer.

8. Mrs A goes on to say her depression medication had to be increased. However, this was soon reduced back to the normal level due to the side effects this had on her.

9. Mrs A is seeking compensation to the value of at least £10,000 based on the severity of injustice scale. She also mentioned she wants to know why her mother was turned away from A&E at the Trust. However, when we spoke to Mrs A, we confirmed she primarily wants compensation as a resolution.

Background

10. Mrs U was in her seventies with a history of fluctuating blood test results dating from 2018 to the day she died in January 2020.

11. Mrs U had a colonoscopy in September 2019, during which polyps were removed. She went to the Practice a few times after this with stomach ache and was waiting for follow-up appointments.

12. On 3 December 2019 Mrs U was admitted to the Trust. After one week the doctors decided to do a computerised tomography scan (a form of X-ray examination) where they found lumps on her stomach lining.

13. On 17 December 2019 the Trust discharged Mrs U. On 23 December 2019 Mrs U had to be admitted to the Trust and the Trust put her on an assessment ward.

14. On 28 December 2019 Mrs U was moved to another wing. Mrs A had a meeting with the Trust on 31 December 2019. The Trust explained to Mrs A her mother was ill and needed chemotherapy, but there was a hole in her mother’s small intestine that needed to heal before she started treatment.

15. Mrs A spoke to the Trust on 6 January 2020 to confirm her mother was still having chemotherapy and the Trust said this was correct. Mrs U passed away later that month.

16. On 13 March 2020 Mrs A had a meeting with the Trust to go through her mother’s care. After this meeting she remained unhappy and so sent a formal complaint to NHS England (NHSE) on 28 April 2020.

17. However, she says NHSE contacted her as she had not provided the consent it needed to process the complaint. Mrs A provided this and eventually sent a formal complaint to both the Practice and the Trust on 22 July 2020.

18. NHSE provided the Practice response dated 11 August 2020 and NHSE’s review and final response dated 9 October 2020. NHSE advised Mrs A the Trust would respond to her separately.

19. The Trust provided its first response dated 12 January 2021. Mrs A wrote back to the Trust on 2 July 2021 as she was unhappy with the Trust’s first response.

20. On 17 September 2021 the Trust provided its final response to Mrs A’s complaint and she then complained to us on 1 February 2022.

Findings

23. 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.

24. We have discussed with Mrs A why she could not bring her complaint to us sooner. We have also considered the time NHSE, the Practice and the Trust took to respond to Mrs A’s complaint.

25. Based on Mrs A’s complaint form, her complaint correspondence with NHSE, the Practice and the Trust, and our telephone discussions and emails with her, we can see this complaint falls outside our time limit.

26. The events Mrs A is complaining about happened from October to December 2019. Mrs A became aware she was unhappy with the Practice and the Trust in December 2019.

27. This means the complaint needed to be brought to us by December 2020 to be within our time limit. Mrs A did not complain to us until February 2022. Mrs A’s complaint is therefore 14 months outside our time limit.

28. Because the complaint is outside our time limit, we have also considered whether there are enough reasons to put the time limit to one side. We asked Mrs A to explain the reasons for any delays in her complaint.

29. Mrs A says after her mother passed away in January 2020, the Trust sent a letter to her father around the end of January 2020 inviting her father and family to a meeting with the consultant medical oncologist to discuss her mother’s care. Mrs A called the Trust to accept this invitation and the meeting took place on 13 March 2020.

30. Mrs A confirmed she and her family had not asked for this meeting. Although she had concerns and did not make a formal complaint, it seems reasonable she waited to see whether the meeting resolved her concerns.

31. After this meeting she remained unhappy and so complained formally via NHSE on 28 April 2020. However, Mrs A did not provide the relevant consent to NHSE for it to access and share personal data until 13 July 2020. This meant that she could only send her formal complaint to both the Practice and Trust via NHSE on 22 July 2020.

32. NHSE paused complaint handling from 1 April to 30 June 2020 because of the Covid-19 pandemic. This three-month delay was beyond Mrs A’s control.

33. Once the formal complaint had been submitted to the Practice via NHSE on 22 July 2020, the Practice wrote its response dated 11 August 2020 and NHSE provided a final response dated 9 October 2020. The Practice complaint was ready for us to consider at this stage.

34. Mrs A did not contact us with her complaint about the Practice once she had received its final response. She says she was waiting for the Trust to respond and conclude its investigations before bringing her complaint to us.

35. We explained this was a missed opportunity for her to bring her Practice complaint to us within our time limits. The Practice complaint was ready for us at that time. She had received a final response that was separate from the issues regarding the Trust and so she could have raised that aspect with us. Mrs A understood and recognised this.

36. Once the formal complaint was submitted to the Trust via NHSE on 22 July 2020, it took the Trust until 12 January 2021 to provide its first response. This is six months from the initial complaint being submitted and this delay was beyond Mrs A’s control.

37. Mrs A wrote back to the Trust on 2 July 2021 as she was not satisfied with the first Trust response, dated 12 January 2021. This is six months after her first Trust response.

38. Mrs A states her father passed away in March 2021. She was being supported by an advocate at Advonet throughout this time. We told her she had the opportunity to go back to the Trust immediately after receiving its first response in January 2021. From January to March 2021, there was a delay in complaining that was within Mrs A’s control. We cannot put that time to one side.

39. Mrs A says when her father passed away, she was grieving and dealing with his finances, the sale of his property, estate agents and solicitors and her advocate at Advonet, who was helping her with her formal complaint. Mrs A says she has siblings but they did not help her with dealing with her father’s estate after his death.

40. We may consider putting this period to one side, but as Mrs A was well enough to deal with her father’s administration, the sale of his property, estate agents and solicitors and an advocate, we have decided not to put this six-month period to one side.

41. If Mrs A was able to do all the other activities mentioned above, we think she could reasonably have continued with her formal complaint with the help of an advocate at Advonet.

42. Once Mrs A went back to the Trust with her letter of 2 July 2021, the Trust provided its final response dated 17 September 2021. The Trust took just over two months to reply and this period was beyond Mrs A’s control.

43. Once Mrs A received her final response dated 17 September 2021, she raised her complaint to us on 1 February 2022. The period from 17 September 2021 to 1 February 2022 is four months. This period was within Mrs A’s control.

44. Mrs A says once she received her final response from the Trust dated 17 September 2021, she contacted her advocate and believed she had provided all the relevant correspondence we needed to see. She sent this to us around 26 November 2021.

45. However, we contacted Mrs A in December 2021 asking for the full correspondence for the complaints about both the Practice and the Trust as we had only received part of the Trust’s responses.

46. Mrs A then took until 1 February 2022 to provide us with all the information and correspondence we needed to be able to move forward with her complaint. We cannot put this four-month period to one side.

47. There were delays up to 23 months in relation to Mrs A’s complaint with the Trust. Of those 23 months, 11 months were within Mrs A’s control and 12 months were not.

48. The Practice aspect had concluded and Mrs A received a final response within three months of her raising her complaint, so there were no delays from the Practice. The final Practice response was dated August 2020.

49. Mrs A waited around 16 months after receiving her final response on the Practice aspect before raising her complaint to us in February 2022. Mrs A says she was waiting for the final Trust response before bringing her complaint to us. This is not enough of a reason for us to put our time limits to one side and this delay was within Mrs A’s control.

50. While we understand the difficulties Mrs A says she experienced and we are sympathetic to the health-related issues and the impact these have caused, she has brought her complaint to us outside our time limit.

51. The reasons she gave for the delays are not enough for us to put the time limit to one side. It is difficult to justify putting the time limit to one side if the complaint could have come to us sooner. We think this is the case here because she was aware and able to make a complaint to both the Practice and the Trust earlier than she did. She could also have brought her complaint to us much sooner following the final response from the Practice and the Trust.

52. We will therefore take no further action with this complaint. We hope this information helps Mrs A understand our decision, further to the telephone discussions we had explaining this.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs A’s complaint about the Leeds Teaching Hospitals NHS Trust (the Trust) and a practice in the Leeds area (the Practice). We were very sorry to hear about the events of the complaint and the impact this had on Mrs A. We recognise Mrs A has been through a difficult and distressing time.

2. Based on the evidence, we have seen Mrs A complained to us outside our time limit. We have not seen good reason to put the time limit to one side.

3. We understand our decision may be disappointing. We will explain the reasons for our decision in detail below.

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