Sheffield Teaching Hospitals NHS Foundation Trust

4. Ms C complains about aspects of the care and treatment the Trust provided to her during hospital admissions between 14 September 2020 and 16 December 2020 after she was involved in a car accident.

5. Ms C complains:

• staff failed to apply silver dressings to her stomach wound and did not refer her to a tissue viability nurse during her first admission from 14 September 2020 to 25 September 2020

• staff made derogatory comments about her weight and humiliated her when she soiled herself

• doctors failed to investigate her ankle/leg injury properly

• during a home visit on 25 September 2020, a district nurse from the Trust cleaned her stomach wound using non-sterile water

• an A&E consultant failed to diagnose cellulitis and dismissed it as a rash when Ms C was readmitted to hospital on 28 October 2020.

6. Ms C says she suffered excruciating pain while she was in hospital recovering from her accident. She says she experienced unnecessary pain and distress after developing an infection due to inadequate wound care in hospital.

7. Ms C says she felt humiliated by the derogatory comments.

8. Ms C says unsanitary wound care from the district nursing team led to her developing an abscess, E. coli infection and cellulitis, which led to further hospital admissions.

9. As an outcome of her complaint to us, Ms C wants the Trust to recognise things should have been done differently and to accept how ill she became. She also wants service improvements and for learning to be drawn from her complaint.

10. On 14 September 2020, Ms C was admitted to hospital after a serious car accident. She had five broken ribs, a broken sternum, leg and ankle injuries and a wound to her stomach. During her hospital stay, Ms C says she overheard a support worker talking about her weight and it being a hindrance when she needed the toilet.

11. Ms C noticed the wound on her stomach was leaking and infected. She says she did not see a tissue viability nurse or have silver dressings applied.

12. Ms C was discharged home around two weeks later but continued to be ill with an infection and was found to have MRSA (a type of bacteria that is resistant to several widely used antibiotics). Ms C says a district nurse who visited her at home used non-sterile water to bathe her stomach wound. Ms C says she went on to develop cellulitis and E. coli.

13. Ms C was readmitted to hospital in mid-October 2020 due to issues with her stomach wound and infection. She was discharged after a week.

14. Ms C was readmitted two days later. She had a scan, which identified she had an abscess and excess fluid.

15. After being discharged in early November, Ms C then had intravenous antibiotics for four weeks, followed by oral antibiotics for a further two weeks. Ms C says she continued to be very ill during this time.

16. Ms C says those weeks at home were some of the lowest in her life and she was frightened she would be readmitted to hospital. She says she has experienced continuing pain and mobility problems. She says the constant pain affects her every day while working, socialising and sleeping.

19. The HSCA 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.

20. Ms C complains about events that happened during her hospital admissions between 14 September and 16 December 2020. She would have been aware she had reason to complain about all the issues she has raised with us by mid-December 2020 at the latest.

21. For her complaint to be made within our time limit, Ms C would have needed to complain to us by mid-December 2021 at the latest. As she complained to us on 4 April 2022, her complaint was made around four months outside our time limit.

22. We have discussed this with Ms C to understand the reasons why she did not complain sooner.

23. Ms C did not start the local complaints process with the Trust until 13 November 2021. This was almost 12 months after she knew she had reason to complain. The Trust sent its final response in mid-February 2022 and signposted Ms C to us. It advised Ms C if she wanted to complain to us within our time limit she must do so as soon as she received its final response. There was then a second delay of around six to seven weeks before Ms C complained to us in April 2022.

24. Ms C has provided the following reasons for the delay in starting the complaint process and complaining to us.

25. Ms C says she had mental and physical trauma and needed counselling. She says the reason she was able to complain in November 2021 was she felt so strongly and emotionally distressed by her treatment that she pushed through the fatigue and emotional distress of the accident.

26. Ms C says she found raising the complaint very emotionally distressing. She says she mentally shut down, became extremely physically fatigued and found she could only function at a basic level.

27. Ms C also says she now suffers from long-term depression and other psychological impacts that can affect her ability to deal with complaints. She says she is now also facing an operation on her ankle and that is limiting her ability to lead the life she led before the accident.

28. Ms C also says she experienced difficulties at work that were very stressful. She told us she returned to work in January 2021 because of financial pressure. She changed jobs in March 2021 but continued to work full time. She says she was informed in April 2022 she was at risk of redundancy. This added to her anxiety and stress.

29. We have seen a report prepared for the purposes of Ms C’s motor insurer dated September 2022. The document says Ms C reported suffering severe long-term depression, being very nervous about travel, having no confidence and having irrational thoughts and fears. It also says she reported being off work for three months (until January 2021), she could no longer go on long walks or travel and she had to crawl upstairs. She also reported there had been an impact on her career and self-esteem. The report said Ms C would need further surgery on her ankle. The clinician who prepared the report said they could not comment on the psychological impact the accident had on Ms C as it was outside their area of expertise.

30. We recognise Ms C had a serious traffic accident that led to significant physical injuries, meaning she was unable to work. We would not expect Ms C to have complained during the period when she was off work recovering from her accident. Any delay in complaining during that period is outside her control.

31. The report prepared for the insurance company does not offer an objective view of the continuing psychological impact of the accident, because the professional who prepared it was not qualified to give an opinion on this. We note the wide-ranging impacts Ms C described to the professional as set out in the report. While we accept Ms C has had physical injuries and mental trauma from the accident, we know she was able to resume full-time work in January 2021. The fact she was able to do this despite the physical and psychological impact suggests she would also have been able to complain to the Trust much sooner than she did. In addition, Ms C had the option of seeking help from an advocacy service if she needed support to make her complaint to the Trust or us.

32. Ms C says she changed job in March 2021. We understand this may have taken up her time and meant complaining was not her priority. However, another seven to eight months passed between that happening and when she started the complaints process.

33. Ms C also says she was at risk of redundancy. This happened in April 2022, so it would not have prevented Ms C from starting the complaints process sooner than she did or complaining to us sooner after receiving the Trust’s response in February 2022.

34. We have also considered the time it took the Trust to respond to Ms C’s complaint. Ms C complained to the Trust (via her local clinical commissioning group) on 13 November 2021. The Trust sent its response on 15 February 2022, which was around three months later, so there does not appear to have been any undue delay in the complaints process.

35. In summary, having considered Ms C’s reasons for the delay in complaining to us, we have not seen enough evidence to set our time limit aside. For this reason, we will not be considering this complaint further. We want to be clear this decision makes no judgement about Ms C’s care and treatment. It is clear this was an extremely difficult experience for Ms C and has had a lasting impact on her. It is important we act within the law, and we regret any further upset this decision may cause. We thank Ms C for bringing her complaint to us.

1. The Parliamentary and Health Service Ombudsman has carefully considered Ms C’s complaint about Sheffield Teaching Hospitals NHS Foundation Trust (the Trust). We recognise the matters she complains about have caused her pain, suffering and deep distress. We do not underestimate the impact the events have had on her.

2. We have decided Ms C’s complaint falls outside our time limit. We have not seen good reason to put our time limit aside. We explain the reasons for our decision below.

3. We understand our decision may be disappointing to Ms C. We are deeply sorry we cannot help further.