Care and treatment
17. 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. We have discussed this with Ms A to understand the reasons why she could not do so. We have also considered the time it took the Trust to respond to her complaint.
18. There are two separate dates that we need to consider:
• the date when Ms A became aware of the pain and suffering from the procedures • the date when Ms A became aware that the two endoscopies were unnecessary.
19. Ms A states that she became aware she had reason to complain on 18 November 2020. She said she ‘was not thinking straight, until this point’.
20. In her correspondence, Ms A notes that, following her first procedure on 17 January 2019, she visited A&E five days later due to ‘severe, unbearable and horrific stomach burning and pain’. Based on this, we consider Ms A would have known on 22 January 2019 that she had reason to complain about the first procedure causing pain and suffering.
21. Ms A complains about pain and issues following the second endoscopy on 24 January 2020. She also complains that she was sedated against her will during this procedure. On 29 January 2020, she saw the consultant about pain and suffering from the second procedure. It seems reasonable to assume she knew she had reason to complain about the second endoscopy at that point.
22. Ms A is also complaining that the endoscopies were unnecessary. She told us that she knew that the first endoscopy was not needed, because she had an endoscopy in 2017 and she was given a diagnosis then. So she must have already suspected that the endoscopies were unnecessary based on what she knew. She would also have known she had reason to complain at the time of the procedures.
23. To make her complaint within our time limit, Ms A would have needed to complain to us about the first endoscopy by January 2020, and about the second endoscopy by January 2021.
24. Ms A did not complain to us initially until June 2021. At that point, her complaint about the second endoscopy was around five months out of our time limit, and her complaint about the first endoscopy was almost 18 months out of our time limit.
25. By the time Ms A returned to us in October 2022, her complaint was even further outside of our time limit.
26. Ms A first complained to the Trust on 17 January 2021, so there is a significant delay between the events and the start of the complaints process.
27. When we asked about the delay in complaining to the Trust, Ms A said she complained to the consultant at the time, and she thought this would be the best thing to do. She said that, as she had complained to a ‘senior’, this would be sufficient. She said she was not aware she could make any more complaints and that ‘it was too much for her’. She has not told us more about why that was.
28. We recognise that dealing with the complaints process can be daunting and difficult to understand. Ms A’s explanations that she thought complaining to the consultant was sufficient and that it was all too much is not enough for us to consider disregarding the time limit. If she was unhappy with her care and did not know what to do next after speaking to her consultant, Ms A could have approached the Trust’s Patient Advice and Liaison Service, or asked an advocacy service or the Citizens Advice Bureau for help. From what we have seen, we are not convinced Ms A could not have complained to the Trust earlier about both endoscopies.
29. The Trust took three to four months to respond to Ms A’s initial complaint. It took a similar time to provide its final response after Ms A had contacted us, and we had decided her complaint was not yet ready for us. The Trust responded reasonably quickly, so there was no unnecessary delay there.
30. We recognise there was a significant delay between Ms A contacting us in June 2021 and our decision that her complaint was not ready for us in April 2022. This delay is unfortunate and outside of Ms A’s complaint, but we do not believe it is important in our consideration because there had already been a very long delay in starting the complaint process before that point.
31. There was another two-month delay before Ms A returned to us after getting the Trust’s final response in July 2022. Ms A did not give a reason for this delay, but for similar reasons, it has not been central to our consideration.
32. Based on the information Ms A has given, we have been unable to identify strong enough reasons to disregard our time limit. Ms A did not complain to the Trust until 17 January 2021, and there is no convincing reason why she could not have done so earlier. We have decided not to uphold her complaint.
Record keeping
33. Ms A says the Trust was mistaken when it said that a nurse conducted the first procedure. She is adamant that a male trainee doctor performed it.
34. We are sorry to hear Ms A feels that this issue has caused her more anguish. We appreciate this has added to her stress at what was already a challenging and upsetting time.
35. Our Principles for Remedy (2009) state that, when things have gone wrong, we expect organisations to ‘put things right’. This includes considering offering ‘all forms of remedy’ such as an ‘apology, explanation and remedial action’ to put things right.
36. In its letter of 25 July 2022, the Trust confirmed that staff had found the missing consent form relating to the first endoscopy, had scanned it and added it to Ms A’s records. The Trust apologised for the miscommunication arising from the missing consent form.
37. Once the consent form was located, the Trust was able to confirm that a gastroenterology registrar gave official permission for Ms A’s procedure. The consent form lists the gastroenterology registrar as the lead endoscopist and a specialist nurse as a supporting endoscopist. The Trust apologised that it had been unable to confirm this initially.
38. The Trust explained that the endoscopy team uses drop-down lists in its computer system to record the member of staff conducting a procedure. Registrars and trainee members of staff should be added to the drop-down list when they start training in endoscopy, but there can sometimes be a delay before this happens.
39. As the doctor who completed the first endoscopy was a registrar at the time, it is possible that he was not on the drop-down list on the system. The specialist nurse could not recall the procedure, so she had to rely on the information that was available on the system and so reported, incorrectly, that she had conducted the procedure alone.
40. The Trust said it would remind staff of the importance of accurate record keeping, and how to accurately record staff information on the system, including using the free text section where staff can enter the name of the lead or supporting endoscopist.
41. We can see in the Trust’s response that it has already acknowledged and apologised for the record-keeping problems. It has also explained how the error with the endoscopist details happened, and it has taken steps to improve its electronic record keeping. All of this is in line with our principles. We are satisfied the Trust has already taken appropriate steps to put this part of the complaint right.