Manchester University NHS Foundation Trust

4. Mrs R complains that between 25 June and 22 July 2020, the rehabilitation unit Manchester University NHS Foundation Trust uses (the care home) did not give her proper support during her rehabilitation after she suffered broken ribs and a broken femur (thigh bone). She complains staff were not trained to use the equipment to help her, and they did not phone for an ambulance after she had a fall under their care.

5. Mrs R also complains the Trust misdiagnosed her pelvic fracture after a fall on 21 July 2020 and discharged her when she was not fit and without filling in a mobility assessment.

6. Mrs R says she has suffered terrible pain and trauma and suffered physically and mentally. By bringing this complaint to us, she would like the Trust to apologise and make system improvements and gain a compensation payment.

7. Mrs R fell at her home on 13 June 2020. She was admitted to the Trust with three broken ribs and a broken femur. The Trust discharged her to the care home for rehabilitation on 25 June.

8. Mrs R says while she was at the care home, the physiotherapist told her she could not move without the help of two staff and a gutter frame. They told her to use the commode and not to try to go to the bathroom. Mrs R had a sensor mat on her bed so staff would know of any issues. She asked for the sensor mat to be removed, and staff told her of the risks before removing the mat.

9. Mrs R fell to the floor on the night of 21 July. Staff were unaware of the fall as the sensor mat had been removed. The night staff went to see Mrs R when they understood something was wrong and used an inflatable chair to raise her up. She wanted the staff to use a hoist to put her back into bed, but the night staff said they were not trained to use the hoist. Mrs R says they helped her back to bed with difficulty and she was in pain.

10. Mrs R went back to the hospital at the Trust and had an X-ray of her hip. The X-ray report said nothing was broken. When she got back to the care home, Mrs R said she was crying with pain and needed help. She went back to the hospital at the Trust on 23 July, and a CT scan (computed tomography, a scan that uses X-rays and computers to allow doctors to see inside the body) showed she had fractures on her pelvis. She had an operation. The Trust discharged Mrs R to another hospital on 11 August.

12. The law says a person needs to make their complaint to us within a year of noticing the problem. We cannot look into complaints brought to us after one year, unless we think there is a good reason to.

13. Mrs R knew about the treatment the staff gave her at the care home and the misdiagnosis from the Trust in July 2020. This means to be within the 12-month time limit set in the law she needed to come to us by July 2021. Mrs R complained to us on 21 June 2022. Her complaint about this care is therefore 11 months outside of our time limit.

14. We talked about this with Mrs R to understand the reasons she could not bring this complaint to us sooner. We also thought about the time the care home and the Trust took to respond to Mrs R.

15. Mrs R was quick to raise concerns with the care home a few days after the fall, with her husband asking questions on 27 July 2020. Mrs R complained formally three months later on 2 November, then again on 18 February 2021. The care home responded on 29 April and told Mrs R about our service in this response. It also told Mrs R to get in touch with the Trust about her complaint about her misdiagnosis on 20 July 2020.

16. Instead of bringing the complaint about the care home to us, Mrs R kept asking further questions, asking for a review of the complaint even after having a meeting on 23 July 2021. Mrs R got two more responses, on 2 November and 22 December. Had Mrs R brought the complaint to us in July 2021 after the meeting, and having already had a detailed response in April, she would have been within our time limit for this complaint.

17. Mrs R did not complain to the Trust until 21 December 2021, 17 months after the events. This was a separate complaint about being misdiagnosed on 20 July 2020. Despite the long gap, the Trust looked into her complaint. It responded on 6 January 2022 and told Mrs R about our service, including our time limit: ‘There are time limits for taking a complaint to the Ombudsman, although these can be waived if there is good reason.’

18. Mrs R was already outside our time limit before she first complained to the Trust. Mrs R then kept raising further questions after the Trust’s response to her complaint. The Trust gave a last response on 11 March 2021.

19. Mrs R had written on the Trust's response, ‘phoned PHSO for a complaint form on 31 March 2022’. It then took her a further two months to bring the complaint to us in June, at which point she was very much outside our time limit. We think Mrs R knew about our service and our time limit for making a complaint by at least this point if not earlier, when the care home responded to her in April 2021.

20. We asked Mrs R about the long gaps in her making her complaints. She said she was recovering from her injuries and was in pain. We understand that Mrs R has been through a difficult and distressing time and she needed time to recover.

21. Mrs R brought her complaint to us 11 months outside our time limit, and we have seen significant gaps where Mrs R either did not do anything about her complaints or kept going back with more questions rather than asking for our independent view earlier. We have also seen that Mrs R’s husband was able to help her to make her complaints to the care home and would have been able to support her with her complaints while she was recovering.

22. Mrs R has made her complaint 11 months outside of our 12-month time limit. This is a long time, and we have not seen strong enough reasons to enable us to set aside our time limit. It is hard to justify putting the time limit to one side if the complaint could have come to us sooner. We therefore cannot take further action on this complaint.

23. It is important we think and act within the law, and we regret any further upset this decision may cause. We hope this statement clearly explains the reasons why we will not be taking the complaint further.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs R’s complaint about the Manchester University NHS Foundation Trust (the Trust). We were sorry to hear that Mrs R suffered pain after her treatment. We understand that Mrs R has been through a difficult and distressing time.

2. Having looked into the complaint, we find it falls outside our 12-month time limit. We have therefore looked into the reasons for any gaps since the events Mrs R has told us about. We have not seen evidence of strong enough reasons for us to put our time limit to one side. We will therefore not be taking the complaint further.

3. We are sorry for any further distress this may cause, and hope the explanations below show how we have looked into this.