NHS in England Closed After Initial Enquiries Search on PHSO website

University Hospitals Birmingham NHS Foundation Trust

P-001976 · Statement · Decision date: 24 April 2023 · View University Hospitals Birmingham NHS Foundation Trust scorecard
Complaint (AI summary)
Mrs N complained about the Trust's medication management for Ms A (too much glucose, missed meds, failed blood thinning), a DNACPR order without consent, poor sepsis management, and conflicting communication.
Outcome (AI summary)
The complaint was closed. It fell outside the ombudsman's time limit, and no sufficient reason was found to set this aside.

Full decision details

The Complaint

4. Mrs N complains on behalf of Ms A about the care she received in March 2020. She is complaining about the following:

• the Trust’s management of Ms A’s medication

Mrs N says the Trust gave Ms A too much glucose on 2 March. She says the Trust did not give Ms A her regular medication from 1 to 8 March. She also says the Trust prescribed but failed to give a blood thinning injection.

• the Trust’s actions around Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

Mrs N says the Trust put a DNACPR order in place on 24 March without her knowledge and despite Ms A testing negative for COVID-19 at the time.

• the Trust’s management of Ms A’s condition

Mrs N says the Trust only gave Ms A antibiotics and ‘pumped her with fluids’ after it diagnosed her with sepsis (a life-threatening reaction to an infection). She says the Trust did not fit Ms A with a feeding tube until 8 March. She says the Trust stopped all medication and put Ms A on end-of-life care on 24 March but did not start this until 28 March. She explains the oxygen was not working on 27 March and it took the Trust an hour to fix it.

• the Trust’s communication

Mrs N says the Trust gave her conflicting information on whether Ms A was being moved to a different ward and failed to tell her when it did move Ms A. She says the Trust also gave conflicting advice on Ms A’s condition and whether she tested positive for COVID-19. She explains the Trust asked her if Ms A could donate her organs despite having COVID-19.

5. Mrs N says the treatment Ms A received contributed to her catching COVID-19 and dying. She says these events were heart-breaking and distressing for her, Ms A and their family. She feels the Trust gave up on Ms A because of her age. She says she found it stressful to see Ms A panic when she could not breathe because the oxygen was not working.

6. Mrs N would like the Trust to apologise, accept its mistakes and improve its service. She would also like financial compensation.

Background

7. Ms A went to the Trust in the late hours of 1 March and was admitted on 2 March. The Trust diagnosed her with sepsis.

8. Mrs N complained to the Trust in June 2020 and received the Trust’s response in November. Mrs N had a meeting with the Trust in August 2021 and received its final complaint response in December.

9. Mrs N looked into taking legal action and then approached us in March 2023.

Findings

11. The Health Service Commissioners Act gives us the power to investigate complaints. This sets out time limits for making a complaint to us. It 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.

12. We spoke to Mrs N to understand the reasons why she could not bring her complaint to us sooner. We also considered the time the Trust took to handle Mrs N’s complaint.

13. Considering the circumstances of the events, we think Mrs N would have known there was a problem when Ms A died unexpectedly. We recognise it was only after Ms A died that Mrs N realised she had a reason to complain about the overall care Ms A received and the overall effect of it.

14. For the complaint to be in time, Mrs N would have needed to approach us by the end of March 2021. As Mrs N did not complain to us until March 2023, her complaint is outside of our time limit by approximately two years.

15. Mrs N explained she did not complain sooner because ‘she was not thinking straight after losing her mum’. She said she also waited to get Ms A’s medical records which was a long process.

16. She told us that after she got the Trust’s complaint response in November 2020, she approached a solicitor who advised her to attend the meeting offered by the Trust. She says the solicitor helped prepare some questions for the meeting.

17. Mrs N told us that after the meeting, the solicitor approached different legal firms to help Mrs N take legal action. She says the solicitor asked her to wait.

18. In October 2022, the solicitor told her no legal firm would take her case on the ‘no win, no fee’ basis. She says this was because Ms A died of COVID-19. Mrs N explained she is not able to fund a legal claim herself.

19. Mrs N also says she was not aware of the service we provide. She says she was looking through Ms A’s things in early 2023 and saw a mention of our service in a bereavement booklet. She says she then spoke to her solicitor for copies of the Trust’s responses and then came to us in March 2023.

20. We reviewed what happened during the complaint process. Mrs N complained to the Trust quickly after Ms A’s death (June 2020). The Trust replied in November, about five months later. This is also when it gave Mrs N Ms A’s records.

21. Mrs N disagreed with the Trust’s response and followed this up. On 31 August 2021 she had the meeting with the Trust (eight months later).

22. The Trust sent the recording of the meeting and provided its final response on 20 December, approximately four months later. Both the Trust’s responses from November 2020 and December 2021 refer Mrs N to us and give our contact details.

23. We note the Trust did not give Mrs N Ms A’s records until November 2020, but we do not feel it delayed Mrs N in making the complaint. This is because she was aware of the issues she had concerns about. This is shown by Mrs N first complaining in June 2020, before getting the medical records.

24. Mrs N told us she could not have complained before because of the bereavement. We are sorry to hear how difficult it was and continues to be for Mrs N. We recognise she did not feel the Trust’s responses gave her any closure.

25. From reviewing the Trust’s responses, we can see one clear period of delay on the Trust’s part in arranging the meeting it offered to Mrs N. We can see Mrs N raised new issues during the meeting. For these reasons, we understand why she chose to continue her complaint with the Trust rather than come to us in November 2020 when the Trust first referred her to us.

26. There also appears to be a period of delay which was not caused by the Trust. This was when her solicitor asked her to wait while they looked into taking legal action. Mrs N told us it was only in October 2022 that her solicitor said no firm would take her case on a ‘no win, no fee’ basis.

27. While it is reasonable to allow time for solicitors to act, we need to consider how long it is reasonable for someone to wait before they might want to take a different route.

28. Mrs N waited about 13 months from the meeting in August 2021 to October 2022. We feel this is more than what we consider a reasonable amount of time to wait, meaning Mrs N could have complained sooner.

29. After her solicitor told her legal action was not possible, Mrs N did not complain to us for another five months. She said this was because she was not aware of our service and she needed to ask for copies of the Trust’s responses from her solicitor. We note that both responses from the Trust were sent to Mrs N and refer her to us giving our contact details.

30. We think Mrs N had the information she needed to approach us before March 2023. We understand why she originally chose to proceed with the Trust after getting its first response, but we have not seen any evidence of why Mrs N could not have approached us in December 2021.

31. We have carefully considered the information provided. We are sorry to hear the legal firms would not take Mrs N’s case on. We appreciate she is unable to fund legal action herself. We feel Mrs N had the opportunity to approach us at an earlier stage. Mrs N chose to take legal action which is within her right to do. But we would have expected Mrs N to come to us sooner as unsuccessful legal action is not a reason for us to put our time limit to one side.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs N’s complaint about the care University Hospitals Birmingham NHS Foundation Trust (the Trust) gave to her mother, Ms A.

2. We are very sorry to learn about what happened and how Mrs N feels Ms A’s death could have been avoided. We offer our sincere condolences to Mrs N. We appreciate how traumatic these events were for the family.

3. The complaint falls outside of our time limit and we have not seen good reason for us to put this to one side. For this reason we are not investigating the complaint further.

Other Decisions About University Hospitals Birmingham NHS Foundation Trust

P-005127 · 27 Mar 2026
Miss A complains the Trust did not allow her to visit her mother and it catheterised her without gaining her …
Closed After Initial Enquiries
P-005065 · 19 Mar 2026
Mr B complains about the care and treatment the Trust provided to his wife after a biopsy and the level …
Closed After Initial Enquiries
P-004931 · 26 Feb 2026
Ms A complains that following her brother, Mr C’s, surgery in October 2023 to repair his abdominal aneurysm, the Trust …
Closed After Initial Enquiries
P-004917 · 25 Feb 2026
Mrs A complains about the care her mother, Mrs N, received from the Trust in June 2022 such as the …
Closed After Initial Enquiries
P-004905 · 25 Feb 2026
Mrs D complains the Trust sutured her incorrectly following an episiotomy repair. She says it sutured undamaged skin and these …
Closed After Initial Enquiries
View all decisions for this organisation →