London North West University Healthcare NHS Trust

4. Mrs H complains about aspects of care and treatment her husband, Mr H, had during his admission at London North West University Healthcare NHS Trust (the Trust) between 2 January and 19 January 2021. She complains:

• staff did not give Mr H dietary supplements after he missed meals. She says throughout his admission he was assessed by a dietician • staff did not give Mr H steroids although they knew this treatment gives patients a ‘brief improvement’ • staff did not do hourly observation checks as they should have. Mrs H explains Mr H’s oxygen saturations were not checked on 17 or 18 January • staff did not do a CT scan before deciding to move Mr H to a different ward on 17 January • staff removed Mr H from the Continuous Positive Airway Pressure (CPAP) machine on 17 January and did not monitor his breathing after this • staff did not carefully monitor Mr H on 17 January which led to him sliding off his commode and falling. She explains he was drowsy so should have been monitored • staff did not explain how Mr H got a cut on his nose • the junior doctor did not take blood from the correct vein and they did not have experience in doing this • staff did not give Mr H a call bell for when he needed assistance, Instead he had to write several notes to explain what he needed assistance with • staff told Mr H he did not have COVID-19 anymore, but this is the cause of death noted on his death certificate. She would like to know why staff changed their opinion • the doctor did not apologise for saying she called the doctor a ‘murderer’. Mrs H explains she did not say this and she wants the doctor to recognise this.

5. Mrs H also complains that staff did not send her a full copy of her husband’s medical records after she requested them. She says she does not have a lot of the CT scans, X-rays or medical notes.

6. Mrs H explains that because Mr H was not given appropriate care, he sadly died of COVID-19. She says the fall could have contributed to this and it could have been prevented. She explains this has caused her and her family much distress and grief. She also explains she has lost out financially as Mr H’s death was sudden and he was working as a project consultant on two big projects.

7. Mrs H would like service improvements and for the Trust to fully address her complaint.

8. Mr H tested positive for COVID-19 in late December 2020. His clinical condition began to deteriorate, and he was taken to hospital by ambulance on 2 January 2021. During the journey his blood oxygen levels were very low and he had a very high temperature.

9. While in hospital, the doctors felt he was suffering from respiratory failure because of COVID-19. They admitted him to a ward for support with his breathing. He refused invasive medical ventilation or to take part in the RECOVERY trial (a clinical trial into treatments for COVID-19).

10. Sadly, Mr H’s condition deteriorated and he died from respiratory failure as a result of COVID-19.

11. Mrs H requested a copy of Mr H’s medical records from the Trust. She sent her first complaint on 3 May. The Trust responded to her complaint on 12 July, two months later.

12. Mrs H was not satisfied with the response so sent another complaint on 13 September. The Trust responded to her second complaint on 13 December, three months later. The Trust explained she had reached the end of the local resolution process and directed her to us.

13. Mrs H approached the Trust again on 13 February 2022. The Trust responded on 28 February and highlighted that she had reached the end of its process. The Trust again directed Mrs H to us.

14. Mrs H then went to an advocacy service and says they advised her to send her additional concerns to the Trust again, which she did on 15 March. From this time she waited for the Trust to respond.

15. As she did not get a response from the Trust, she came to us on 24 June.

17. The Health Service Commissioners Act 1993 (the law) says a person needs to make their complaint to us within a year of becoming aware of the problem they want to complain about. We do have some discretion to put the time limit to one side, if there is good reason for us to.

18. We firstly considered when Mrs H became aware of her concerns and when she approached us.

19. We can see that Mrs H became aware of problems with Mr H’s care and treatment before his death in January 2021. She came to us on 24 June 2022, just over five months outside of our time limit.

20. Mrs H also became aware that she did not have access to Mr H’s full medical records after his death but before she made her first complaint on 3 May 2021. For this, she also came to us on 24 June 2022, at least one and a half months outside of our time limit.

21. To consider if we should set the time limit to one side, we carefully looked at Mrs H’s reasons for the delays in:

• approaching the Trust with her complaint • responding to the Trust’s complaint reply • approaching us after completing the Trust’s local resolution process.

Approaching the Trust with her complaint

22. Mrs H explains she was grieving her husband’s death during this time. She explains it was very distressing for her which affected her ability to complain to the Trust sooner.

23. We do not underestimate the upset Mrs H would have been through after her husband’s death. Understandably this would have been a very difficult time for her. This is likely to have affected her ability to approach the Trust with her complaint.

24. We can see that during this time, Mrs H was able to approach the Trust to get a copy of Mr H’s medical records, before making her first complaint. Arguably, if Mrs H could have approached the Trust to request information from it, she could have also approached the Trust to make a complaint.

25. Mrs H approached the Trust with her complaint within the one-year time limit set by the NHS Complaints Regulations 2009. As she approached the Trust within this timeframe, we find this delay reasonable.

Responding to the Trust’s complaint response

26. Mrs H received a response from the Trust on 12 July, two months later. It then took Mrs H two months to reply to the Trust’s response.

27. We asked Mrs H why she did not act sooner after getting the Trust’s response. Mrs H did not give us any reasons for the delays. This suggests that for two months Mrs H had the ability to progress her concerns, but did not.

28. We expect individuals to be actively seeking a solution to their concerns, without delay. We have not seen any evidence to suggest Mrs H was actively doing this at the time. For this reason, this delay seems to be avoidable.

Approaching us after completing the Trust’s local resolution process

29. The Trust gave Mrs H its final response on 13 December. This response directed Mrs H to us and included our contact details. It explained ‘it is important that you make the complaint as soon as you receive our final response as there are time limits for the Ombudsman to look into complaints’.

30. This shows us that Mrs H was fully aware of how to contact us, and that she should do this soon after getting the response because of our time limit for considering complaints. Mrs H did not approach us soon after this. Instead, she wrote back to the Trust on 14 February, two months later.

31. We asked Mrs H why she did not come to us sooner. Mrs H did not give us any reasons for this. As she was aware we had a time limit and because she does not have any reasons for not acting on the Trust’s final response sooner, this delay seems to be avoidable.

32. The Trust responded quickly on 28 February. It again explained that Mrs H had reached the end of its process and directed her to us. It provided our contact details. Like the last response, it mentioned our time limit and the importance of coming to us soon after getting the response.

33. At this stage, we would have expected Mrs H to come to us. However, Mrs H contacted an advocacy service to ask for advice. They advised her to contact the Trust again, which she did on 15 March.

34. Mrs H explained she thought she needed advice as she had never been through the complaint process before. She explained that once she got advice from the advocacy service, she decided to follow it as they were experts. Once she saw the Trust was not responding, she contacted the advocacy service again who then advised her to come to us.

35. We recognise that this was the first time Mrs H had been through the complaint process. We understand why she approached the advocacy service for advice and why she followed their advice. This explains the delay between 15 March, when she approached the Trust again, and 23 June when she approached us. During this time, it is clear Mrs H was attempting to get a resolution to her concerns.

36. However, this delay could have been avoided if Mrs H had come to us soon after being directed to. The evidence above shows us that Mrs H missed two opportunities to come to us sooner.

37. We can also see that in total the Trust took five months to complete its investigation into Mrs H’s complaint and to direct her to us. This is within the six month time limit set by NHS Complaints Regulations 2009. This shows us that the time it took for the Trust to consider her concerns was not unreasonable and it did not cause a delay, affecting her ability to come to us within our time limit.

38. For us to set our time limit to one side we would need to see that Mrs H wanted to pursue her concerns but was prevented from, or unable to. There were some delays in the complaints process where we have not seen good reasons for the delay. This means we cannot set out time limit to one side.

39. We recognise how important this complaint is to Mrs H and that this is not the outcome she had hoped for. Although our decision may be disappointing, we hope we have clearly explained the reasons for it. We would like to thank her again for giving us an opportunity to consider her complaint.

1. The Parliamentary and Health Service Ombudsman recognise the events of Mrs H’s complaint have been very difficult for her. We would like to thank her for raising her concerns with us, and for taking the time to provide us with information that helped us to consider her complaint.

2. Having carefully considered her concerns, we can see her complaint falls outside of our time limit and we have not seen good reasons to set our time limit aside. This means we cannot consider Mrs H’s complaint further.

3. We explain the reasons for our decision in this statement.