Southern Health NHS Foundation Trust

4. Ms A complains about aspects of care and treatment her sister, Ms P, received from Southern Health NHS Foundation Trust (the Trust) between 18 May and 6 August 2018. She complains:

• staff inappropriately discharged Ms P from the perinatal mother and baby unit on 17 July. She says Ms P was not well enough to be medically unsupervised at home and staff should have looked more at her first episode of post-natal depression when coming to discharge decision. She says staff did not follow the MBRACE report (an annual investigation into the deaths of women during pregnancy, childbirth and the year after birth) • staff did not give Ms P enough support to prepare for her discharge. She says there was no discharge document or care programme approach (CPA) • staff gave Ms P escitalopram (used to treat depression and anxiety) and increased the dosage after discharge. She believes this medication gave Ms P suicidal thoughts before so she should not have been given it • staff missed an opportunity to readmit Ms P, or to give her more support, when the community health visitor attended on 19 July and found her unwell and alone at home with her two children • she did not get a report from the Head of Nursing and Allied Health Professionals as she was promised. Instead, she got the report from the Divisional Director • the independent clinical review was inadequate and inaccurate and the final paragraph of the report was insulting and devastating.

5. She explains that if these failings had not happened, Ms P’s death could have been avoided. The death caused her, her family and Ms P’s family significant grief and upset. She explains they are devastated by what happened and the impact will be everlasting.

6. She would like an independent investigation into what happened and financial compensation for how they have been affected.

7. Ms P was admitted to the perinatal mother and baby unit on 22 May 2018, where she was cared for until her discharge on 17 July. When she was discharged, she was referred to the perinatal community health care team for outpatient support.

8. The community health visitor visited Ms P on 19 July and raised concerns that she was not well and was home alone with her two children. Ms P stayed at home until she sadly died in early August.

9. The Trust investigated and completed this on 25 October. Its investigation did not find that Ms P’s death could have been avoided. The coroner did an inquest into Ms P’s death in May 2019.

10. In September 2019, Ms A discussed her concerns about the care with the Trust’s consultant perinatal psychiatrist. The consultant wrote to Ms A on 20 November confirming their discussion.

11. On 30 June 2020, Ms A made a formal complaint. The Trust held a local resolution meeting on 14 August and continued to investigate the concerns after the meeting. Ms A sent an email with her outstanding concerns on 23 September.

12. The Trust sent a complaint response on 2 October and directed Ms A to us if she was unhappy with the outcome. It advised her we had time limits for considering complaints. Ms A replied to the Trust on the same day highlighting more concerns. The Trust held a clinical panel on 28 October. On 25 November, the Trust sent a final response to the complaint. It directed Ms A to us.

13. Ms A approached the Trust again. We do not know what day she did this. The Trust held another local resolution meeting on 30 June 2021. It wrote to Ms A on 8 July confirming the extra points that were discussed and agreeing to send a more detailed complaint response.

14. Ms A says the Trust completed its investigation on 11 February 2022. Ms A called us on 17 February to say she was unhappy with the Trust’s response and wanted to bring the complaint to us. Ms A brought her complaint to us on 17 June.

16. 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 can put this time limit to one side if there is good reason to.

17. Ms A knew there was a problem after Ms P sadly died in early August 2018.

18. We recognise the death was unexpected and it would have been a very difficult time for Ms A. We understand that making a complaint would not have been Ms A’s priority. This affected the time it took her to complain to the Trust.

19. The Trust finished its investigation in October 2018. The coroner also investigated Ms P’s death and their investigation seems to have finished around May 2019. We would not expect Ms A and her family to approach us during this time, because it was important for the Trust and the coroner to investigate first.

20. In September, Ms A had a meeting with the Trust’s consultant perinatal psychiatrist. They wrote to Ms A on 20 November confirming the points made in the meeting and addressing the concerns. We would not expect Ms A and her family to approach us before this time, as they were trying to resolve things with the Trust first.

21. After this date we can see that Ms A did not act on her concerns until 30 June 2020, seven months later. This pushed her complaint significantly outside of the one-year time limit. We asked Ms A what the reasons were for this delay.

22. Ms A explains she was trying to get a copy of Ms P’s medical records. She was also getting advice on if she should take legal action. She explains the solicitor told her she would need to send a formal complaint to the Trust first.

23. We understand these points would have caused some delay in Ms A complaining to the Trust. It is important to note that it is not a requirement to get a patient’s medical records or to get legal advice before making a complaint.

24. Ms A also explains that from March 2020, the COVID-19 pandemic made it very difficult to get in contact with different organisations for information and support. She says this, along with dealing with the shock, grief and trauma of Ms P’s death, was very difficult for her. We do not dispute the impact this had on her.

25. We understand the pandemic would have made it difficult to speak to staff at the Trust. But we do not feel it would have stopped Ms A from making a complaint. We have looked at the Trust’s website and it clearly shows how to submit a complaint online.

26. After Ms A made her complaint in June 2020, she actively followed up her concerns until she got the Trust’s final response on 2 October. The response directed her to us and told her about our time limit for accepting complaints.

27. Instead of approaching us, Ms A went back to the Trust on the same day. Ms A missed another opportunity to approach us after 25 November when she got the next complaint response from the Trust.

28. We would have expected Ms A to come to us at this time, rather than go back to the Trust. This is because it had already given her its final response, and directed her to us twice.

29. We do not know the exact date Ms A approached the Trust again but she explains this was soon after getting the response. She also says the local resolution meeting was delayed until 30 June 2021 because of COVID-19 restrictions. She said she got the final response on 11 February 2022 and carried on communicating with the Trust until the end of April.

30. Ms A called us on 19 February 2022 to express her unhappiness with the Trust’s response. We advised her she needed to complete a complaint form and send this to us. She did not do this until four months later.

31. Mrs A explains she wanted an independent investigation into the events she complains about and whether Ms P’s death could have been avoided. She says this is why she kept approaching the Trust instead of us.

32. We recognise the importance of an independent investigation. After the Trust had told Ms A its findings and after the coroner investigated, we would have expected her to approach us. Had Ms A come to us as advised to by the Trust on 2 October and 25 November 2020, there would not have been more delays.

33. For us to set our time limit to one side, we would need to see that Ms A wanted to progress her concerns but was stopped from or was unable to. We have not seen good reasons for the delays or that Ms A was stopped from coming to us sooner. This means we cannot put our time limit to one side.

34. We recognise how important this complaint is to Ms A and 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 for giving us the opportunity to consider her complaint.

1. The Parliamentary and Health Service Ombudsman recognises the circumstances of Ms A’s complaint have been very difficult for her and her family. We thank her for raising her concerns with us.

2. Having carefully considered her complaint, we can see it falls outside of our time limit. We have not seen good reasons to put our time limit to one side, so we cannot consider Ms A’s concerns further.

3. We recognise Ms A will find our decision will be disappointing. We hope this statement clearly explains how we have reached this decision.