Humber and North Yorkshire Integrated Care Board

The Practice 3. Mrs A complains the Practice did not arrange a home visit to see her husband when he was unable to attend an appointment in person, despite her making several requests for this. She also says the Practice failed to appropriately communicate that her husband was at the end-of-life stage during an appointment on 17 September 2018.

4. She says her husband was left untreated as he could not come to the Practice and he was told he was dying without having the support and comfort of his loved ones.

5. Mrs A wants the Practice to make service improvements.

The ICB 6. Mrs A complains the Single Point of Access (SPoA) service made an incorrect decision to send carers instead of paramedics after her husband fell at home on 20 September 2018.

7. She says an opportunity was missed to take him to hospital and he was in agonising pain for over three days with an undiagnosed broken leg.

8. Mrs A wants the ICB to make service improvements.

The independent provider 9. Mrs A complains that carers moved her husband without using the correct equipment after he fell at home on 20 September 2018.

10. She says her husband had agonising pain after being lifted.

11. Mrs A would like service improvements.

12. On 17 September 2018, a GP visited Mr A at home. The doctor discussed end of life care in preparation for Mr A’s condition deteriorating and gave details of the SPoA service (a service giving simplified access to health services).

13. On 20 September, Mr A had a fall at home. Mrs A made a phone call to SPoA. The rapid response team did not have capacity to attend and sent carers from the care service who lifted Mr A into bed without a hoist.

14. On 23 September, a district nurse called an ambulance which took Mr A to hospital. His leg was found to be broken in three places. Shortly after this, Mr A sadly died.

15. On 30 October, Mrs A made a complaint to the ICB, which was known as the Northeast Lincolnshire Clinical Commissioning Group (the CCG) at the time.

16. The ICB sent its response to Mrs A on 21 October 2019. The ICB directed Mrs A to our service and advised her of the time limits for bringing a complaint to us.

17. In February 2020, Mrs A wrote to the ICB to raise more concerns about its complaint response.

18. On 25 February, the ICB sent a letter to Mrs A with its draft complaint statement, asking her to review and return it, which she did on 10 September.

19. On 25 June 2021, the ICB sent a second response and again advised Mrs A of our service and repeated the time limits for complaining to us.

20. Mrs A sent her complaint form to our service on 5 December 2021.

21. On 14 October 2022, we closed Mrs A’s complaint as being out of time for us to consider.

22. On 9 January 2023, Mrs A’s daughter contacted our service to give new information that she felt would change our decision that the complaint was out of time. We agreed to completing a further review of the complaint.

25. To be clearer and because only the ICB investigated the complaint, our decision below is the same for all three organisations.

26. Our legislation says we will not investigate complaints brought to us more than 12 months after the complainant was aware of a problem unless we think it is reasonable to. What this means in practice is that we will not usually investigate a complaint brought to us outside of the time limit unless we can see good reasons for any significant delays. We discussed this with Mrs B to understand the reasons why she could not come to us sooner.

27. Mrs B explained her mother was in her eighties and had not fully explained her situation to us. She explained her mother had been severely affected by the death of her husband of 60 years and had suffered badly with her mental health, needing the care of her doctor. She told us during the time between the delays, her mother had fallen apart and was diagnosed with diabetes which she struggled with.

28. Mrs B told us that shortly after the death of her husband, her husband’s dog died. She had also been the victim of fraud meaning she lost her car and was unable to drive for two years.

29. She told us these things may seem minor, but in combination and together with the complaints process, she was unwell and unable to follow things up with the ICB earlier. She told us her mother was very passionate about getting closure and knew she had to carry on for her father’s memory, so she actively pursued the complaint once she was well enough to remember the events.

30. We have reviewed this evidence further and can see that one month after her husband’s death, Mrs A made the original complaint to the ICB (October 2018). We understand the complaints process was long and took 12 months to complete at first. Importantly, Mrs A was directed to our service in the Trust’s complaint response letter dated 21 October 2019.

31. We have found three delays where we feel Mrs A could have done more to progress her complaint and bring it to us:

32. the time between the ICB’s final response on 21 October 2019 and Mrs A writing to it in February 2020 to ask it to do more work on her complaint 33. the time between the ICB sending its draft complaint statement to Mrs A on 25 February 2020 and her returning this on 10 September 2020 34. the time between the second response on 25 June 2021 and her referring the complaint to us on 5 December 2021.

35. We asked Mrs B about these delays and she explained the family were trying to work out what to do next, her mother’s mental and physical health deteriorated and she had a lot going on in her own life, meaning she could not complain sooner. Mrs B confirmed that her mother had not been given a formal diagnosis but had struggled with her mood.

36. It is clear from speaking to Mrs B how much of an impact losing her husband had on Mrs A, and we understand she found it very difficult during the complaint process. We have carefully considered the reasons given by Mrs B about why her mother could not complain sooner.

37. We know Mrs A had the support of Mrs B during the complaints process. While we understand how distressing it was for Mrs A, we are satisfied she had good support in place to help to move things on much sooner than she did. Mrs B confirmed she was involved in the complaints process from the start and supported her mother in making the complaint.

38. Mrs B explained the ICB was responsible for the delays we found. She says her mother contacted the ICB by post and exchanged letters between February and September 2020. We contacted the ICB to see how much contact it had with Mrs A between February and September 2020. The ICB confirmed it sent Mrs A a complaint statement letter in February 2020 but says it did not receive any further correspondence from Mrs A until she wrote to it in August 2020 asking for an update. It replied to say it was still waiting for Mrs A to return the complaint statement letter. We do not think the ICB was responsible for any delays between February and September 2020.

39. Mrs B says we should not apply a time limit when the complaint relates to a death. It is important to explain that the seriousness of a complaint is a not a reason for us to put the time limit to one side. We apply the same rules for every case when considering time limit.

40. We are satisfied the complaints process was clearly explained to Mrs A and her daughter during the ICB’s complaint process. It directed her to our service and explained our rules on the time limit. There is evidence Mrs A was in a position to complain shortly after her husband’s death and while we understand how distressing it was after he died, we see no reason why she could not complain to us after getting the ICB’s final response letter.

41. Mrs A was clearly unhappy with the response sent by the ICB and felt able to go back to it to express her unhappiness. At this point, Mrs A could have referred the complaint to us.

42. We do appreciate how difficult this period was for Mrs A and thank Mrs B for giving us the extra information. Taking this into consideration, our decision is the same and we have not seen good reason to put the time limit to one side.

43. We understand this decision is likely to be disappointing for Mrs A. Our decision is not meant to take away from Mrs A’s distressing experience.

1. We have carefully considered Mrs A’s complaint about the care and treatment a practice in the North East Lincolnshire area (the Practice), Humber and North Yorkshire Integrated Care Board (the ICB) and an independent provider in the North East Lincolnshire area gave to her husband, Mr A. The complaint falls outside of our time limit and we have decided there is no good reason for us to put it to one side and investigate it further.

2. We do not underestimate the distress the death of her husband had on Mrs A. Clearly this has had a lasting impact on her and we are truly sorry to hear of how much she continues to be affected.