16. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. It says we cannot investigate complaints brought to us after one year, unless we consider there is a good reason to. We have discussed this with Mr P to understand the reasons why he could not complain to us sooner. We have also considered the time the Trust took to respond to Mr P’s complaint.
17. Mr P became aware of his concerns during Mrs C’s admission and when she sadly died (May 2021). To meet our time limit for looking at a complaint, Mr P would need to have complained to us by May 2022. Mr P did not make his written complaint to us until 18 April 2023. This is 11 months outside of our time limit.
18. Mr P made a formal complaint to the Trust on 25 August 2021, just over three months after Mrs C’s death. We have seen that Mrs C’s daughter had also made a complaint to PALS in May 2021 and that Mr P was aware the Trust was completing an investigation. We can see Mr P acted quickly at this time.
19. The Trust completed its RCA investigation report in November 2021, around six months after Mrs C’s death. The Trust had a meeting with Mr P the next month (December 2021) and it shared the investigation report. The Trust responded to the complaint within a reasonable time. The NHS Complaints Regulations suggest six months is a reasonable time to respond to or update a complainant.
20. On 22 February 2022, Mr P wrote to the Trust with his outstanding concerns. Mr P acted quickly at this time.
21. After the external review, the Trust had another meeting with Mr P. It shared the outcome of the external review with Mr P at the meeting and sent a final written response on 18 May 2022. This is under three months from Mr P sending his outstanding concerns to the Trust. The Trust responded to Mr P’s outstanding concerns within a reasonable time, in line with the NHS Complaints Regulations.
22. The Trust’s complaints process took around one year in total. Within this time there were two written responses, including an external review and two meetings. We have not seen any long or unreasonable delays by either the Trust or Mr P.
23. The main delay in this case is the 11 months between the Trust sending its final response on 18 May 2022 and Mr P coming to us with a written complaint on 18 April 2023. We can see Mr P first contacted us on 22 March 2023 and we asked him to complete a complaint form. There was a long delay of over ten months between Mr P getting the Trust’s final response and coming to us. We carefully considered Mr P’s reasons for the delay.
24. Mr P told us he contacted his MP and different legal practices with his concerns. Mr P told us he wrote to his MP on 14 April 2022 and got a response on 9 May 2022. This all happened just before he got the final response from the Trust, so it does not explain his delay in coming to us. We understand Mr P did not get a helpful response from his MP.
25. Mr P told us that just after contacting his MP, he went to different legal practices to find out if they would take on a medical negligence claim on a no win, no fee basis. Mr P says he was told they only take on medical negligence cases where the deceased had dependants. While Mr P would have spent some time dealing with this, it seems this happened just after he got the final response from the Trust. We cannot see that this explains his delay in coming to us.
26. Mr P says he found studying the Trust reports time consuming and distressing. We can appreciate it would have taken Mr P some time to carefully review this information. It is also understandable that this process caused some distress to Mr P. We note Mr P was still able to contact his MP and law practices quickly after getting the Trust’s final response. We think this shows he could also have come to us despite the difficulties he describes.
27. Mr P says neither the Trust or his MP told him about us. He says if he had known about us, he would have submitted a complaint immediately. Mr P says he only became aware of us when he saw an interview on TV and he made his complaint shortly after this.
28. When the Trust wrote to Mr P on 13 September 2021 to acknowledge his complaint, it stated, ‘In the event that we are unable to resolve your concern locally, the contents of your case file will be shared with the NHS Complaints Ombudsman’. The Trust did not mention us in any further correspondence.
29. Our NHS Complaint Standards explain how organisations providing NHS services should approach complaint handling. They say ‘Staff [should] make sure they tell people about their right to complain to the Ombudsman if they are not satisfied with the written final response’. The Trust did not act in line with the NHS Complaint Standards. It should have told Mr P he could complain to us if he was not satisfied with its final response.
30. We have carefully considered whether this explanation is enough to allow us to put our time limit to one side and we have decided it is not.
31. We thought carefully about how complainants have some responsibility for finding out the next steps to take their complaint forward without undue delay. Mr P could have asked the Trust what he could do next to take his complaint forward, especially as the Trust mentioned us early in the complaint process. He could also have searched the internet to find out about us. If Mr P had taken these steps, he could have complained to us sooner.
32. We fully appreciate the importance of this complaint to Mr P. We are sorry for Mr P’s loss and do not underestimate the distress this caused. We hope this statement clearly explains why we will not be considering the complaint further. We regret any further upset this decision may cause.