University Hospitals Coventry and Warwickshire NHS Trust

3. Ms N complains about the care the Trust gave to Mrs T during her time on the ward between 12 and 23 October 2020. She complains about:

• the Trust missing several opportunities to escalate her mother’s care to the intensive care unit, including when her saturations became low on 20 October • the Trust withdrawing treatment for Mrs T and failing to follow the correct process for doing this. Ms N says staff said the reasons for withdrawing treatment were due to her mother’s Hodgkins lymphoma (cancer of the lymphatic system). But, Ms N feels this is not correct as her mother had been living with this condition for five years. She also does not believe her mother would have agreed to not continuing treatment • a delay in staff doing a CT-PA scan (a test that looks at the pulmonary arteries). Ms N also says a member of staff incorrectly advised her that Mrs T had been taken for the scan but that it did not go ahead as another patient was prioritised. She says this was incorrect as her mother did not leave the ward • a delay in the Trust arranging and reviewing a chest X-ray • staff not inserting a nasogastric (NG) tube for her mother overnight on 22 October. Ms N says she was advised this was supposed to happen as her mother was nil by mouth. She says the medical notes incorrectly state the NG tube had fallen out, but there is no evidence nursing staff inserted it in the first place. She is also concerned that a member of staff said her mother was having a drink on the morning of 23 October despite being nil by mouth • the Trust failing to communicate effectively with the family about her mother’s condition. Ms N says the Trust misled the family about how unwell her mother was • the family had to battle to see Mrs T towards the end of her life. Ms N says the family were only allowed to spend five minutes each with her before she was eventually moved to a side room. She says at this point, only her and her father were able to stay with Mrs T but her two sisters had to witness her death on Facetime (video call).

4. Ms N says the poor care ended in Mrs T’s death at the end of October. Ms N says the loss has been an ongoing struggle for her which she has not been able to accept. She says the poor communication from the Trust left her in a constant state of distress. She says it was a big shock to get a call saying her mother was on end of life care. Ms N told us the poor communication meant the family lost an opportunity to prepare for her mother’s death.

5. Ms N would like an investigation into her mother’s care and for the Trust to accept its failings. The most important outcome to Ms N is to make sure the same poor treatment does not happen to another family. Ms N would also like us to consider a financial payment in recognition of the impact these issues had.

6. Ms N complained to the Trust on 30 November 2020. The Trust replied to Ms N on 26 February 2021. In its response the Trust told Ms N she could return to it if she had any outstanding issues. It also told her she could refer her complaint to us and she should do this quickly because of our time limits.

7. Ms N wrote to the Trust again on 25 July 2021 with more questions. Ms N came to us on 23 November as she had not had any updates from the Trust since August. We closed the complaint as it was not yet ready for us and asked the Trust to update Ms N. We cannot see any evidence we advised Ms N of our time limit.

8. The Trust replied to Ms N again on 6 May 2022. This was ten months after Ms N had sent her follow up letter. In the complaint response the Trust referred Ms N to us again, although it did not tell her about our time limit. Ms N brought her complaint to us on 13 July 2023.

11. The law 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 have discussed this with Ms N to understand the reasons why she did not come to us sooner. We have also considered the time the Trust took to reply to Ms N’s complaint.

13. Ms N told us she first became aware of the issues with her mother’s care on 23 October 2020. We agree this would be the date Ms N became aware of most of the issues she has complained about.

14. There are some complaint issues we think Ms N may have become aware of a few days earlier than this. But overall, Ms N brought most of the issues in her complaint to us about one year and eight months outside our time limit.

15. There are issues Ms N did not become aware of until she got the Trust’s complaint response on 26 February 2021. This includes Ms N’s complaint that staff incorrectly said Mrs T had been taken for a scan and her complaint about the NG tube. This means Ms N brought these parts of the complaint to us about one year and four months outside our time limit.

16. There are two periods of time where we can see there have been delays in Ms N progressing her complaint. The first is the five-month period between the Trust sending its first complaint response and Ms N writing back to it. The second is the 14-month period between the Trust sending its second response and Ms N sending the complaint to us.

17. We asked Ms N the reasons for these delays. Ms N told us there was no specific reason, but the complaint responses had been a lot to take in. She said the traumatic nature of the events, combined with the distress they caused, had made it difficult for her to put her thoughts into words.

18. Ms N also told us she has an extremely busy job and family life including having grandchildren. She told us she kept thinking about her complaint and something was not sitting comfortably with her, so she eventually decided to take it further.

19. We can only imagine how difficult it must be for Ms N to have to complain after her mother’s death. We also appreciate the complaint responses were a lot to take in and she needed time to think about them. We do not doubt Ms N has a very busy job and personal life.

20. We accept these reasons may have caused a short delay in Ms N progressing her complaint. But, we do not agree they would have stopped her from progressing and avoiding the five month and later 14month delays.

21. The Trust took four months longer than the six months the NHS complaints regulations expect organisations to handle complaints by, when replying to Ms N’s second complaint letter. But, even if the Trust had replied sooner, because Ms N had already delayed, her complaint would still have been outside our time limit.

22. We considered that we did not make Ms N aware of our time limit when she first came to us. We also considered that the Trust did not make Ms N aware of our time limit in its second complaint response.

23. But these are not strong enough reasons to put our time limit to one side. This is because the Trust had made Ms N aware of our time limit in its first complaint response. Ms N has also not said that she did not complain to us sooner because she was unaware of our time limit.

24. We are sorry we are unable to consider Ms N’s complaint further. We hope we have thoroughly explained our reasons for this decision.

1. We have carefully considered Ms N’s complaint about the care University Hospitals Coventry and Warwickshire Trust (the Trust) gave to her mother, Mrs T. We are very sorry to hear of the impact her mother’s death had on Ms N and the rest of the family. We are also sorry to hear about the concerns Ms N had about Mrs T’s care and treatment.

2. The complaint falls outside of our time limit. We have considered the reasons for the delay in bringing the complaint to us and have decided not to put our time limit to one side. We understand how disappointing this decision will be for Ms N as we know how important the complaint is to her. We have explained the reasons for this decision below.