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Nottinghamshire Healthcare NHS Foundation Trust

P-002332 · Statement · Decision date: 28 September 2023 · View Nottinghamshire Healthcare NHS Foundation Trust scorecard
Complaint (AI summary)
The Trust failed to plan for his brother's care, ensure medication, and contact him before his death, leading to fatal clozapine poisoning.
Outcome (AI summary)
The complaint was not investigated as it fell outside the 12-month time limit, with no strong reasons to waive this.

Full decision details

The Complaint

3. Mr A complains that in 2020 the Trust:

• failed to make a plan for his brother, when it was clear his parents could not care for him • failed to make sure his brother was taking his medication correctly • made no effort to contact his brother shortly before his death.

4. Mr A says his brother did not take his medication correctly which caused his mental health to get worse and ended in fatal clozapine (psychiatric medication) poisoning.

5. Mr A wants an acknowledgement of failings and service improvements.

Findings

8. The law says a person needs to make their complaint to us within 12 months of becoming aware of the problem. We cannot investigate complaints brought to us after this, unless we consider there is a good reason to.

9. Mr A said he became aware of a problem after his brother’s inquest (an investigation into the cause of death) on 26 February 2021.

10. To be within our time limit, Mr A needed to come to us by 26 February 2022. He came to us on 10 January 2023, 11 months outside of our time limit. We looked at the reasons why Mr A did not come to us sooner.

11. Mr A complained to the Trust on 5 April 2022. This is one year and two months after the date he became aware he had reason to complain.

12. Mr A has given reasons for the delay in taking his complaint to the Trust. He explained it took him time to process findings from the inquest and to form his views. Mr A also said he had depression. We fully appreciate and sympathise with the difficulties he was experiencing at this time.

13. We also think this is a long period meaning it was even outside of the NHS complaint handling regulations. Because of this, the Trust did not have to investigate Mr A’s complaint.

14. There was a delay of four months after the Trust sent its response to when Mr A came to us.

15. Mr A said this is because it took him time to process the Trust’s response. We understand this took some time. We think it is reasonable to say that by this time, Mr A was finding things more manageable because he was able to complain to the Trust. This suggests he could have then come to us sooner.

16. We have decided not to put the time limit to one side as we have not seen strong enough reasons for the delays.

17. It is important we consider and act within the law and we regret any upset this decision may cause Mr A. We hope this statement clearly explains the reasons for our decision and why we will not be considering the complaint further.

Our Decision

1. We have carefully considered Mr A’s complaint about Nottinghamshire Healthcare NHS Foundation Trust (the Trust). We are sorry to learn about Mr A’s complaint and his brother’s death.

2. Mr A’s complaint falls outside our 12month time limit and we have not seen strong enough reasons to put this to one side. This means we will not be investigating the complaint. We explain the reason for our decision below.

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