Black Country Healthcare NHS Foundation Trust

3. Mr A says the Trust wrongly prescribed his mother with 8mg of Risperidone (antipsychotic medication) from March 2017. Mr A and his father, Mr T, stopped giving Mrs A Risperidone in May 2018. The Trust started Mrs A on Risperidone again in August.

4. Mr A says the Risperidone medication caused his mother to become brain damaged. He says his mother was not able to talk, had sleep apnoea (when your breathing stops and starts when you sleep) and restlessness. He says she forgot how to swallow food and needed full-time care at home.

5. Mr A wants the Trust to admit what it got wrong and make a financial payment to him.

6. Mrs A’s GP referred her to the Trust’s adult mental health services on 10 March 2017 as she had confusion and paranoia. The Trust gave Mrs A Risperidone medication for an acute psychotic episode.

7. In May 2018, Mr A and Mr T stopped giving Mrs A Risperidone. On 28 August, the Trust reduced Mrs A’s Risperidone prescription from 2mg once at night to 1mg once at night.

8. Mrs A died in August 2021 while she was in the care of another trust.

9. Mr A complained to the Trust on 4 July 2022. The Trust gave its final response on 26 January 2023. Mr A brought his complaint to us on 1 February.

12. 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 12 months, unless there is a good reason to.

13. Mr A says he first knew he had reason to complain on 24 May 2018. This is the date Mr T told the Trust he and Mr A had stopped giving Mrs A Risperidone. Mr A and Mr T say it was affecting Mrs A badly. Mr A says Mrs A was fine after they stopped giving her Risperidone.

14. Mr A says the next time he knew he had reason to complain was on 8 March 2021 when he had concerns about Mrs A’s apnoea, poor swallowing, lack of communication and falls. Mr A says these were caused by Risperidone.

15. Mr A made his complaint in writing to the Trust on 4 July 2022. This was more than four years after he first knew he had a reason to complain and nearly 16 months after he last knew he had a reason to complain.

16. The Trust investigated his complaint and gave a final response on 26 January 2023. The Trust took nearly seven months to investigate the complaint, so that did contribute to the delay in the complaint reaching us.

17. As Mr A says he knew he had reason to complain on 24 May 2018, the law says he had until 23 May 2019 to bring the complaint to us. If we use his later date of 8 March 2021, by law he had until 7 March 2022 to bring his complaint to us.

18. Mr A complained to us on 1 February 2023. Mr A’s complaints are almost three and a half years outside of our time limit.

19. Mr A says the reason there was a delay bringing his complaint to the Trust and then us is because he took legal action in October 2019. He says he wanted money from the Trust to help pay for his mother’s care home costs. This was before he made a complaint to the Trust on 4 July 2022.

20. Mr A’s solicitor asked for Mrs A’s medical records from the Trust in October 2019. Mr A’s solicitor told him in July 2020 that there was nothing in the medical records to show anything had gone wrong. Mr A’s solicitor told him they would no longer be making a claim.

21. Mr A says on 22 September he asked for his mother’s medical records again. Mr A got these on 2 December. He says the records show something had gone wrong.

22. Mr A also told us he contacted another solicitor in September 2021. In January 2022, this solicitor said there was nothing in the medical records to show anything had gone wrong.

23. We realise what Mr A has been through. There seem to have been several opportunities for him to bring his complaint to us sooner. When we consider the actions Mr A was able to take, we think these show he could have brought the complaint to us sooner, if he had chosen to.

24. Mr A could have made his complaint when he:

• stopped giving his mother Risperidone in May 2018 • first contacted a solicitor in October 2019 • first got his mother’s medical records in July 2020 • raised concerns to the Trust in March 2021 • contacted another solicitor in September 2021 • got his mother’s medical records again in December 2021.

25. Having considered all the evidence, we have decided not to put the time limit to one side and investigate the complaint further. It is important that we make our decisions in line with the law. We regret any upset this decision may cause Mr A and Mr T. We hope this statement clearly explains the reasons for our decision.

1. We have carefully considered Mr A’s complaint about the care and treatment his mother, Mrs A, had from Black Country Healthcare NHS Foundation Trust (the Trust). We are sorry to hear about the family’s experience and of Mrs A’s death. We recognise Mr A and his father have been through a difficult and distressing time.

2. Mr A’s complaint falls outside of our 12-month time limit. Mr A gave us his reasons for bringing his complaint to us outside of our time limit but we decided these are not enough to put the time limit to one side.