19. The NHS guidance on complaining explains a complaint must be made to the NHS no later than 12 months after the date when a person knew of a reason to complain.
20. The law also says a complainant must refer a complaint to us within 12 months from the date they knew they had a reason to complain. We can put the time limit to one side if we see good reasons for the delay.
21. We first establish the date when Mr O knew he had a reason to complain.
22. Mr O became aware of his first concern, loss of sight in his right eye, immediately after his surgery on his left eye in August 2020.
23. Mr O’s complaint about poor aftercare relates to the 12 months after his surgery, when he was concerned he was not being seen by Mr A. We think Mr O was aware of this concern before his appointment on 13 August 2021.
24. Mr O requested to see Mr A on 13 August 2021 to discuss his surgery and why he was having problems with his right eye. It was at this time Mr O found out that Mr A had not done the surgery.
25. Mr O says he was at an appointment at the Trust on 25 January 2022 when he was told by a doctor that he should never have had a corneal graft surgery as this was not recommended in patients with stem cell deficiency.
26. These are the dates when Mr O knew there was a problem.
27. In line with the NHS guidance on complaint handling, we would have expected Mr O to have submitted his complaint to us by 12 August 2021, 13 August 2022 and 25 January 2023 to meet the 12-month time limit.
28. Mr O first submitted his complaint to the Trust on 21 October 2022. This means his complaints about his surgery, the surgeon and aftercare were all outside of the NHS complaints guidance 12-month time limit.
29. Mr O’s concern that the surgery should never have been done was within the NHS guidance 12-month time limit.
30. The Trust accepted the complaint and sent its response to Mr O three weeks later, on 11 November 2022. The Trust advised in its letter that if Mr O was unhappy with the response, he could contact a complaints co-ordinator at the Trust or he could bring his concerns to us.
31. As Mr O was not happy with the response, he quickly escalated his complaint to the Trust by email 11 days later, on 22 November.
32. The Trust sent its second response after 12 weeks and two days, on 16 February 2023. It offered Mr O the opportunity to attend a meeting to discuss his ongoing concerns or to bring his concerns to us.
33. Mr O phoned the Trust six days later, on 22 February, to request a meeting. The meeting was arranged for 8 March 2023. The Trust then sent its final response letter to Mr O on 10 March 2023.
34. Three months passed and Mr O sent his complaint to us on 14 June 2023.
35. Mr O’s complaint about his surgery should have been made to us by 12 August 2021. He brought the complaint to us 22 months outside of our time limit.
36. Mr O’s complaint about the aftercare and Mr A not doing the surgery should have been brought to us by 13 August 2022. This complaint is ten months outside of our time limit.
37. Mr O’s complaint that he should not have had the surgery should have been brought to us by 25 January 2023. This complaint is outside of our time limit by about four and a half months.
38. We will next look at any reasons for the delays.
The Trust’s complaint handling
39. The NHS Complaints Policy says the aim is for complaints to be responded to within 40 working days. But, there are no guarantees to complaint handling times, it is on a case-by-case basis. The NHS Regulations state that if a complaint is not resolved within six months, the organisation should write to the complainant and explain what is happening and what they are doing.
40. Mr O complained to the Trust by letter on 21 October 2021. The Trust sent a response three weeks later, on 11 November. This response was provided within the timescales in the NHS Complaints Policy.
41. Mr O was not happy with the complaint response, and he sent an email to the Trust on 22 November. We can see the Trust sent its response letter to Mr O around 12 weeks later, on 16 February 2023.
42. Mr O contacted the Trust by phone on 22 February to ask for a meeting. This was arranged for two weeks later, on 8 March. The Trust then sent its final response letter to Mr O two days later, on 10 March.
43. Overall, it took the Trust about 17 weeks to send three complaint responses and arrange a meeting. This meets the timescales of the NHS Regulations, so we do not think the Trust’s complaint handling caused any delays.
Mr O progressing the complaint
44. We asked Mr O about the delays in complaining to better understand what happened. Mr O explains he was complaining verbally to Trust staff about the reduced sight in his right eye immediately after his surgery on 12 August 2020 and at his outpatient appointments after surgery.
45. Mr O tells us after he became aware in January 2022 that he should never have had the corneal graft surgery, he tried to submit a formal complaint but was told it would have to be in writing.
46. Mr O says he did not know how to progress a complaint because with his sight impairment he could not write or make a complaint by email. Mr O says he then decided to contact the General Medical Council (GMC) about his concerns and a member of staff from the GMC typed up a complaint letter for him to raise with the Trust.
47. Mr O does not remember the dates for this.
48. We understand from the Trust complaint file that Mr O’s complaint letter was received on 21 October 2022. We can see that after getting the response letter from the Trust dated 11 November, Mr O responded quickly to escalate his complaint. Mr O sent his second complaint by email to the Trust on 22 November.
49. Mr O contacted us on 10 January 2023 by phone and was advised we could not consider his complaint because he had not completed the Trust’s complaints process. The Trust sent Mr O its second response letter on 16 February 2023 and Mr O quickly asked for a meeting under a week later, on 22 February.
50. Mr O contacted us again by phone on 10 March to say he had attended a meeting at the Trust and he was not happy with the outcome. We sent a complaint form to Mr O and a letter explaining we needed the Trust’s final response letter and a completed complaint form.
51. Mr O tells us at this time he felt very deflated and low in mood. He says he felt like he was hitting brick walls whichever way he turned. He says he was grieving the life he used to have and was coming to terms with his new life.
52. Mr O phoned us again on 14 June and was again advised he needed to send his final response letter from the Trust and a completed complaint form We received a completed online complaint form on 14 June and an email with attachments of letters from the Trust about his complaint.
53. Mr O says the delay of three months when contacting us again on 14 June 2023 was because he was in the anger stage of grief and wanted answers and justification.
Our consideration of the reasons for delay
54. We can see Mr O mentioned his concern about his sight reduction in his right eye after his surgery and that informally, Mr O was trying to get answers.
55. We have seen no evidence that Mr O made a formal complaint to the Trust about any of his concerns until it received his letter on 21 October 2022. But, we could see the Trust apologised to Mr O in its letter dated 16 February 2023 about the difficulty he had when speaking to the Trust’s complaints team about how to make a complaint.
56. We asked the Trust about Mr O contacting the complaints team between January and October 2022 to say he wanted to make a complaint. The Trust advised us there is no record of Mr O contacting them before it got his complaint letter on 21 October 2022. It said the general process if somebody called would be to offer help and direct people to advocacy groups who can support them through a complaints process.
57. The Trust said there was contact with Mr O after he made his complaint. It said Mr O contacted the chief executive on 27 January 2023 about his complaint. In response to this the deputy director of quality phoned Mr O. The Trust says Mr O said he felt like it was not helping him to put his case across and it was preventing him from getting answers.
58. The Trust said it was agreed with Mr O that it would send a response to his second complaint letter and Mr O could review it and confirm if it answers all his concerns. The Trust explained this was the reason why there was an apology about his experience when trying to make a complaint.
59. Mr O became aware on 25 January 2022 that it was not recommended for corneal graft surgery to be carried out on anyone with stem cell deficiency and this prompted him to start the complaint process. There is no evidence of Mr O making any kind of formal complaint about his concerns until his complaint letter was received at the Trust on 21 October 2022.
60. We have not seen good reasons to put the time limit to one side.
61. We understand Mr O immediately felt something had gone wrong with his surgery in August 2020 and he raised this informally with doctors. Then over a period of 12 months up to August 2021, Mr O became aware of his other concerns about poor aftercare and the fact that Mr A did not do the surgery.
62. We recognise Mr O says he did not know how to progress a complaint with his sight impairment. We considered if this reason justifies the delay. In circumstances like this we would expect the necessary enquiries to be made about how to complain and to see what help or reasonable adjustments are available.
63. We understand experiencing loss of sight must have had a significant negative impact on Mr O’s mental health, but we do not think this alone justifies the delay.
64. We have not seen that Mr O got assistance or help from advocacy services, the Citizens Advice Bureau or similar community and voluntary organisations.