NHS in England Closed After Initial Enquiries Search on PHSO website

Walsall Healthcare NHS Trust

P-002522 · Statement · Decision date: 20 March 2024 · View Walsall Healthcare NHS Trust scorecard
Complaint (AI summary)
Miss B complained the Trust declined to consider a second opinion for her superior mesenteric artery blood clot in January 2022, resulting in ongoing pain and illness.
Outcome (AI summary)
The ombudsman closed the complaint because it fell outside the time limit and there were no strong reasons to waive this limit.

Full decision details

The Complaint

4. Miss B complains that in January 2022, the Trust declined to consider a second opinion she got from a doctor abroad about how to treat her superior mesenteric artery blood clot and instead told her no surgery was needed.

5. A superior mesenteric artery blood clot is an abrupt ending in the primary blood flow to the majority of the small bowel as well as (typically) the ascending colon.

6. Miss B says because of the lack of treatment, she was left in pain and had to take many medications. She says she struggled to eat food, lost considerable weight and was so ill she spent most of her time in bed, affecting her quality of life and mental health.

7. Miss B wants a care plan so her surgery can go ahead or compensation to pay for private treatment.

Background

8. Miss B told us the Trust diagnosed her with a superior mesenteric artery blood clot on 23 December 2021, which would be treated with blood thinning treatment and no intervention (surgery) was needed.

9. Miss B told us because she was unhappy with the lack of treatment offered for her diagnosis, in January 2022 she got a second opinion from a doctor in another country who advised she could be treated with alternative treatments. She told us the Trust declined to consider the second opinion.

10. On 29 March, Miss B approached an advocacy service to help with her case. She had also previously approached solicitors about her case.

11. Miss B received a letter on 1 April about a medical negligence claim enquiry, which assessed there was an insufficient prospect of success with her case.

12. On 14 April, the Trust referred Miss B to a different vascular surgeon at another trust.

13. Miss B received an email from her advocate on 29 April, to make her aware of the one-year timescale to make a complaint with the Trust and three-year timescale to seek legal advice.

14. Throughout this period (and up to August 2022), Miss B continued to contact the Trust by email about different parts of her care and treatment.

15. Miss B formally complained to the Trust on 5 August. On 5 September, the Trust held a complaints meeting to discuss Miss B’s concerns.

16. On 12 September, Miss B told the Trust by email that she would complain to the General Medical Council (GMC) and get legal advice if she did not get the outcome she wanted. Miss B also told the Trust on 10 and 11 October that she was going to bring her complaint to us and had filed a complaint with the GMC.

17. On 12 October, a second solicitor wrote to Miss B to advise her enquiry had been made too early as they needed the Trust’s complaint response. They said she should go back to them when she had this.

18. The Trust sent its final response on 14 October and told Miss B about her right to escalate her complaint to us. It also advised there were time limits for bringing a complaint to us.

19. On 18 October, Miss B contacted the Trust because she was unhappy with its response. She also included questions about other parts of her care and treatment. On 17 November, the Trust sent another complaint response.

20. On 2 December, Miss B told the Trust she would bring her complaint to us. On 6 December, Miss B asked the Trust for another meeting..

21. The Trust responded on 8 December to explain it felt it had provided a full response since the meeting in September and in its final responses in October and November. It again explained Miss B had the option of coming to us should she be unhappy with the responses.

22. On 5 January 2023, Miss B explained she was made aware during a clinic appointment that she could approach us if she was unhappy. On 30 January, a third solicitor wrote to Miss B to advise it was unable to take her case forward.

23. A fourth solicitor wrote to Miss B on 7 March, to advise it was unable to take her case forward. It provided details of alternative legal advice. On 11 April, Miss B asked the Trust for another meeting. On 22 May, Miss B had a meeting with the Trust.

24. On 1 June, the Trust sent a letter stating the actions agreed during the meeting. This included getting an update of her referral at another trust.

25. The Trust sent a further final response on 23 August, which explained the above and that Miss B could bring her complaint to us. On 23 August, Miss B brought her complaint to us.

Findings

27. Section 9(4) of the Health Service Commissioners Act 1993 (the law) says a person needs to make their complaint to us within one 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 do.

28. We first considered when Miss B became aware of her reasons to complain and whether her complaint was made to us in time.

29. It seems Miss B was unhappy with her care in December 2021. We think she would have been aware of her reason to complain in January 2022, when she says the Trust refused to consider the second opinion she had.

30. This means to be within our time limit Miss B needed to come to us by January 2023 at the latest.

31. She did not bring her complaint to us until 23 August 2023, seven months outside of our time limit.

32. Because of this we went on to consider if there are strong reasons why she could not complain to us sooner. We have discussed this with Miss B to understand her reasons.

Time taken for the Trust’s complaint handling

33. Miss B complained to the Trust on 5 August 2022, eight months after she says she was unhappy with the treatment offered and seven months after she says she got a second opinion which the Trust declined to consider.

34. The Trust held a meeting with Miss B on 5 September and provided its final response on 14 October, two months and two weeks after the complaint was received.

35. Miss B contacted the Trust again on 18 October. On 17 November, the Trust sent another response to Miss B, four weeks after the email was received.

36. Miss B contacted the Trust on 6 December to ask for another meeting. On 8 December, the Trust responded to ask her to complete a meeting pack.

37. Miss B sent the meeting pack to the Trust on 11 April 2023 and attended a meeting with the Trust on 22 May. The Trust sent a letter on 1 June, including the actions agreed with Miss B during the meeting.

38. We can see that overall the complaint handling took around five months, during which the Trust met with Miss B twice.

39. We have next considered Miss B’s reasons for delaying in progressing the complaint.

Reasons for delay

40. Miss B told us the delay between knowing there was a problem (in January 2022) and when she complained to the Trust one year and six months later (in August 2023) was because she had taken legal advice from many solicitors. She thought they would be a better first point of contact.

41. Miss B also told us she was hoping the Trust would provide the treatment she was asking for, or she would get compensation to allow her to pay privately. Miss B told us when she did not get what she wanted by using other channels, she came to us as a last resort.

42. We have considered Miss B’s reason for delay alongside the timeline of the events.

43. Firstly, we recognise this was an extremely difficult time for Miss B and we do not want to underestimate the significant impact this had on her. We have listened to Miss B’s reasons for the delay.

44. As above, the local complaints process initially caused around two months and two weeks of delay. We can also see an additional delay of around two months and two weeks after Miss B returned to the Trust because she was unhappy with the response.

45. We can see that when Miss B did complain to the Trust, it responded quickly including holding two meetings to review the complaints.

46. We can see other significant periods of delay (which seem to be caused by Miss B) that led to the complaint being out of time. These are:

• between becoming aware of the reason to complain in January 2022 and when she complained to the Trust in August 2023 (one year and six months) • between receiving the Trust’s final response in October 2022 and bringing the complaint to us in August 2023 (ten months).

47. For both of the above periods, Miss B told us the reason for her delay was because she had actively approached several solicitors and had continued to contact the Trust.

48. We can see she approached four solicitors between April 2022 and March 2023. Miss B also told us she had made enquiries with several other solicitors, the most recent being in January 2024.

49. It does not seem that these enquiries took a large amount of time. It seems Miss B failed to escalate her complaint to us after getting their responses. There also seems to have been a significant delay between Miss B receiving the final response and making enquiries with different solicitors. We do not think this is a strong enough reason for delay for us to put our time limit to one side for the whole period.

50. Miss B had use of an advocacy service from March 2022, who advised as early as April 2022 of the one-year timescale to make a complaint with the Trust. Miss B took a further six months from this time to complain.

51. Miss B told the Trust by email in September, October and December 2022 that she would bring her complaint to us if she did not get the outcome she was looking for. Miss B had also raised a complaint with us before.

52. The Trust advised in its response as early as October 2022 that if Miss B was unhappy she could escalate her complaint to us. It also advised there are time limits for taking a complaint to us.

53. We think Miss B would have been aware of our timescales and processes and known that she needed to bring her complaint to us quickly. But, she did not bring her complaint to us for some time.

54. We cannot see any clear reason why Miss B could not have brought the complaint to us sooner.

55. We recognise this will not be the decision Miss B was hoping for. We hope our statement sets out the careful consideration we have given to her reasons for delay.

Our Decision

1. We have carefully considered Miss B’s complaint about Walsall Healthcare NHS Trust (the Trust). We are sorry to hear about her blood clot and the events of her complaint.

2. We have decided not to consider Miss B’s complaint further because the complaint falls outside of our time limit. We have not seen strong enough reasons to put our time limit to one side to consider it further.

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

Other Decisions About Walsall Healthcare NHS Trust

P-004611 · 13 Jan 2026
Miss K complained the Trust did not admit her grandmother, Mrs L, to intensive care, delayed inserting a cannula, and …
Not Upheld
P-003626 · 26 Jun 2025
Mrs Y complains about the care and treatment her mother received from both Trusts following a leg fracture in April …
Partly Upheld
P-003434 · 28 Mar 2025
Mrs A complains about the care and treatment provided by the Trust to her mother, Mrs D. She says the …
Partly Upheld
P-003472 · 27 Mar 2025
Miss V complains the Trust did not test her mother’s blood and failed to identify her cancer on two separate …
Not Upheld
P-003113 · 12 Nov 2024
Mr V complains that Walsall Healthcare NHS Trust failed to diagnose his cellulitis and sepsis in February 2022.
Closed After Initial Enquiries
View all decisions for this organisation →