Croydon Health Services NHS Trust

3. Mrs L complaints about aspects of the care and treatment the Trust gave to her husband, Mr L in December 2020. Specifically, she says:

• the Trust failed to keep Mr L, who had lung cancer and pneumonia, in a private room between 9 December 2020 and 16 December 2020 despite her, and some staff, requesting this • the Trust initially gave Mr L his diabetes medication during his hospital admission but then failed to do so between 7 December 2020 and 16 December 2020 • the Trust initially gave Mr L antibiotics between 7 December 2020 and 9 December 2020 until his condition improved, but refused her requests to administer more when he deteriorated on 10 December 2020 and despite them being prescribed • the Trust cancelled Mr L’s planned discharge on 11 December 2020 so it could drain fluid from his lungs but failed to carry out the procedure.

4. Mrs L says the Trust’s failure to properly treat her husband’s pneumonia caused his death. She says the Trust should have kept her husband isolated because of his clinical history and, if it had isolated him, and given him his diabetes medication and antibiotics when she asked, he would not have died. She says she and her children have been left extremely distressed.

5. Mrs L would like the Trust to acknowledge and apologise for its failings. She would also like it to make systemic improvements and pay her a financial remedy in recognition of the impact of its failings.

6. Mr L was diagnosed with lung cancer in 2019. In December 2020, he began to experience respiratory difficulties and became unwell. He visited the emergency department and was admitted to hospital. Mr L was diagnosed with pneumonia and stayed on a standard ward for around two weeks before he sadly died on 16 December 2020.

7. In August 2023, Mrs L raised a complaint with the Trust about the care and treatment it gave to Mr L. The Trust issued its response to her concerns on 21 November 2023 and she escalated her concerns to us.

10. The ‘Health Service Commissioners Act 1993’ (the Act) is a law that sets out our role, responsibilities, and the things we must consider as the final step in the complaints process.

11. Section 9(4) of the Act says we should not investigate a complaint if it is brought to us more than one year after the affected person first became aware of their reason to complain, unless we consider there is good reason to do so.

12. After speaking with Mrs L and considering the evidence available to us, we understand Mr L was admitted to hospital on 7 December 2020 because he was experiencing respiratory problems and became unwell. Sadly, Mr L died on 16 December 2020. During the period between Mr L’s admission and his death, Mrs L witnessed the care she subsequently complained about and was unhappy with it.

13. This means it was during Mr L’s stay in hospital that she became aware of her reason to complain. With this and the Act in mind, the law says Mrs L needed to make her complaint to us within a year (December 2021).

14. Mrs L first complained to the Trust about Mr L’s care and treatment on 18 August 2023. The Trust issued a response on 21 November 2023. Two days later, Mrs L responded to the Trust’s letter and said she was unhappy with its response. On 3 December 2023, she approached us and asked us to consider her complaint. This means we received Mrs L’s complaint around two years outside of our time limit.

15. From the evidence available to us, we can see a significant gap where we can attribute a delay on Mrs L’s part in progressing her complaint. While we recognise Mrs L progressed her complaint to us promptly once she had raised her concerns with the Trust in August 2023, there is a large gap between Mr L’s death and Mrs L complaining to the Trust.

16. This gap is two years and eight months.

17. As such, we discussed with Mrs L the reasons why she did not raise her concerns sooner. She told us when Mr L died, she was very upset, and it was difficult to cope while also looking after her children. She said COVID-19 pandemic was still prevalent and the lockdowns meant it continued to have an effect on her life.

18. She told us her emotions settled down a bit more as time passed and, in late 2021, she requested copies of Mr L’s clinical records from the Trust which she received in early 2022. She said upon initially reviewing the clinical records, she decided to request more from Mr L’s GP, and another local hospital trust. She was unable to confirm when she received Mr L’s GP records, but told us the clinical records from the other trust did not arrive until December 2023.

19. Further, Mrs L told us that despite being in possession of some of Mr L’s clinical records in early 2022, she felt unable look at them in any detail until 2023. Having done so, and despite still waiting for further records, Mrs L told us she finally felt able to raise her complaint in August 2023.

20. We were sorry to hear how significantly Mrs L was impacted by the death of her husband, and how it meant she struggled to cope. We recognise the experience was traumatic for her and how the COVID-19 pandemic was an uncertain time for everyone, which brought about feelings of anxiety and worry.

21. We understand how difficult it is to lose a loved one and that there are often more pressing matters to deal with following a death. On top of this, such as in Mrs L’s case, the grief and emotion that comes with the death of a loved one can mean acting on a complaint is not a priority or even possible at the time. As such, we understand and accept why Mrs L felt unable to pursue the complaint in the initial weeks and months following Mr L’s death.

22. That said, in late 2021, around a year after Mr L died, Mrs L told us she felt able to request his clinical records and her emotions had settled down a bit. She has told us she requested the records to try and make sense of what had happened, and so she could point to evidence to support her complaint. Having considered Mrs L’s reasons, we do not think they are sufficient justification for setting aside our time limit. This is because we need to see extenuating or exceptional circumstances to put our time limit to one side.

23. There is not an expectation that a person who wants to complain about clinical care must review clinical records to make a basis for their complaint. A person can make a complaint without evidence, or reference to clinical records, and it will be investigated by the relevant organisation.

24. While this does not mean a person should not request clinical records this if they feel it is necessary, we must consider this carefully, including whether the time taken by a person to review the records they have requested is proportionate and necessary in the circumstances.

25. We recognise Mrs L’s concerns are about matters she witnessed at the time they happened, and therefore we think it would have been reasonable for her to have complained sooner. We are therefore not persuaded Mrs L needed Mr L’s clinical records before making her complaint in August 2023. Further, when Mrs L raised her complaint in August 2023, this was around four months before she had received all of the clinical records she had requested.

26. We recognise Mrs L has told us that although her emotions had settled down a bit in 2021, she could not look at the clinical records in any detail until 2023 because she was upset. However, as outlined above, we do not consider it was necessary for her to have reviewed the records before she raised her concerns.

27. With all the above in mind, we have not seen any evidence Mrs L’s reasons for her delay in raising her concerns initially, before then approaching us, are enough justification for us to set aside our time limit. There was a significant gap (two years and eight months) where Mrs L could have progressed her complaint but did not do so.

28. While we recognise this may be disappointing for Mrs L, it is important we consider and act within the law and we regret any further upset this decision may cause.

1. We have carefully considered Mrs L’s complaint about aspects of the care and treatment Croydon Health Services NHS Trust (the Trust) gave her husband, Mr L, in December 2020. She says Mr L was not kept in a private room in hospital despite their requests and did not provide the correct medication. She also says the Trust did not carry out a procedure to drain Mr L’s lungs. We were sorry to hear the details of Mrs L’s complaint, and we understand how difficult this experience has been for her.

2. After carefully considering the evidence available to us, we have decided Mrs L’s complaint falls outside of our one-year time limit and we are not persuaded it is reasonable to set the limit to one side in this case. We recognise this may be disappointing for Mrs L, but we explain the reasons for our decision below.