11. The Ombudsman’s powers are set out in the HSCA. This is the law that governs our work. Section 9(4) of the HSCA says a person needs to make their complaint to us within a year of becoming aware of the problem. It says we cannot investigate complaints brought to us after one year, unless we see there is a good reason to do so.
12. Mr G complains about the care and treatment he received between October and December 2019. Mr G was diagnosed with severe heart failure on 7 January 2020. When speaking with us, Mr G and Ms G agreed they became aware they had reason to complain about the Ambulance Trust the day the ambulance did not arrive, 25 November 2019, and about the Practice and the Trust at the point of diagnosis, on 7 January 2020.
13. We call these their ‘dates of knowledge’. For Mr G’s complaints to have come to us in time, he would have needed to have brought them to our Office within 12 months of his dates of knowledge, therefore by 25 November 2020 and 7 January 2021 respectively.
14. We first received contact from Mr G when he submitted his complaint form to us on 10 October 2023. This meant his complaints came to us two years and nine months, and two years and 11 months respectively, outside our 12-month time limit.
15. We spoke with Mr G and with Ms G to understand the reasons why they could not bring Mr G’s complaints to us sooner. We also considered the time the organisations took to respond. We discuss the timeline and these considerations below.
Practice complaint 16. From the information shared with us we can see Ms G acted very promptly, emailing the Clinical Commissioning Group (CCG) with Mr G’s complaint about the Practice on 10, 12 and 13 February 2020. We can see NHS England responded five months later on 27 May 2020, and sent the Practice’s response two months after that, on 10 July 2020.
17. We see Ms G telephoned in June to raise Mr G’s outstanding concerns, and NHS England responded two months later, on 3 September 2020, signposting her to our Office.
18. We think this is all prompt and timely. Ms G acted quickly after she and Mr G became aware of the need to complain. The regulations say the organisation investigating a complaint should respond within six months, and we see NHS England and the Practice acted in accordance with this.
19. We cannot see that Mr G or Ms G took any further action on the Practice complaint after receiving the letter dated 3 September 2020, until Mr G submitted his complaint to us three years and one month later. This is a significant period of delay.
Trust complaint 20. After Ms G raised Mr G’s complaint about the Trust to the CCG on 10, 12 and 13 February 2020, we can see the Trust completed a Root Cause Analysis (RCA). It issued the RCA report, which addressed the complaint concerns, on 23 June 2020. We again consider this prompt and timely, in line with the regulations.
21. We cannot see that Mr G or Ms G took any further action on the Trust complaint after receiving the RCA report dated 23 June 2020, until Mr G submitted his complaint to us three years and four months later. This is a significant period of delay.
22. It was only after contact with our Office that Ms G pursued Mr G’s complaint with the Trust, emailing these ongoing concerns on 24 October 2023. The Trust sent a response two months later on 20 December 2023, in line with the regulations.
Ambulance Trust complaint 23. From the information provided to us, Ms G first raised Mr G’s complaint to the Ambulance Trust by email on 24 October 2023, after Mr G had brought his complaint to our Office. This was three years and ten months after Mr G was aware he had a reason to complain. This is a significant period of delay.
Considering the delay 24. When any complaint comes to us outside of our time limit, we must consider the time taken by the person complaining and the time taken by the organisations to respond. From the dates outlined above, we are satisfied the organisations all responded without delay, in line with the regulations. We are left with the view that the considerable delay of over three years, for each complaint, occurred when the matter was left with Mr G and Ms G to pursue.
25. We spoke with Mr G and Ms G, to explore the reasons for this delay. During our call, they confirmed they were unhappy on the day the ambulance didn’t arrive in November 2019, on receipt of the Trust’s RCA report in June 2020, and when receiving the last letter from NHS England in September 2020. Despite knowing of their unhappiness, and awareness of wanting to complain at those times, they did not take any further action until Mr G submitted his complaint to us over three years later.
26. When we spoke, Ms G explained that when Mr G was diagnosed and his life changed, her life changed too. She said she sought bereavement counselling as it felt she had lost the person Mr G was. Ms G explained her own mental health suffered, that she had a nervous breakdown which lasted several years, due to a culmination of what happened on top of the COVID-19 pandemic.
27. From speaking with Ms G, it is clear what happened to Mr G had a significant impact on her life. She suffered a great shock and became considerably unwell following Mr G’s diagnosis, and we accept this will have had an impact on her ability to complain. That said, we can see Ms G did complain to the CCG weeks following Mr G’s diagnosis, in February 2020. We also see she telephoned the CCG in June 2020, after receiving its first response, to pursue hers and Mr G’s ongoing concerns.
28. This shows us that even in the immediate aftermath of Mr G’s diagnosis, at a time he was most unwell, when she was seeking counselling support and when the COVID-19 pandemic was in full force, Ms G was able to engage with the complaints process. We recognise that life was very difficult for Ms G at this time. It remains we are left without good reason as to why, if she could engage at these earlier occasions, she was unable to engage again in June 2020 when receiving the Trust’s RCA report, or shortly after in September 2020 when receiving the letter from NHS England, or at any time in respect of the Ambulance Trust complaint.
29. Ms G says once better she went into a work placement, and it was only upon speaking with a colleague that she was told about our Office. We can see at the close of NHS England’s letter dated 3 September 2020, it explained their option of contacting the Ombudsman. The letter explains our role, that we are a free service, and gives our website address and telephone number.
30. The letter advises that we were not accepting new complaints because of the COVID-19 pandemic and said more could be found out on our website. Had Mr G and Ms G looked on our website, they would have seen that by September 2020 we had lifted our pause, and we were accepting new complaints again. Had they come to us then, the Practice and Trust complaints would have been in time.
31. We asked Mr G why he was unable to pursue the complaint himself. Whilst we recognise Mr G gave his consent for Ms G to act as his representative to pursue the complaint on his behalf, we cannot see this was because he was unable to do it himself. Typically, a representative would be involved because the person affected is a child, or is a vulnerable person, or has mental health or medical conditions that may affect their capacity or would hinder them from being able to pursue their own complaint themselves.
32. We are not aware that any of these circumstances apply to Mr G. In fact, the complaint form we received in October 2023 was completed and submitted by Mr G himself, evidencing his ability to do so. Appropriately, we must explore why he could not have acted sooner.
33. We recognise Mr G would have been very unwell in the immediate period after his diagnosis, and after he first became aware of a need to complain, and we respect this would have affected his ability to complain at that time. However, we are left with a period of over three years before he submitted his complaint to us. When we spoke, Mr G did not provide good reason to us, for why he could not take on his complaint himself.
34. Ms G suggested Mr G needed prompting to undertake daily tasks, and as such she took the complaint on herself. We were not led to believe this need for prompting was due to any medical difficulty Mr G suffers. As such we remain without good reason for why Mr G could not have continued with his own complaint, particularly during the period when Ms G was struggling to do so.
35. Lastly, when we first enquired about the time that had passed, Ms G responded by email on 23 October 2023. She said she had found an email thread from the CCG which says she only had 12 months to complain and said: ‘I think that I just gave up at this point and did not read or understand fully what was going on’.
36. We do not underestimate the effort and energy it takes to pursue complaints. We recognise that doing so likely felt extremely difficult and burdensome whilst Mr G and Ms G both readjusted to Mr G’s circumstances and their new way of living, whilst this felt a period of grief, whilst Ms G was studying, during the pandemic and whilst they fulfilled all other daily living activities. We also recognise that distress is not linear or time-bound, and we acknowledge they both remain distressed by what happened.
37. It remains that we can see in the immediate aftermath of what happened, at the time when the impact of what had happened was most pronounced, Ms G was able to act and engage, to raise Mr G’s formal complaint in detail, without undue delay. Considering this, we cannot see Mr G’s or Ms G’s ongoing difficulties were a barrier to them being able to pursue their concerns with the Practice and the Trust or contact the Ambulance Trust or our Office much sooner than they did.
38. We are very sorry to have learned how they have been affected and we understand how much this complaint means to them. It is important we consider and act within the law and we regret any further upset this decision may cause. For the reasons explained, we do not see good reason to set aside our time limit. We hope this statement clearly explains the reasons why we will not be considering this complaint further.
Newer information 39. We also want to address the matter of the new information Ms G told us she found. When we spoke, Ms G explained she had requested Mr G’s records, and it was only when she went through these for a second time in late 2022 that she found some new information. She described finding a letter from hospital, sent after Mr G had treatment for meningitis in 2018, which spoke about his heart. She says nothing was ever done in response. Ms G told us she feels this letter could suggest something might have been done about Mr G’s heart as early as 2018.
40. Ms G suggested that this brought Mr G’s complaints in time, as she only found this letter in late 2022. We do not agree. We can see that Mr G and Ms G were first aware of the need and reason to complain when Mr G got his diagnosis on 7 January 2020. This is evidenced by the fact Ms G did raise these complaints soon after, in February 2020.
41. It was only because of their knowledge at that earlier time, that Ms G requested a copy of Mr G’s records where she found this letter. We recognise Ms G chose to review the records however this is not a requirement of our process. We consider a person can complain as soon as they become aware they have reason to. This does not require them to conduct their own investigation or review the records in detail, before doing so.
42. We are also left without good reason for why it took until late 2022 for this letter to be found, and not before. We do not see that finding this information in late 2022 prevented Mr G or Ms G from pursuing these complaints much sooner.
43. Ms G told us this letter raises an additional complaint, about why nothing was done by healthcare professionals at that earlier time. We would have expected Mr G and Ms G to therefore have raised this additional complaint with the relevant organisation(s) at that point in time, without delay. Ms G told us neither she nor Mr G had yet complained about this issue.
44. We are unaware of any barrier that prevented them from complaining at that time, or any good reason as to why they have still not raised these complaints with the relevant organisation(s). Should this remain an outstanding concern, Mr G and Ms G will need to complete the organisational complaint process first. More information on this can be found in our letter accompanying this statement.