Barts Health NHS Trust

4. Miss E complains about the actions of Barts Health NHS Trust during her late father’s admission between 28 January and 11 February 2021. Specifically, she complains:

• her father sustained injuries to his head, arms and abdomen • the Trust failed to provide planned one-to-one nursing care, scans and a chest X-ray, as shown in the hospital notes • a student doctor and a nurse changed her father’s catheter, when this should have been carried out by his urology consultant using special equipment • the Trust used a hoist to move her father, saying he would not uncross his legs • on 5 February 2021, her father was found choking by an occupational therapist and there were no staff on the ward • on 11 February 2021, the Trust failed to assess whether her father was medically fit for discharge and, unsafely discharged him without palliative care in place • the Trust failed to flag her father’s care with its safeguarding team or the dementia team.

5. Miss E also complains the Trust’s communication with the family was poor and dishonest. Specifically, that it failed to inform them of her father’s injuries, the neglect he experienced, the severity and consequences of the choking incident, and it failed to clearly communicate the significant decline in his overall health.

6. Miss E also complains about the way the Trust handled their complaint, specifically that its response was delayed and contained inaccurate information.

7. Miss E’s father sadly died at home on 13 February 2021. Miss E says the choking incident caused a decline in his physical and mental health, and he was traumatised and frightened because of the hospital care he received. She also says the catheter change caused her father pain and made him feel uncomfortable, which impacted his mobility. Miss E feels staff were oblivious to this issue and that it led to mistreatment.

8. Miss E told us her father spent 44 hours at home without end-of-life support, and during this time he was in agony, extreme distress, thrashing and jerking.

9. Miss E says the family did not know their father was near end of life when they asked the Trust to discharge him. They told us they were angry, saddened and traumatised by the injuries they saw when their father arrived home, and with the severe decline in his health and numerous physical injuries. They also said they were traumatised as a result of caring for their father without appropriate end-of-life support, and they found it hard to function properly afterwards.

10. Miss E, and her sister, also experienced significant stress and upset because of the Trust’s complaints process, which made them feel frustrated, angry and worn out. Miss E says when they received the Trust’s report, having done their own examination of the hospital notes, the lies, omissions and deceit became clear, adding further shock and distress.

11. As an outcome Miss E is looking for service improvements in the care of patients with dementia including its communication with families, she would like the Trust to listen to families and have honest conversations. Miss E also wants service improvements in the Trust’s complaints process.

12. On 28 January 2021, Mr E was admitted to hospital because of a chest infection. The Trust planned to give Mr E intravenous (into the vein) antibiotics over the next 24 hours. Mr E remained in hospital until 11 February 2021, and during this time his health deteriorated.

13. Mr E’s family are concerned about the care the Trust provided, and believe he was neglected and came to harm. When Mr E arrived home, he was very poorly. Sadly, Mr E did not recover and died two days later.

14. A coroner’s report states the cause of death as bronchopneumonia due to chronic obstructive pulmonary disease, with chronic kidney disease and carcinoma of the bladder being significant conditions contributing to the cause of death, but not related to the condition causing it.

All parts of Miss E’s complaint

17. The law says a person needs to make their complaint to us within a 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 so. We have discussed this with Miss and Ms E to understand the reasons why they could not do so. We have also considered the time the organisation has taken to respond to their complaint.

18. The events of Miss E’s complaint happened in January and February 2021. Miss E complained to the Trust on their behalf on 11 and 26 February 2021. Miss E sent us their written complaint in January 2024. Their complaint about care and treatment, and communication, is therefore almost two years outside our time limit.

19. In relation to the complaint about the Trust’s complaint handling, the latest date that Miss and Ms E were aware they had reason to complain is 22 January 2022, when they chased the Trust’s response and expressed concerns at having to do so a year after their father had passed away. This means their complaint about the Trust’s complaint handling is one year out of time.

20. In line with section 9.4 of the Health Service Commissioners Act 1993, we have considered whether it is reasonable for us to set aside our time limit.

21. We have seen that local resolution was not straightforward in this case. Whilst Miss and Ms E complained to the Trust quickly, there were some delays in the Trust providing its response. In November 2021, the Trust said this was because of staff shortages and pressures on its clinical staff.

22. The Trust thought local resolution ended on 22 April 2022 when it emailed its final response to Ms E. Ms E says she did not receive this email and letter. The Trust forwarded a copy to them on 30 April 2024, following our intervention. We have no reason to doubt what Miss E has told us.

23. Miss and Ms E also told us the last time they contacted the Trust to chase its response was on 24 January 2022. They did not take any action to pursue their complaint until they contacted us on 28 January 2024.

24. Miss and Ms E have explained a variety of reasons for the delay in pursuing the complaint. They said they were severely traumatised with the manner and circumstances of their father’s death, and that after a year of fighting for answers they felt worn out and that they were being thwarted and obstructed along the way. We recognise the complaints process has not been easy for them, we are terribly sorry to hear that they felt this way.

25. They also told us about serious family health and other issues that became urgent at that time, which they had to deal with. We are very sorry to hear about the difficulties the family faced during that time.

26. Miss E also had a total knee replacement in July 2022, and had a difficult recovery because of fall. In February 2023, Miss E began rehabilitation and around this time, both Miss and Ms E were poorly with COVID-19.

27. Miss E said that from April to November 2023, they dealt with clearance of their parents’ property so that it could be refurbished to provide a new home for her sister and nephew, and they also contracted builders. We understand major refurbishment works then took place between December 2023 and July 2024.

28. Miss E also told us that another reason for the delay is that they thought that they had three years to bring the complaint to us. They decided to pursue their complaint in January 2024 because of the nature of their concerns and unanswered questions. We have explained to Miss E that the three-year time limit relates to the limitation period for a clinical negligence claim, rather than law which governs our work.

29. Overall, we can see Miss and Ms E were actively pursuing the complaint during 2021, this included obtaining and cross-referencing clinical records, sending questions to the Trust, and liaising with the coroner’s office. They also instructed a legal firm in relation to a clinical negligence claim and provided two archive boxes of records and information they had obtained.

30. We have seen a letter from the legal firm dated 26 October 2021, which explains that they were unable to take on the case. That letter also includes advice on the alternative options under the complaints procedure, and signposts Ms E to us and provides our contact details.

31. The Trust’s response letter of 1 July 2021 also details the available options under the NHS Complaint Procedure, and states that if they were not happy with how the Trust dealt with their complaint and would like to take the matter further, they could contact us. The Trust also provided our contact details.

32. It is clear what happened has been very distressing for Miss and Ms E, and we understand how much this complaint means to them. Overall, we do not think their reasons justify the extent of the delay.

33. Having taken all of the circumstances into account, we have not seen any reasons why Miss or Ms E could not have contacted us in January 2022 when they were experiencing delays with the Trust. If they had contacted us at this time, we could have advised them on our process and the steps they should take.

34. Whilst we understand the family were dealing with a serious health issue for a family member in March 2022, there are long periods following this when either Miss or Ms could have taken steps to pursue the complaint, whether that be contacting the Trust to check the position with its response, contacting our helpline to find out the next steps, or sending a complaint form to us.

35. It seems that a key reason for the complaint not being pursued sooner is their understanding that they had three years to bring their complaint to us. Miss E feels the letter they received from the legal firm reinforced the idea that they had three years to complain from the date of death. We can see the solicitor states this when advising of the option to seek alternative legal advice, and approaching another firm, rather than pursuing the complaint through our organisation.

36. We recognise how distressing the events within Miss E’s complaint have been and continue to be for her and her sister. It remains that we see various opportunities where we consider they could and should have pursued their complaint much sooner. It is important to explain that as well as the above consideration, there can also be practical difficulties to consider complaints a long time after the events happened. This has also formed part of our decision-making process.

37. For these reasons we will not be considering this complaint further. It is important we consider and act within the law and we regret any further upset this decision may cause. We thank Miss and Ms E for bringing their complaint to us and we hope this statement clearly explains the reasons why we will not be considering the complaint further.

1. We have carefully considered Miss E’s complaint about Barts Health NHS Trust (the Trust). We are very sorry to learn about the sad circumstances which led Miss E to approach us.

2. We recognise Miss E, and her sister Ms E, have been through a very traumatic experience and offer our sincere condolences on the loss of their father.

3. After careful consideration, we have decided the complaint falls outside of our time limit and we will take no further action on it. We recognise Miss E will be disappointed by this decision as it is not what she was hoping for.