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Dartford and Gravesham NHS Trust

P-002888 · Statement · Decision date: 18 August 2024 · View Dartford and Gravesham NHS Trust scorecard
End of life care Administration Drugs / medication Drugs / medication Care and discharge planning
Complaint (AI summary)
Mr R complained his mother was placed on end-of-life care, denied food/water, had her hearing aid lost, diabetes medication stopped, and wrongly given certain medications, which he believes led to her death.
Outcome (AI summary)
The ombudsman closed the complaint as it fell outside of the time limit for investigation, and there was no reasonable justification to waive this limit.

Full decision details

The Complaint

3. Mr R complains the Trust placed his mother, Ms Q, on end-of-life care and stopped giving her food and water after her admission in November 2020. He also complains that whilst in hospital, staff: • lost her hearing aid • stopped diabetes medication, and • wrongly gave her midazolam and morphine.

4. He says she was discharged home in December 2020 and the events led to her death six-months later. Mr R says the events were distressing and have caused heartache for him and his father.

5. As an outcome to his complaint Mr R would like an apology and financial compensation.

Background

6. Ms Q had a stroke and was admitted to the Trust in November 2020. Whilst in hospital she caught COVID-19 and doctors believed she was approaching the end of her life. She went home in the middle of December with a plan to manage her needs there. She sadly passed away sixmonths later.

Findings

8. 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.

9. We have discussed this with Mr R to understand why he could not do so. We have also considered the time the Trust took to respond to him.

10. Mr R has told us the problems he has complained about resulted in the death of his mother six-months after her discharge. However, he complained to the Trust on 11 January 2021 – five months before she sadly died. We therefore consider he believed things went wrong when the Trust discharged her home in December 2020.

11. For Mr R’s complaint to have been in time, we would have needed to receive it by December 2021. Instead, he complained to us in October 2023. This is significantly outside of our time limit. Whilst we can set the time limit to one side, we can only do so if there was a good reason for the delay.

12. Whilst there are some valid explanations for the delay they do not sufficiently explain just how far his complaint falls outside our time limit. We have explained further below.

13. Mr R said the Trust took too long to respond to his complaint and purposefully delayed doing so. He says he tried to take legal action which added to the delay, and he has health problems and is a full-time carer for his father. We have looked at these reasons in turn.

14. The Trust responded to Mr R’s complaint in a letter dated 28 April 2021 and referred him to us if he remained unhappy. However, he did not approach us at this point and asked the Trust for a complaint resolution meeting.

15. 16 months passed between the Trust’s letter and the resolution meeting, which happened in August 2022. We have asked Mr R about what he did to minimise this delay.

16. He has provided the correspondence he had with the Trust’s CEO trying to arrange a meeting. The CEO agreed to meet, but was unable to do so immediately and blamed COVID19 for the delay. Despite Mr R’s best efforts, it seems the meeting happened as soon as possible, even though this was significantly after the Trust sent him its final response letter.

17. With the above in mind, the delays up to 10 August 2022 were justified. It was on this date the Trust provided the meeting he wanted and follow-up letter. He reasonably knew there was nothing more the Trust’s complaint process could provide at this point. Therefore, it would have been reasonable to approach us then.

18. Mr R took 14 months to approach us after the complaint resolution meeting.

19. The reason Mr R did not bring his complaint to us during this time was because he was attempting to resolve matters via legal action. Ultimately the claim was unsuccessful. Mr R says the solicitors decided the compensation they might achieve would not justify the likely costs.

20. The legal route is one possible option to resolve a complaint about the NHS. It could reasonably have achieved the outcomes Mr R wants. However, there is a choice between taking that route or pursuing the complaint with us. In this instance Mr R attempted to take legal action. Unfortunately, it was unsuccessful for him.

21. Nevertheless, this is not a sufficient reason for us to set the time limit aside. Mr R actively selected one option with the knowledge we could also have considered his complaint.

22. Therefore, we consider the time Mr R spent pursuing legal action is not a persuasive reason to set the time limit to one side in this instance.

23. Mr R has told us he has problems with his back and is a fulltime carer for his father. We acknowledge the difficulties these pose for him and the amount of time they take up. These factors could potentially cause delays in pursuing his complaint.

24. Despite these problems he approached the Trust with his complaint promptly. He also spent a significant amount of time pursuing his complaint with the Trust’s CEO in writing, and organising and attending the resolution meeting. His problems did not prevent him from pursuing legal action, and he has demonstrated no problems discussing the complaint with us.

25. Mr R approached us significantly after he believed something had gone wrong. We accept the Trust took a long time to handle his complaint locally and this justifiably contributed to the delays. However, this alone is not enough to disregard the entirety of the delay. The other reasons Mr R has presented are not sufficient explanations.

26. Although we are unable to look at Mr R’s complaint we understand how upsetting the events have been for him. We recognise the distress he has experienced and that it still affects him to this day. Whilst this is not the outcome he was hoping for, we hope we have clearly explained the reasons for our decision.

Our Decision

1. We have carefully considered Mr R’s complaint about Dartford and Gravesham NHS Trust (the Trust). We have decided the complaint falls outside of our time limit. We have decided it is not reasonable for us to put our time limit aside to consider his complaint further.

2. Our decision does not take away from the upsetting events Mr R has told us about. We understand how devastating he has found the loss of his mother and the sad circumstances in which this happened.

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