County Durham and Darlington NHS Foundation Trust

3. During Mr G’s admission at the Trust from 3 to 16 February 2022, Mrs G complains:

• staff gave him haloperidol, and at too high a dose • staff did not provide enough treatment for his respiratory symptoms, including escalating his treatment when his condition worsened • staff decided to implement a do not attempt cardiopulmonary resuscitation (DNACPR) order • staff did not communicate with family members about deterioration in his condition and decisions about the level of care they would provide, for example, his DNACPR order.

4. She also complains, from August 2021, the respiratory consultant delayed Mr G’s referral to the lung disease team to consider starting him on anti-fibrotic medication.

5. Mrs G says the wrong medication, lack of treatment, and denying Mr G resuscitation meant he avoidably died. She says Mr G’s death has been distressing and caused her financial difficulties.

6. She says the lack of communication meant her family were not prepared for Mr G’s death and staff excluded family members from decisions about his care.

7. She says the delayed referral meant Mr G did not start anti-fibrotic medication that would have improved his condition and avoided his hospital admission and his death.

8. Mrs G wants explanations from the Trust about why things went wrong, improvements to prevent a repeat of the events, and a financial remedy.

9. Following Mr G’s admission, Mrs G complained to the Trust on 22 March 2022. The Trust responded to her complaint on 26 August 2022. The Trust told Mrs G, if its response did not resolve her concerns and she wanted to progress her complaint further, she should contact its complaints team again.

10. Mrs G complained to the Trust again on 20 November 2023. The Trust responded on 26 April 2024. The Trust confirmed its response marked the end of its complaint process. The Trust advised Mrs G to complain to us if she wanted to take her complaint further. Mrs G complained to us on 12 May 2024.

12. The law (Health Service Commissioners Act 1993) 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.

13. We discussed this with Mrs G to understand the reasons why she did not complain to us within one year. We also considered the time it took the Trust to respond to her complaint.

14. Mrs G links the delay in Mr G’s referral to the lung disease team and the care she complains about during his hospital admission to his death. Therefore, we consider she had awareness of these problems and their impact by the end of his admission at the Trust.

15. We also consider the lack of communication she alleges during his admission, and how staff left her unprepared for Mr G’s death, would have become apparent at the time he died.

Mrs G also confirmed she was aware of these problems by 16 February 2022 in her complaint to us.

16. Therefore, we saw a period of almost 27 months from the date Mrs G was aware of her complaint until she complained to us.

17. We saw Mrs G made her initial complaint to the Trust promptly. This was around five weeks after Mr G’s hospital admission. Following the Trust’s response to her second complaint, she raised her complaint to us just over two weeks later. We consider these events show Mrs G could progress her complaint promptly and she did so on these occasions.

18. The main gap in time we saw in Mrs G progressing her complaint was the 15-month period between receiving the Trust’s first response and her complaining to the Trust again. We asked Mrs G why she did not or could not progress her complaint sooner.

19. Mrs G told us after getting the Trust’s first response, and discussing it with her family, she did not want to progress the complaint further. She felt deflated by the Trust’s response, and she found it upsetting. Therefore, she decided not to make a follow up complaint.

20. She said her family later persuaded her to follow up with the complaint. This was because they continued to consider the Trust got things wrong and that she should take her complaint further. On this basis, she later changed her mind and complained to the Trust. She added she was not aware of the time limits in making a complaint.

21. We did not see reasons which justify this delay. We recognise Mrs G found the Trust’s first response disappointing. That said, we expect complainants to progress their complaint promptly when it is within their control to do so. During this period, Mrs G chose not to progress her complaint.

22. While Mrs G may have lacked knowledge about our time limit, the Trust’s first response told her to contact its complaint team within 30 working days if she wanted to progress her complaint. Therefore, she received information explaining who she needed escalate her case to and she should do so soon after she got the Trust’s response.

23. We recognise Mrs G also told us, collectively, the length of time the Trust took to respond to both her complaints was around ten months. She said this also explained why she approached us outside of our time limit.

24. We appreciate the time the Trust took in its investigations contributed to the passage of time. That said, this was not as long as the 15-month period between the Trust’s first response and Mrs G following up to escalate her complaint. This period alone is longer than our time limit.

25. Therefore, the passage of time before Mrs G escalated her complaint through the Trust’s complaint process is the main reason explaining why she made her complaint to us outside of our time limit.

26. As we saw Mrs G chose not to progress her complaint rather than factors preventing her, we cannot see reasons to justify this delay. This means we cannot see good reasons to set aside our time limit and consider her complaint further.

27. We recognise this outcome is likely to be disappointing for Mrs G given she still seeks explanations about Mr G’s death.

28. We hope we have clearly explained the factors we have considered and the reasons for our decision.

1. We recognise Mrs G has been through a very difficult time. Sadly, her husband, Mr G, died at the end of his admission at the Trust.

2. We carefully considered Mrs G’s concerns. Having done so, we saw she made her complaint to us outside of our time limit. We did not see good reasons to set our time limit aside and consider her complaint further.