University Hospitals of Derby and Burton NHS Foundation Trust

3. We have carefully considered Mrs A’s complaint about the care and treatment the Trust gave her husband, Mr A, during his admission between 25 June 2022 and his sad death on 27 June 2022.

4. She complains the Trust:

• Put in place a Do Not Attempt Resuscitation Order (DNAR) without the family’s input or knowledge. Mrs A said that the family were not involved in the decision making and were unable to advocate for him. She said the DNAR contributed to Mr A’s death.

• On 27 June 2022, wrongly administered opioid pain relief to Mr A and did not monitor him for side effects, which led to his death. Mrs A believes he died sooner than he should have.

• Did not properly explain if it was providing treatment or end of life care to Mr A nor did it explain when its treatment plan changed.

5. She explained she feels angry and frustrated with the Trust’s poor choices and lack of interest, because of these, Mr A stood no chance of recovery. She said his death had a huge impact on her and their two sons. They all live with the upset every day.

6. Mrs A wants the Trust to admit that bad decision making led to Mr A’s death and be reprimanded for its actions. She also wants to know how many people have died in similar circumstances to her husband.

7. In 2013, Mr A was diagnosed with bowel cancer. He was receiving long term cancer treatment. On 25 June 2022, the Trust admitted him after a three-day history of vomiting.

8. The same day the Trust implemented a Do Not Attempt Resuscitation (DNAR). The family did not find out this was in place until after Mr A died.

9. On 27 June 2022, the Trust administered a dose of oxycodone, and the family did not know why Mr A needed this dose. Mr A was not monitored after the dose, his condition deteriorated, and Mr A sadly died.

10. Mrs A made her complaint to the Trust on 28 June 2022. The Trust sent its final response on 18 April 2023. Mrs A made her complaint to us on 26 January 2024.

11. The law says a person needs to make their complaint to us within a year of becoming aware of the problem (we call this the date of knowledge). We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

12. Mrs A’s date of knowledge was 27 June 2022. This was when Mrs A became aware she had cause to complain.

13. We can see the Trust provided its final response on 18 April 2023 after a local resolution meeting on 28 March. This means Mrs A took a further nine months to bring the complaint to us on 26 January 2024, it was six months and 30 days outside of our time limit.

14. We have discussed this with Mrs A to understand the reasons why she could not bring her complaint to us sooner. Mrs A explained that after Mr A’s funeral, she put their full efforts into the complaints process. She confirmed that there was no gap in their contact with the Trust.

15. Mrs A said the Trust drew out the complaints process and it took it nine months to arrange a resolution meeting. When the Trust sent its final response, the family took some time to deal with the emotional toll of Mr A’s death as the loss hit them all at once. They needed their time to grieve.

16. She explained that her sons C and O work full time and C has stepped into his father’s shoes and looks after the family. They spent some time to figure out what their next steps were, and it was by chance that Mrs A saw a news article about our service, and this firmed their decision to bring the complaint to us. They phoned us for more information in Novembre 2022 and sent their complaint after taking some time to bring the complaint form together.

17. We understand that it can be difficult to make a complaint when grieving. There are organisations that can help with this, they can represent people in complaints and request records for them if needed. We think it would have been reasonable for Mrs A to have sought help from such an advocacy organisation, to alleviate the pressure on the family and bring the complaint sooner.

18. We do not think the explanation for the delay is reason enough for us to put our time limit on one side.

19. We recognise that Mrs A thinks the Trust drew out the complaints process. The regulations say that we expect a written response from the Trust in six months and nine months is longer than we would like to see. It can take a longer period to arrange for the relevant staff to attend a local resolution meeting, and so we did not think this unreasonable. Nonetheless, despite the length of time it took the Trust to respond, the complaint at that point was still in time.

20. The time it took the family to bring the complaint to us, pushed the complaint outside of our time limit. For this reason, we do not think it is reasonable for us to put our time limit on one side.

21. We understand how much this matter means to Mrs A, and it is clear how well she advocated and cared for her husband. We thank her for sharing the details of the complaint. It is important we consider and act within the law and we hope this statement clearly explains the reasons for our decision.

1. We have decided not to consider Mrs A’s complaint further. This is because the complaint falls outside of our time limit. We carefully considered Mrs A’s reasons for not bringing the complaint to us sooner. We did not think there were sufficient reasons to set aside our time limit and so we will take no further action.

2. We were sorry to hear of Mr A’s death and we thank Mrs A for taking the time to tell us about her husband’s experience and the ongoing impact this has.