Barts Health NHS Trust

3. Mr G complains about the following aspects of care the Trust provided following his father’s admission in August 2022. He says the Trust: • communication was poor, with him and between staff • told him his father was too unwell to continue treatment but also not unwell enough to receive palliative care • did not administer intravenous fluids and antibiotics as it should have, or manage his nutrition, hydration and mouthcare • considered his father’s death imminent and did not assess his response to the treatment it was providing.

4. Mr G considers his father’s death avoidable. He says the Trust’s poor care accelerated his deterioration and eventual death. He feels poor communication meant he could not rely on the information he was given. It also meant he was not with his father when he passed away two days after he was discharged.

5. Mr G would like the Trust to acknowledge it did not give his father the care it should have. He would also like it to apologise for the impact this had and assure him lessons have been learned. He would like us to consider recommending a financial remedy too.

6. We have included this brief background to provide some broad context to our decision. We have not included all the detail Mr G provided.

7. Mr G’s father was admitted to the Trust on 1 August 2022. He remained in hospital for a few weeks, until the Trust discharged him back to his nursing home. Mr G had returned from his home to the UK and was under the impression his father was clinically stable at that time.

8. Sadly, Mr G returned home and was unable to be with his father when he died in September. He had already complained to the Trust before his father’s death.

11. 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 Mr G to understand the reasons why he could not do so. We have also considered the time the Trust has taken to respond to Mr G.

12. Mr G was aware of the concerns he raised at the time of the events, in August 2022. When he brought his complaint to us in March 2024, it was more than six months outside of our time limit.

13. We looked at whether we could justify exercising our discretion around the time limit in order to consider the complaint further. To do this, we considered if Mr G had provided compelling reasons for the delay in bringing his complaint to us.

14. Mr G said he could only come to us once the Trust signposted him and it never told him there was a timeframe in which he would need to bring his complaint to us. This partly reflects what we have seen. The Trust’s responses signposted him to us but did not specifically mention we have a time limit. We do not consider this in itself to be a good reason for the delay in approaching us.

15. Mr G had complained to the Trust promptly, in early September 2022, when his father was still alive. The Trust responded at the end of November, responding to his concerns and explaining how he could make a legal claim. It also included information about how to raise any outstanding questions and how to escalate his complaint to us.

16. Mr G wrote back to the Trust in December. He said he would contact its legal team and escalate his complaint through the Trust and to us. The Trust sent its final complaint response in late January 2023. Like the previous response, it enclosed information about our service and who at the Trust he should direct any unanswered questions to.

17. The local resolution process had concluded at this point. On both occasions, the Trust responded within three months. This was well within the six month timeframe set out in the NHS Complaints Regulations.

18. In mid-May, more than three months after the response, Mr G asked the Trust how to escalate the complaint. He followed this up with a telephone call in mid-September. The Trust apologised for overlooking his email and said ‘as stated in our response letters to you, you can now approach the [PHSO]’. Mr G did not approach us at this stage.

19. A few weeks later, Mr G asked the Trust for a meeting. He had further contact with the Trust in November to see if he could have a meeting before contacting us. The Trust advised he could come to us without a meeting. The Trust also provided information about how to proceed with a legal claim.

20. The Trust signposted Mr G to us again in December when he queried the arrangements for the meeting with the Trust. Mr G then telephoned us in early January 2024.

21. Following the completion of local resolution, it is a requirement that the complaint is made to us in writing. Mr G did not meet this requirement when he contacted us in January 2024 so we requested further information from him and the Trust. We sent him a complaint form in mid-February, which he completed and returned in early March.

22. Mr G feels he was trying to pursue the complaint and the Trust was pushing him away. There is no evidence the local resolution process was a key factor in the complaint being brought to us outside of our time limit. Key gaps in the timeline relate to periods where Mr G does not appear to have pursued his complaint as actively as he did initially.

23. We appreciate Mr G was dealing with administrative matters relating to his bereavement and in practical terms, this meant he was travelling and spending time on matters other than his complaint. While we do not underestimate the impact this had, we do not consider it unreasonable to expect Mr G to have acted more promptly than he did.

24. In summary, we consider Mr G could have approached us sooner after the Trust’s response in January 2023. There was sufficient information on the Trust’s response to make him aware of our service and there was no indication he needed anything further.

25. Had Mr G approached us in January 2023, his complaint would have been within our time limit. Had he approached us when the Trust confirmed he could escalate his complaint, it would not have been so far out of time. We cannot justify exercising our discretion based on the available information.

26. For the reasons set out above, we cannot justify putting the time limit aside to consider the complaint further. We appreciate this is not the outcome Mr G wanted and we would like to offer our condolences for his loss. We hope we have clearly explained why we have decided not to investigate this complaint.

1. We have carefully considered Mr G’s complaint about the Trust. We recognise how strongly he feels about the care his father received before he sadly passed away. We were sorry to hear of his loss.

2. As we will go on to explain, the complaint falls outside of our time limit. Having considered the timeline and Mr G’s reasons for the delay, we have decided there is no good reason for us to put our time limit aside to consider it further. We appreciate how challenging Mr G’s experience was and we do not wish to detract from this.