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A practice in the Leeds area

P-003028 · Statement · Decision date: 22 October 2024
Complaint (AI summary)
Mr & Mrs R complained the care home provided inadequate end-of-life care and the Practice failed to address their concerns for their mother in 2019, potentially shortening her life.
Outcome (AI summary)
Complaint closed. The complaint fell outside the ombudsman's time limit, and no good reason was found to put the limit aside.

Full decision details

The Complaint

The care home provider 3. Mr & Mrs R complain the care home provider failed to provide adequate end of life care and treatment to their mother, Ms O, between 12 August 2019 and 9 September 2019.

4. Mr & Mrs R believe the way the care home provider handled her mother’s care negatively affected her health and without these failings she could have lived longer.

5. Mr & Mrs R wants the care home provider to acknowledge the failings and apologise. They also want them to put in place significant service improvements and a financial remedy.

The Practice 6. Mr & Mrs R complain the Practice failed to address their concerns regarding the care of their mother, Ms O, at the care home between 12 August 20219 – 9 September 2019.

7. Mr & Mrs R says if the GP Practice would have listened to their concerns about the care lack of care, Ms O, may have lived longer.

8. Mr & Mrs R wants the Practice to acknowledge the failings and apologise. They also want them to put in place significant service improvements and a financial remedy.

Background

9. Ms O was an 82-year-old lady who died on 7 September 2019. Ms O passed away at a care home where she was being looked after for end-of-life care.

Findings

12. 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 & Mrs R to understand the reasons they could not do so.

13. According to our Service Model Guidance:

• 2.249 We must consider the time limit in every case before making a decision to investigate a complaint.

• 2.250 For health complaints, the aggrieved must refer the complaint to us within one year from the day they first became aware that they had a reason to complain (Legal requirement).

14. In order to consider time limit we need to consider when the person became aware of the complaint they are bringing to us, as the starting point for considering time limit. We also need to consider what date they came to us as the end point. Where there are a number of issues within a complaint we need to look at each part of the complaint separately to understand what date we would have expected the person to bring that part to us by in order to meet our time limit. If it is outside of our time limit we will go on to consider the reasons why it has come to us outside the time limit. We have looked at each area of complaint below in this way to understand more.

Care and treatment - the care home provider

15. On 7 September 2019, Ms O passed away at a care home. As the complaint brought to us relates to her end of life care we can say the couple would have been aware of the issues by the point of her death and they have not disputed this. We would expect for this to be brought to us by September 2020 (within 12 months). As they approached us in December 2023 this is around 39 months outside our time limit.

16. We therefore turned to consider what had happened between their date of knowledge and when they did approach us, that may have prevented them doing so, and whether there is any basis to set our time limit aside.

17. Mr & Mrs R raised a complaint to the manager of the home in September 2019. We note the care home provider did not respond to Mr & Mrs R’s concerns, but they were aware of the complaint. We understand this was touched upon in a meeting on 5 November 2019, where the care home provider acknowledged that a complaint had been made but stated that there would be no response before completion of the Leeds County Council (LCC) investigation. We understand the LCC final report and adjudication was completed on 23 June 2023. I can also see that they requested a Subject Access Request on 9 August 2023. They received the information on 29 August 2024.

18. We understand the LCC final report and adjudication was completed on 23 June 2023. We do not believe Mr & Mrs R received a response to their complaint further to this but nor do they appear to have chased this with the care home provider. However, we do appreciate they had been told there would be no response by the care home provider ahead of the completion of the LCC investigation. However, even when that was completed there was a further six months before Mr & Mrs R approached us. Mr & Mrs R also say they were not aware of the PHSO but we have seen they were provided a complaints leaflet by the Practice which explains our role and signposts to us.

19. Also, the PHSO details are widely available on search engines. As such, we are not persuaded six months in order to take the next step is a reasonable enough timeframe to support us putting aside our time limit in this case. Particularly, where so much time had already elapsed further to the events they are complainant about, occurring.

Care - the Practice

20. We know that on 7 September 2019, Ms O passed away at a care home and the issues complained about occurred in August to September 2019 relating to the Practice’s response to the couple’s concerns about her end-of-life care.

21. We understand Mr & Mrs R was aware of these by the point Ms O passed away in September 2019. Mr & Mrs R did not complaint to the Practice until 14 January 2022 and they received a response on 2 February 2022.

22. We would expect for this to be brought to us by September 2020 (within 12 months). As they approached us in December 2023 this is around 39 months outside our time limit.

23. We therefore turned to consider what had happened between their date of knowledge and when they did approach us, that may have prevented them doing so. We then considered whether there is any basis to set our time limit aside.

24. We note that Mr & Mrs R did not approach the Practice with their concerns until 14 January 2022 and the Practice sent a final response on 2 February 2022. They also provided a complaints procedure – patients leaflet noting what to do if they were dissatisfied with the outcome. We therefore cannot say there was any significant delay as a result of the complaints process which took about two weeks.

25. I will now consider the delay for raising the complaint to the Practice and us (PHSO). When I asked Mr & Mrs R why they had not raised a complaint to the Practice in 2019, they replied that this was because they were waiting for the LCC to conclude their investigation. I also asked Mr & Mrs R why they had not raised this to us prior to December 2023, and again they replied saying that they were dealing with other complaints with Leeds City Council.

26. We understand the LCC final report and adjudication was completed on 23 June 2023. Nevertheless, there was a further six months before Mr & Mrs R approached us. When we discussed this, they explained they were not aware of us. I explained that on 2 February 2022, they were provided with a complaint procedure - patients leaflet which highlighted the process on how to escalate a complaint to the PHSO. Mr & Mrs R confirmed that they did not look at the leaflet.

27. Whilst we appreciate there was clearly a lot happening with the different complaints processes, we understand they were told what to do if they were unhappy about the response (specifically to come to us) and did not do so. Whilst they have explained they did not see that information we also appreciate that if they were unhappy, it seems reasonable that they would have reviewed the information they had been provided, or undertaken some basic internet research which would have shown who to take complaints to about the NHS if you remain unhappy. We have seen they are confident in raising complaints having done so across various organisations and as such, we are not persuaded it was not reasonable to approach us sooner.

Conclusion

28. Overall, our decision is that the complaint is out of time for both organisations. We have explored the reason provided for the delay but those are not strong enough to allow us to put the time limit aside. We appreciate that Mr & Mrs R had a lot to deal with and have ongoing concerns. We hope we have explained the reasons we cannot take this complaint any further.

Our Decision

1. We have carefully considered Mr & Mrs R’s complaint about a practice in the Leeds area (the Practice) and an independent provider in the Leeds area (care home provider). The complaint falls outside of our time limit and we have decided there is no good reason for us to put our time limit aside to consider it further.

2. We hope our explanation below reassures Mr & Mrs R of our careful consideration of his case and that our decision does not aim to take away any of the pain or distress they have experienced.

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