A practice in the Gloucester area

The Practice

4. Dr M complains about the following aspects of care Dr A provided to Mrs M on 28 February 2022:

• failure to administer oxygen. Dr M does not accept the explanation that doctors do not routinely carry oxygen due to health and safety legislation • delays in requesting an ambulance despite his mother being very unwell and having severe hypoxia. He also says when Dr A eventually did this he did not request an emergency ambulance • failure to obtain accurate oxygen readings. He says Dr A expressed doubts about the accuracy of the readings at the time but did attempt to use a different method.

5. Dr M feels his mother’s death was avoidable due to the poor care provided which has significantly affected his mental health. As an outcome to the complaint Dr M would like service improvements and a financial remedy.

The Trust

6. Dr M complains about the delay in an ambulance arriving on 28 February to take Mrs M to hospital. Dr M says by the time the ambulance arrived his mother had already died. He feels his mother’s death was avoidable which has significantly affected his mental health. As an outcome to the complaint Dr M would like service improvements and a financial remedy.

8. The law says a person needs to make their complaint to the Ombudsman 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 Dr M to understand the reasons why he could not do so. We have also considered the time the organisations have taken to respond to Dr M.

9. Dr M raised his complaint with the Trust in a relatively timely way just over a month after his mother’s death. It then took the Trust just over six months to respond. The Trust advised Dr M he could take his complaint to us at this point.

10. Following this response, Dr M then did not bring his complaint to us until 4 March 2024. This was a year and four months after having received the response from the Trust.

11. We can see that during this time, Dr M began to pursue his second complaint with the Practice. It is understandable Dr M raised his complaint with the Practice before bringing both complaints to us together.

12. However, where we do have concerns is regarding the time it took Dr M to refer both his complaints to us after receiving a response from the Practice. This was a delay of almost ten months. We asked Dr M the reasons for this delay.

13. Dr M told us at the time he was suffering from symptoms of chronic inflammation and pain. He told us this was following a virus he had in 2000. He explained he was being clinically investigated for this to eliminate cancer as the possible cause for his underlying condition.

14. We asked Dr M for the dates of when he was undergoing these investigations. Dr M confirmed this was between 2000 and 2004. As such, we do not consider it is reasonable for us to put our time limit aside for this reason as this predates Dr M’s complaint.

15. We understand Dr M was still possibly suffering from inflammation and pain around the time he was dealing with the complaint. We were sorry to hear of how this affects Dr M.

16. Whilst we understand this might have caused a short delay in Dr M referring his complaint to us, we do not see this accounts for the entirety of the 10-month delay. This was a considerable delay which is the main reason Dr M’s complaint is outside our time limit.

17. We have also considered that there was a short delay in the Trust providing Dr M with a response initially. We do not feel this accounts for most of the delay either.

18. Because we have not seen a reasonable explanation for the delay, we have decided not to put our time limit to one side. We appreciate this will be disappointing and we are sorry we cannot help Dr M with his complaint further.

1. We were sorry to hear of the death of Dr M’s mother, Mrs M, and of the impact this has had on him. We offer our sincere condolences to Dr M.

2. We have carefully considered Dr M’s complaint about the Practice and the Trust. 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.

3. We appreciate this will be a disappointing decision as we know how much this complaint means to Dr M. We have explained our reasons for this decision below.