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University Hospital Southampton NHS Foundation Trust

P-003077 · Statement · Decision date: 7 October 2024 · View University Hospital Southampton NHS Foundation Trust scorecard
Transfer, discharge and aftercare Care and discharge planning
Complaint (AI summary)
Inappropriate discharge of her husband with high troponin, without complete paperwork or risk awareness, leading to his death. She sought explanation, apology, improvements, and financial remedy.
Outcome (AI summary)
Closed. The complaint fell outside the Ombudsman's time limit, and no good reason was found to waive this requirement.

Full decision details

The Complaint

4. Mrs T complains about University Hospital Southampton NHS Foundation Trust (the Trust) and aspects of the care and treatment provided to her husband, Mr T, from 21 to 24 March 2020.

5. Specifically, she complains that:

• Mr T was inappropriately discharged from hospital when his troponin level was too high • The self-discharge paperwork was not completed, and he was discharged home alone despite the risks to his health • Mr T was not made aware of the risks and threat to his life before he was discharged.

6. Mrs T says that as a result Mr T died, and this has been devastating for her and their children.

7. Mrs T wants the Trust to explain what happened, an apology, to see service improvements when patients are discharged and a financial remedy.

Background

8. Following Mr T’s sad death, Mrs T complained to the Trust. There was correspondence between them both until the Trust provided its final response in February 2022.

9. Mrs T brought her complaint to us with the assistance of an advocate. We closed the case as we considered Mrs T could potentially take legal action to resolve her complaint. Mrs T contacted solicitors but was unsuccessful in finding legal representation.

10. Mrs T brought her complaint back to us in February 2024.

Findings

12. The law says a person needs to make their complaint about the NHS 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. Mrs T knew about her concerns by 21 July 2020 at the latest, which is when she complained to the Trust.

14. The date she brought the complaint back to us in February 2024 is the relevant date for our time limit consideration. This means the complaint was two years and seven months outside of our time limit.

15. We have discussed this with Mrs T and her advocate to understand the reasons why she could not bring the complaint to us sooner. We have also considered the time the organisation has taken to respond to the complaint and the time the complaint was with us previously.

16. We can see Mrs T first raised her complaint with the Trust in a timely manner after her husband died. She also went back to the Trust promptly after receiving its responses.

17. Looking at the time the Trust took to respond to the complaints, we can see it took three months to respond to the first complaint, two months to the second and almost eight months to respond to her final letter.

18. The NHS complaint regulations set out that organisations should aim to respond to complaints within six months. Based on this, we can see the first two responses were provided in a timely manner, but the last response was delayed by two months. The Trust acknowledged this delay in the final response.

19. Mrs T brought her complaint to us very quickly after receiving the Trust final response. The complaint was already beyond our time limit at this point. Unfortunately, due to queues which had built up during the COVID-19 pandemic, it was 10 months before we allocated it to a caseworker.

20. Once we closed our case in January 2023, deciding Mrs T could potentially take legal action to resolve her complaint, Mrs T contacted solicitors quickly. She received responses from them in March 2023, saying they would not pursue the case on her behalf.

21. Looking at the events up to this point, we can see any delays are accounted for and were outside of Mrs T’s control.

22. However, after Mrs T had responses from solicitors, it was then 11 months before she contacted us. This was via her advocate, explaining she was unable to pursue legal action and asking us to consider the complaint.

23. As explanation for the delay, Mrs T and her advocate have said Mrs T felt drained after our decision. They raised some concern about the conversation we previously had with Mrs T about financial remedy, legal action and the decision we reached. They said due to this Mrs T lost faith in the process and made her reluctant to return to us.

24. We are sorry Mrs T felt frustrated by our conversations and decision. In our letter in January 2023, we explained that if Mrs T had any feedback about our service or decision, then she should let us know within a month.

25. This means there was opportunity for Mrs T or her advocate to discuss those concerns with us at the time but they did not do so. In our decision statement, we also explained the importance of contacting us as soon as possible due to our time limit, if Mrs T wanted us to look at her complaint again.

26. We do not consider that concerns about our previous decision justify a delay of 11 months in returning to us after she had followed our recommendation to contact solicitors.

27. We have considered Mrs T personal circumstances. We are sorry to hear about her car accident requiring physiotherapy and her perimenopause symptoms which require hospital input. We appreciate those things were challenging for her, and that the accident had affected her mental health.

28. Mrs T told us about legal action which was ongoing in relation to a claim she had against a builder. She commenced this in August 2022 and during the 11 month period of delay we are considering, she went to a preliminary court hearing and continued to pursue the claim.

29. During the 11 month period, Mrs T was also supporting her children, two of whom have additional needs. We recognise they were still grieving for their father and trying to navigate life without him. We appreciate they needed Mrs T’s support.

30. We acknowledge Mrs T health issues, separate legal action and supporting her children meant she had a lot to contend with. We can see that these things, on top of a full-time job, would certainly justify some delay in her returning to us.

31. However, 11 months is a lengthy period. As set out in paragraph 25, we previously explained to Mrs T the need to return to us promptly. It is not a difficult or lengthy process to bring a complaint back to us after trying to take legal action. Mrs T was supported by an advocate and had been throughout. All that was required, which was what her advocate did, was to email the original caseworker to tell them they would like us to look at the complaint again.

32. We therefore think it would have been reasonable for Mrs T to do this much sooner than she did, even taking account of the challenges we can see she was facing. Having considered the explanations for the delay, we do not consider it justifies the extent of the delay.

33. Had this delay not happened, Mrs T would have brought the complaint back to us sooner. Although it would still have been beyond our time limit, it would not have been so far out of time. Based on the information available, we cannot justify exercising our discretion to put the time limit to one side. This means we will not consider the complaint further.

Our Decision

1. We have carefully considered Mrs T complaint about the care the Trust provided to her husband in the days before his sad death.

2. Having done so, we can see the complaint falls outside of our time limit. We have decided there is no good reason for us to put our time limit aside to consider it further. This means we will take no further action on the complaint.

3. We recognise our decision will be disappointing for Mrs T as we know how important this complaint is to her. We hope the following information clearly explains the reasons for our decision.

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