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Norfolk and Norwich University Hospitals NHS Foundation Trust

P-003082 · Statement · Decision date: 31 October 2024 · View Norfolk and Norwich University Hospitals scorecard
Complaint (AI summary)
Norfolk Trust delayed treatment, gave incorrect antibiotics, and discharged his partner too soon. Queen Elizabeth Trust provided poor nursing care, delayed investigations/treatment, and had poor communication.
Outcome (AI summary)
The complaint was closed. The complaints fall outside the ombudsman's time limit, and no good reason was found to set this aside for further consideration.

Full decision details

The Complaint

The Norfolk Trust

4. Mr K complains about aspects of the care and treatment his late partner, Mrs J received in November 2022 by the Norfolk Trust.

5. Specifically, he complains:

• there was a delay in treating Mrs J and the medical team provided incorrect antibiotics for the infection she had • Mrs J was discharged too soon when she was not medically fit and no follow up was put in place.

6. Mr K says because of these issues, Mrs J’s health deteriorated, she had to be readmitted to another hospital and she died.

The Queen Elizabeth Trust

7. Mr K complains about aspects of the care and treatment his late partner, Mrs J received in December 2022 by the Queen Elizabeth Trust.

8. Specifically, he complains:

• Mrs J received poor nursing care which affected her dignity • there was a delay in investigating Mrs J’s symptoms and processing blood samples • there was a delay in providing treatment for the infection Mrs J had • about a delay in moving Mrs J to critical care unit • there was poor communication about Mrs J’s prognosis towards the end of her life, and the medical team switched off her life support machine without telling anybody, which added to his distress.

9. Mr K says because of the clinical care Mrs J received, this led to her health deteriorating, and she died.

10. As an outcome to his complaints, Mr K wants an apology and to see service improvements so that no one else goes through the same thing.

Background

11. On 20 November 2022, Mrs J was admitted to the Norfolk Trust with pain in her side and a background of urinary tract infections. The medical team said she had a kidney infection, and she was prescribed antibiotics to treat this.

12. The Norfolk Trust discharged Mrs J on 23 November as it said she had clinically improved.

13. On 24 November, Mrs J deteriorated, and Mr K took her to the Queen Elizabeth Trust where she was eventually transferred to the critical care unit for treatment. Sadly, Mrs J died on 2 December.

14. Mr K told us he raised his complaints with the NHS Trusts in January 2023. The Norfolk Trust responded in April 2023, he had a complaints meeting with the Queen Elizabeth Trust in May 2023 and it provided a final response to him the same month. The recording of the complaints meeting failed, so Mr K was not able to receive a copy of this.

15. Mr K first approached us in January 2024. At that time, we asked him for more information about his complaints, he did not respond to us until April 2024. Mr K told us he was not sure if he received our first response in January.

Findings

18. 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 K to understand the reasons why he could not do so. We have also considered the time the organisations have taken to respond to Mr K.

19. Mr K told us he became aware of his cause to complain when Mrs J sadly died in December 2022. By law, he would have needed to bring his complaint to us by December 2023.

20. Mr K told us it took time for the Trusts to respond to his complaints. NHS regulations say organisations should complete an investigation and send the complainant a response within six months. Mr K raised his complaints in January 2023. The Norfolk Trust provided its response to Mr K three months after he raised it, and the Queen Elizabeth Trust responded to Mr K within four months. We have not seen anything to make us think the complaint has gone outside our time limit because of the time the Trusts took to provide the responses.

21. We can see Mr K raised his complaints promptly and received a final response by May 2023. He then waited eight months before approaching us in January 2024. We discussed this further with Mr K to understand the reasons for the delay.

22. Mr K told us it was a difficult time for him following Mrs J’s death, there were two NHS Trusts involved in his complaint and he had to pursue it on his own. He explained he also requested Mrs J’s medical records after he received the final complaint response, as he wanted to view these before deciding if he should send the complaints to us. He said there was a delay in the medical records being sent to him and he approached us when he felt able to.

23. We are sorry to hear of the distress and challenges that Mr K had around this time. As Mr K was able to pursue his complaints shortly after the events occurred, we do not see any barriers which meant he could not also raise his complaints with us sooner, and he could have sought help and support from an advocacy organisation to do this.

24. We also recognise the recording of the complaints meeting failed, but the Queen Elizabeth Trust wrote to him after this with its final response, and this was an opportunity for Mr K to approach us.

25. The Norfolk Trust explained our role to him in its complaint response, and we think he could have taken action shortly after receiving the final complaint response in May 2023, to contact us.

26. We also appreciate Mr K wanted to view Mrs J’s medical records. Mr K knew of his cause to complain when Mrs J died and when he raised his complaints. Viewing medical records first, is not a requirement of bringing a complaint to us and is not a valid reason for the eight-month delay in Mr K approaching us.

27. We have carefully considered Mr K’s reasons for not complaining to us sooner. Ultimately it was Mr K’s decision to request Mrs J’s medical records before approaching us, which he was entitled to do. We have seen nothing which might have prevented him from being able to send his complaints to us at the same time. There are no strong reasons for us to be able to set aside our time limit.

28. It is clear it has been a difficult period for Mr K, and we understand how much these complaints mean to him. Overall, we do not think Mr K’s reasons justify the extent of the delay in bringing his complaints to us.

29. For this reason, we will not be considering his complaints further. It is important we consider and act within the law and we regret any further upset this decision may cause. We thank Mr K for bringing his complaints to us and we hope this statement clearly explains the reasons why we will not be considering them further.

Our Decision

1. We have carefully considered Mr K’s complaints about the Norfolk Trust and the Queen Elizabeth Trust. The complaints fall outside of our time limit, and we have decided there is no good reason for us to put our time limit aside to consider them further.

2. We acknowledge how important Mr K’s complaint is and recognise this has been a difficult time.

3. We understand our decision may be disappointing to Mr K and we are sorry to add any further distress. We explain the reasons for our decision below.

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