Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

4. Mrs A is complaining about Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust. She says that the Trust: • did not appropriately complete a falls risk assessment, leading to falls on 14 and 18 October 2021 • did not share full information about her fall on 18 October with the ambulance service, meaning the call was incorrectly categorised • did not care for her appropriately following a fall on 18 October, including not offering appropriate pain relief, and inappropriately attempting to move her into a wheelchair • During the complaints process, the Trust did not keep or request evidence which was related to the complaint, such as CCTV evidence.

5. Mrs A is also complaining about North Cumbria Integrated Care NHS Foundation Trust. She says that on 18 October 2021 she was left in a room with no support and was left without a catheter for around seven hours. She also says the Trust inappropriately transferred her in the middle of the night to another hospital.

6. Mrs A says she needed an operation to repair the broken hip in October 2021. She then required two further operations in September 2022, to replace the broken hip. She has told us she is unable to mobilize independently and has lost her independence.

7. Mrs A said she feels she has been really poorly treated and was made to feel unimportant. She says her mental health was negatively impacted by the experiences she had and this has caused trauma. She also says she is scared to go back into hospital and finds it difficult to do so and worries about how she will be treated.

8. Mrs A would like the Trusts to accept and explain their failings, issue an apology, and produce an action plan to avoid similar events happening again.

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 Mrs A to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to the complaint. We note that Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (the Trust) co-ordinated the complaint process on behalf of both organisations complained about.

12. Having thought about the issues of this complaint, we think Mrs A would have known about all of these issues by 29 November 2021. This is because the falls happened approximately six weeks before this date, and all of these complaint issues relate to these falls. We know some issues may not have been immediately obvious, however we think a period of six weeks would have allowed for enough time for Mrs A to consider the issues she was unhappy about. This means Mrs A should have brought the complaint to us by 29 November 2022 at the latest for it to be in time. The complaint was brought to us on 4 October 2023. Therefore, we need to think about the complaints process with the Trust and the reasons Mrs A has told us about as to why she could not bring it sooner.

13. We know a formal written complaint was sent by email to the Trust on 23 March 2022, so about six months after the latest date of knowledge. We know there were meetings to formally discuss the complaint on 21 April 2022 and 22 August 2023. We also know the Trust responded to the complaint in writing on 20 July 2022, 23 September 2022, 13 April 2023, 29 August 2023. In addition, we are also aware that each of these letters signpost to our service in order to bring the complaint to us if Mrs A is not happy with the response.

14. We asked Mrs A about this, and she explained that while the letters did signpost to us, she was verbally told by the Trust that she could not come to us until the Trust had been given every opportunity to resolve the complaint. We understand this, and do not necessarily disagree. It is true that often the organisation is best placed to answer the complaint and resolve it, and so giving opportunity for this is generally reasonable.

15. Having said this, we do need to think about this within the context of the specific circumstances. In this case, we see that no new issues were raised following the response on 13 April 2023, and so everything had been dealt with and responded to at that time.

16. We also asked Mrs A why she did not come to us at this point. She explained she was waiting for a new advocate to be assigned, and once this happened they advised going back to the Trust for another meeting. We do not have any issue with Mrs A following the advice of her advocate in this circumstance. We do know Mrs A had used the services of another advocate earlier in the complaints process, though we understand the advocate may need to change and this can take time.

17. We do see in this case, however, that Mrs A would have known about each of these issues within around six weeks of the falls which occurred. We also see these issues were not all raised or addressed at the time of the first formal complaint, and there are no clear reasons for this being the case. Having reviewed the complaint letters, there are no clear instances where a response from the Trust is what has prompted raising these issues at a later date. We think the issues which were not raised until later in the complaints process very likely could have been raised sooner. These likely could have been discussed in the meeting on 21 April 2022, and formally responded to in the letter of 20 July 2022.

18. We are also aware that the final response to the complaint was on 29 August 2023, and the complaint was brought to us on 4 October 2023. We contacted Mrs A to ask if there were any reasons she did not come to us sooner at any of the points she received responses from the Trust. As mentioned, she explained there had been a previous delay due to a new advocate being assigned, however this happened in June 2023. She also explained she did not come to us at the point of any of the previous responses as she did not feel her questions had been fully answered. In addition, she told us the reason she did come to us following the response in August 2023 was because she had not been happy with the attitudes of the people attending the local resolution meeting related to this. However, she did not explain any reasons for delays in coming to us between August and October when we asked about this, and we are not aware of any reasons for this from any of the other evidence we have. Therefore, we cannot see a clear reason here which would explain this final delay.

19. Overall, we are satisfied that Mrs A knew of the issues she was complaining about by 29 November 2022 and could have raised all of these issues at the time of her original complaint to the Trust in March 2022. Had this happened, it is likely answers to these would have been provided much quicker. It is likely Mrs A could have received responses to each of these issues when the Trust wrote to her on 20 July 2022. We cannot see any reason she did not raise all of these issues at once. As such, we cannot put aside our time limit, as we think the complaint could have been brought to us sooner had it been put to the Trust in full at the start of the local complaints process. We are also mindful that once Mrs A did decide to complain to us, there was a delay of roughly one month for which there is no clear reason.

20. We would like to say we are sorry to hear of the circumstances surrounding this complaint. We know Mrs A experienced significant pain as a result of her falls, and needed an operation to repair a broken hip. This has undoubtedly been a distressing time and we understand how her life would have been impacted by this. We therefore know our decision will likely be frustrating, and we are sorry for this.

1. We have carefully considered Mrs A’s complaint about Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and North Cumbria Integrated Care NHS Foundation Trust. The complaint falls outside of our time limit, and we have decided it is likely Mrs A could have complained to us sooner.

2. Having reviewed the information related to this complaint, we see Mrs A returned to the Trust several times with her complaint to introduce new issues. As she would have been aware of these issues earlier, we think she could have raised them sooner and thus complained to us sooner. In addition, there was also a delay in coming to us following her final response, and we can see no clear reason for this delay.

3. We do recognise the pain and distress Mrs A has clearly been through, and we know our decision is likely to be upsetting for this reason. We are sorry for any additional distress which might be caused by us not looking into this complaint, as we know how important it is to her. We will go on and explain our decision below.