4. Mrs E complains about the care the Trust provided to her late son Mr E. She says on 11 April 2022, her son attended A&E reporting chest pains but a doctor sent him home without any diagnosis.
5. Mrs E says her son died later that day due to the failure to diagnose his condition. She says this has left a huge hole for his loved ones which can never be filled.
6. As an outcome to the complaint, she would like truthful answers, an acknowledgment of failings, and service improvements.
7. Mr E presented to A&E on 11 April with chest pains. After performing tests, the Trust discharged him. Later that day, Mr E went into cardiac arrest and was brought back to A&E, He sadly died a short time later.
8. Mrs E raised a complaint with the Trust about her son’s care on 10 July. The Trust decided to open a serious incident (SI) investigation to look at her son’s care and address her concerns. A SI investigation looks at serious incidents in healthcare where the potential for learning or the consequences for patients, their families or staff, are significant.
9. The Trust completed the SI investigation on 2 February 2023. Following this, Mrs E met with the Trust to discuss the findings. The Trust also provided her with a written complaint response on 14 June.
10. Mrs E sent a further complaint to the Trust on 14 September. The Trust responded on 11 October and referred Mrs E to the Ombudsman. Mrs E referred her complaint to us on 11 March 2024.
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.
13. Mrs E complains about care the Trust provided to Mr E on 11 April 2022. We consider she was aware she was unhappy with the care the Trust provided in the weeks following these events. To meet our time limit, Mrs E needed to bring her complaint to us by April 2023. She brought the complaint to us in March 2024, 11 months beyond this.
14. We discussed this with Mrs E to understand the reasons why she could bring her complaint to us sooner. We also considered the time the Trust has taken to respond to Mrs E.
15. Mrs E raised her complaint with the Trust in a timely way on 10 July 2022. Following this, we can see the Trust closed her complaint and opened a SI investigation instead. It took just under seven months for the Trust to complete this investigation (from the date Mrs E had submitted her complaint).
16. The NHS England Serious Incident Framework guidance advises that timeframes for completion of investigations can vary and are proportionate to the individual incident. However, it outlines that SI investigations can take anywhere from 60 days up to six months. The Trust was one month outside this timeframe.
17. Following the completion of the SI investigation, it appears Mrs E remained unhappy with the findings and so the Trust reopened her complaint. She received a complaint response on 14 June 2023.
18. Again, Mrs E was unhappy with this response and so sent further concerns to the Trust on 14 September. We asked Mrs E why it took her three months to send her follow up concerns. Mrs E told us she would not have left the complaint for three months. She was unable to provide us with an explanation for this delay. We have spoken to the Trust who confirmed Mrs E did not contact it during this time.
19. The Trust responded to Mrs E’s complaint on 11 October 2023 and referred her to us. It then took Mrs E five months to refer the complaint to us. We again explored the reasons for this delay with Mrs E.
20. In a phone call with us, Mrs E initially told us that this was because her husband had sepsis in October. However, we have since confirmed with Mrs E that her husband had sepsis carin October 2022 and not October 2023.
21. Mrs E submitted a complaint to us about a different NHS organisation in December 2023. We asked Mrs E why she did not raise her complaint about the Trust with us at the same time. Mrs E told us she thought she had submitted both complaints to us together. She explained there was perhaps a mistake on her part or a mistake on our part.
22. We have reviewed the complaint Mrs E submitted to us in December 2023. It was clear from her complaint form that Mrs E was only raising a complaint about the other organisation and not the Trust. As such, we are not persuaded there was a mistake at this time.
23. We know from what Mrs E has told us she has had a very difficult time, and we are very sorry to hear of what she has been through.
24. We have seen no reasonable explanation for the five-month delay in referring the complaint to us or for the three-month delay between 14 June and 14 September 2023. Had these delays not occurred, Mrs E’s complaint would have been significantly less outside our time limit.
25. We acknowledge the Trust’s complaint handling has also contributed to the delay as in total this took one year and three months to conclude. However, there were two complaint responses during this time, a SI investigation as well as a meeting. Taking this into account, we do not think the complaint process was significantly lengthy.
26. We do not underestimate the effect Mr E’s death has had on Mrs E and the rest of his family. It is important we act in line with the law and our policy when considering complaints. We regret any further upset our decision may cause. We thank Mrs E for bringing this matter to us.
1. We were sorry to hear of the death of Mrs E’s son, Mr E. We can see that the events she has complained to us about continue to have a profound impact on Mrs E.
2. We have carefully considered Mrs E’s complaint about 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 for Mrs E as we know how important her complaint is to her. We have explained our full reasons for this below.