Royal Free London NHS Foundation Trust

The Practice 3. Mr K complains the Practice did not identify his mother needed to be admitted to hospital when his family raised concerns from 3 to 5 October 2022.

4. Mr K feels the Practice dismissed his concerns and says his mother’s admission to hospital later that week reflects this. He is concerned his mother deteriorated and died following her admission.

5. Mr K would like the Practice to acknowledge its failings, apologise for the impact they had, and improve its service. He would also like us to consider making a financial recommendation.

The Trust 6. Mr K complains after his mother attended the Trust on 7 October 2022, it: • took too long for the surgical team to see her in the emergency department (ED) • gave his mother intravenous fluids eight hours later than a doctor had recommended • took too long to carry out an endoscopy procedure • took eight days to fit a feeding tube • did not tell the family about his mother’s fall on 10 October until 13 October • placed a COVID-positive patient in his mother’s room on 17 October • did not provide consistent information during the complaints process.

7. Mr K is concerned poor care from the Trust may have contributed to his mother’s death. He feels poor communication meant his family did not have timely updates about her care. He says his family have not yet found closure around their bereavement.

8. Mr K would like the Trust to acknowledge its failings, apologise for the impact they had, and improve its service. He would also like us to consider making a financial recommendation.

9. We have included this brief background to provide some broad context for our decision. We have not reflected all the detail Mr K provided to us.

10. Mrs K’s family was in contact with her GP Practice in early October 2022. She was admitted to the Trust a few days later. Mrs K sadly died on 20 October. Mr K complained to the Practice on 21 November and received its response on 7 December.

11. Mr K then complained to the Trust on 9 January 2023 and received its response on 27 March. He replied on 13 April and requested a meeting. While the meeting arrangements were being made, an inquest into Mrs K’s death took place in September. Mr K contacted us a few weeks before he met with the Trust on 4 December.

12. The Trust wrote to Mr K after the meeting, its letter is dated 19 December 2023. He then brought his complaint about the Trust to us in June 2024. He brought his complaint about the Practice to us in July 2024.

15. 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 Practice and the Trust took to respond to him.

16. As Mr K only had concerns about the Trust’s complaint handling in late 2023, this was within our time limit. Mr K was aware of the concerns he raised regarding clinical care at the time of the events, in October 2022. When he brought these complaints about the Practice and the Trust to us in July 2024, they were more than eight months outside of our time limit.

17. We looked at whether we could justify exercising our discretion around the time limit in order to consider the clinical complaints further. To do this, we considered if Mr K had provided compelling reasons for the delay in bringing his complaint to us.

The Practice

18. Mr K complained to the Practice promptly after his mother’s death and it responded soon after, in December 2022, signposting to us. Mr K had not contacted the Trust and he could have approached us then, or soon after the Practice’s response.

19. Instead, he did not contact us until 11 months later when he made a telephone call to us in November 2023. At that point, we told him about our time limit. We would have expected Mr K to bring his complaint to us in writing following this, by completing a complaint form. However, this did not happen. Mr K next contacted us eight months later.

20. We understand Mr K had an advocate who was helping him through the complaints process. He told us the time it took engaging with the advocacy service contributed to the complaint being out of time. Mr K looks to have approached the organisations relatively quickly so we cannot see the advocacy was a significant factor.

21. By the time Mr K came to us in July 2024, his complaint had fallen outside our time limit by eight months. The time it took for him to contact us following the Practice’s response, and his call to us, is the key reason for this.

22. There is no good reason for the delay in Mr K bringing the complaint about the Practice to us, so we cannot consider this part of the complaint further.

The Trust

23. Mr K complained to the Trust within 12 months, in line with the NHS Complaint Regulations. He told us the delay in relation to the complaint about the Trust had been due to the Trust in 2023, and was down to him in 2024.

24. The Trust’s first response was within the six month timeframe set out in the NHS Complaint Regulations. Mr K asked the Trust for a meeting around two weeks after receiving this response. The Trust has acknowledged it took a long time to arrange a meeting. We can see this period accounts for more than seven months.

25. In the meantime, an inquest into Mrs K’s death also took place. This did not have a bearing on Mr K’s ability to complain as he had already contacted the Trust about his concerns.

26. The meeting with the Trust took place in December 2023 and Mr K came to us more than six months later, in June 2024. We recognise parenthood and losing faith after the meeting meant he was not actively pursuing the complaint. We do not underestimate the challenges Mr K was experiencing at what was already an emotionally challenging time.

27. The time taken to arrange the local resolution meeting by the Trust and Mr K’s delay after the meeting contributed to the complaint being out of time by a similar amount. We can see Mr K would have been aware of us as the Practice had signposted him in December 2022. Additionally, when he approached us in November 2023, we told him about our time limit.

28. Mr K had been able to engage with the Trust and knew he needed to contact us at the earliest opportunity. We cannot see that his situation prevented him from taking action. We are therefore of the view it would have been reasonable for Mr K to bring his complaint about the Trust to us much sooner than he did. This means we cannot investigate the complaint.

29. For the reasons set out above, we cannot justify putting the time limit aside to consider the complaint further. While Mr K’s concerns about the Trust’s complaint handling do not fall outside our time limit, we have seen no indication this affected him so significantly that we would look at this issue in isolation.

30. We appreciate this is not the outcome Mr K wanted and we would like to offer our condolences for his loss. We hope we have clearly explained why we have decided not to investigate this complaint.

1. We have carefully considered Mr K’s complaint about the Practice and the Trust. We were sorry to hear his concerns about the care his mother, Mrs K, received in the last weeks of her life.

2. We recognise Mr K’s bereavement has had a lasting impact on his family. Unfortunately, we are unable to look into his concerns. The majority of 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. We have explained our reasoning in this decision statement.