Mersey Care NHS Foundation Trust

UHLG

4. Mrs T complains about the following issues in respect of her father’s hospital admission under UHLG from December 2020 to March 2021:

• staff delayed her father’s discharge unnecessarily despite deeming him medically fit • in January, a nurse made a mistake with Mr O’s catheter meaning it did not empty • staff did not assist Mr O to shower during his stay • staff did not provide Mr O with mental stimulation such as newspapers and encouragement to complete puzzle books • staff failed to act on signs Mr O’s mental health was deteriorating • staff did not investigate Mr O’s one-sided weakness identified on 3 February • staff put Mr O back on dalteparin (a drug used to prevent blood clots) despite this previously having a negative effect on his mental health.

5. Mrs T says UHLG’s actions caused Mr O to suffer unnecessarily and affected his mental and physical health. She says he was in a vicious circle where poor care affected his mental health which in turn affected his recovery and physical health. Mrs T says the issues with Mr O’s catheter led to him catching urosepsis causing his physical health to worsen.

6. Mrs T is also concerned the stress Mr O experienced during this admission, and the failure to investigate his one-sided weakness, increased his risk of a stroke (which he died of on 17 March). Mrs T says she will always wonder if the stroke could have been avoided if UHLG had done things differently.

7. Mrs T says UHLG’s actions have caused her great distress. She now takes antidepressants and has had three courses of counselling. She cannot bring herself to go into her father’s old house. As an outcome to the complaint Mrs T would like service improvements and a financial remedy.

MCFT

8. Mrs T complains about the following in respect of her father’s admission to ward 35 in March 2021:

• staff failed to investigate Mr O’s high blood pressure • staff did not discuss the DNACPR with Mrs T even though they noted Mr O did not understand what they had discussed • staff failed to contact her when they found her father unresponsive

9. Mrs T says MCFT’s actions put Mr O at higher risk of a stroke. She wonders if his death on 17 March following a stroke could have been avoided if MCFT had investigated his high blood pressure. She also says MCFT’s actions caused unnecessary distress. She says the poor communication means she lost out on valuable time with her father.

10. Mrs T wants assurances things have changed at MCFT and a financial remedy.

UHLG

12. Our legislation 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 T to understand the reasons why she could not bring her complaint to us sooner. We have also considered the time UHLG took to respond to Mrs T’s complaint.

13. Mrs T raised her initial concerns with UHLG in February 2021. We can see that at this time, Mrs T only raised some of the concerns which she subsequently raised with us but not others. UHLG responded to Mrs T’s initial complaint in writing on 9 August, around five months later.

14. Mrs T then raised her complaint with us on 22 November. We advised Mrs T to go back to UHLG with the outstanding points she wanted addressing. Mrs T did this promptly and UHLG again responded on 19 April 2022. Mrs T then raised her complaint with us again the following the day.

15. At this stage, we identified that parts of Mrs T’s complaint were about another NHS organisation. We discussed this with Mrs T who agreed she would raise the complaint with the other organisation and then return to us with both complaints following this.

16. Unfortunately, it then took over a year for the other organisation to respond. Mrs T returned to us on 11 August 2024 having received the response from the other organisation.

17. We have looked at UHLG’s complaint file and the emails of complaint it received from Mrs T. We note that Mrs T has not raised any of the issues outlined in the complaint summary above at any stage with UHLG.

18. By the time Mrs T brought her complaint back to us in August 2024, most of these issues were significantly outside our time limit. The length of time varies dependent on when Mrs T told us she became aware each individual issue. However, each issue is between one a half to two and a half years outside of our time limit.

19. We asked Mrs T why she has not raised these issues with UHLG previously. Mrs T initially advised us she thought she had raised these issues. Following further discussion, Mrs T said she was not aware of some of the things that occurred at the time. She said she only became aware after getting her father’s medical records.

20. We can see Mrs T received her father’s medical records on 20 September 2021. Mrs T then returned to UHLG on 18 November with a follow up complaint. As such, we consider Mrs T could have raised the additional issues at this time.

21. Mrs T told us she can only put this down to stress that she did not do so and because she was traumatised by the events. She said there was so much to raise about her father’s care and that so much had gone wrong. Mrs T also said that some things may not have seemed important to her at the time but now she has had chance to reflect, the issues are important.

22. We understand this was a stressful time for Mrs T and that there were many concerns she had about Mr O’s care. We were sorry to hear of how difficult Mrs T found raising these.

23. We have carefully weighed up Mrs T’s reasons for not raising these part of the complaint with UHLB. Having done so, we are not persuaded we should put our time limit to one side for the above issues. We consider Mrs T could have raised these with UHLG in November 2021 when we directed her to do so.

24. We know these issues continue to cause upset to Mrs T. We are sorry we cannot look at them further due to our time limit and for any additional upset this causes Mrs T.

MCFT

25. Mrs T’s complaint about the care her father received on ward 35 was brought to us on 11 August 2024. By this time, this complaint was a year and 10 months outside our 12-month time limit. We have discussed this with Mrs T to understand the reasons why she could not raise this with us sooner. We have also considered the time MCFT took to respond to Mrs T’s complaint.

26. Mrs T tells us she first became aware of her concerns about MCFT when she got her father’s medical records which MCFT confirmed was 15 October 2021. However, Mrs T did not raise a complaint with MCFT until 9 March 2023. This was a delay of one year and five months.

27. We asked Mrs T the reasons why she did not raise her concerns about MCFT sooner. Mrs T told us that she did not realise the concerns about MCFT were about a separate organisation. This is because the issues she raises about MCFT occurred in Aintree Hospital which is part of UHLG. She said this caused a significant delay in her complaint reaching us.

28. Mrs T told us she only became aware the complaint regarding ward 35 fell under MCFT, after bringing the complaint to us in April 2022. At this point there was a delay in the case being allocated to a caseworker which did not occur until January 2023. We then informed Mrs T in March 2022 she would need to raise a complaint with MCFT separately.

29. We are not persuaded this is reason enough for us to put our time limit aside. In her complaints to UHLG, Mrs T did not raise any of the concerns which occurred on ward 35. As Mrs T at the time thought these complaints were regarding UHLG, then she could have raised these with UHLG. Had she done so, it is likely UHLG would have advised her it was not responsible for these issues and would have liaised with or directed her to MCFT.

30. We have considered that MCFT took a year and four months to respond to the complaint and this has contributed to the delay in the complaint being dealt with. However, even if MCFT had responded in a reasonable timeframe, Mrs T’s complaint would still fall outside our time limit due to the earlier delays.

31. In reaching this decision, we are in no way underestimating Mrs T’s concerns about MCFT and the impact these had on her.

1. We were incredibly sorry to hear of the loss of Mrs T’s father, Mr O, and of the concerns she has about his care and treatment. We can see these issues continue to have a profound impact on Mrs T.

2. We have carefully considered Mrs T’s complaints about UHLG and MCFT. We consider the issues regarding UHLG and MCFT outlined below fall outside our time limit. We have seen no good reason to put our time limit aside to consider these issues further.

3. We appreciate this will be a disappointing decision for Mrs T and we apologise for any further distress this causes her. We have set out our full reasons for this below.