University Hospitals of North Midlands NHS Trust

3. Mr D complains about the care and treatment his wife, Mrs D, received from the Trust in relation to a Transcatheter Aortic Valve Replacement (TAVR) procedure she underwent on 18 October 2021.

4. Mr D complains the Trust did not advise his wife how risky the procedure was and did not properly assess her fitness prior to procedure. He is concerned the catheter was initially placed too high and she was not given the correct dosage of anaesthesia.

5. Mr D also complains the Trust provided him with incorrect information on the day as it told him his wife had died before the procedure had even begun which is not true. Additionally, he complains the Trust has not provided him with sufficient explanations for what happened.

6. Mr D says his wife would not have gone ahead with the procedure had she known how risky it was. He says the procedure would not have taken place had the Trust properly assessed her fitness as it would have found her heart was not strong enough for surgery. He also says the placement of the catheter put too much strain on her heart and the dosage of anaesthesia caused her to have seizures. Overall, he feels his wife’s death was avoidable.

7. Mr D explains his wife’s death and the circumstances surrounding it have caused him a great amount of grief and distress. He told us he cannot move on until he receives further answers from the Trust.

8. Mr D would like the Trust to provide him with further explanations, acknowledge any failings and apologise.

9. Mrs D was 72 years old and had aortic stenosis. This is a condition where the aortic valve in the heart is narrowed or blocked slowing blood flow from the heart to the body. The aortic valve is the valve between the lower left heart chamber (the left ventricle) and the body’s main artery (the aorta).

10. Mrs D went to hospital on 18 October 2021 to undergo a TAVR. This is where a thin flexible tube is used to place a new valve inside the damaged one. The tube is then expanded, pushing the old valve out of the way. The new valve works like a healthy one, restoring normal blood flow.

11. Mrs D very sadly died during the procedure. We understand the coroner recorded her cause of death as aortic stenosis. We cannot imagine how distressing Mrs D’s death must have been for Mr D and his family particularly as it was so sudden and unexpected.

12. Mr and Mrs D’s daughter contacted the Trust with the family’s concerns about the circumstances surrounding her death on 21 July 2022. The Trust provided a formal complaint response on 28 February 2023 and Mr D brought his complaint to us on 26 June 2024.

15. Section 9(4) of the Health Service Commissioner’s Act says a person needs to make their complaint to us within a year of them becoming aware of the problem they are complaining about. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

16. Mr D became aware of his concerns on 18 October 2021 and complained to us on 26 June 2024. This means he brought his complaint to us around 20 months outside our time limit.

17. We can see Mr D and his family raised a complaint with the Trust around nine months after Mrs D died. We appreciate her death was very sudden and would have come as a complete shock to the family. We therefore think it is understandable it took them some time to process what happened and raise their concerns with the Trust.

18. We can see the Trust then took around seven months to provide its response to their complaint. Looking at the Trust’s complaint file, Mr D and his family did not contact the Trust again after receiving this complaint response. Mr D then contacted us with his complaint around 16 months later.

19. We have spoken with Mr D to find out what happened during these 16 months to see if there is a good reason he did not come to us sooner. Mr D told us he approached 16 or 17 solicitors about what happened to his wife. He said none of these solicitors wanted to take his case on and one of them suggested he come to us. He said he did not know about our time limit and did not trust our organisation.

20. We can see the Trust’s complaint response advised Mr D to contact its complaints team if he wanted to discuss his complaint further or needed any clarification. It also included our details and explained how he could bring his complaint to us if he wished to take the matter further. It explained we have time limits for looking at complaints and he should come to us as soon as he receives the Trust’s final response.

21. Overall, we think Mr D could have come to us much sooner than he did. The Trust told him about our office in February 2023. He instead tried to pursue legal action for over a year before coming to us. We do not think it is unreasonable he looked into taking legal action against the Trust. We think the amount of time he spent doing this and the number of solicitors he approached was excessive.

22. The Trust warned him we have time limits for looking into complaints and advised him to come to us as soon as possible but he did not do this. We appreciate he had concerns and doubts about coming to us particularly as he questions the Trust’s response and our independence. However, we do not think this is a good enough reason for the long delay.

23. This means we have not seen a good reason to set our time limit to one side and we will not be considering Mr D’s complaint any further. We hope we have clearly explained the reasons for our decision. We know Mr D is disappointed with our decision. We are very sorry we cannot help him with his complaint. We would like to again pass on our sincere condolences for the incredibly sad loss of his wife.

1. We have carefully considered Mr D’s complaint about University Hospitals of North Midlands NHS Trust (the Trust).

2. The complaint falls outside of our time limit, and we have not seen a good reason for the delay in coming to us. We will therefore not be taking any further action. We are very sorry to hear about Mr D’s concerns and would like to pass on our sincere condolences for his sad loss.