Portsmouth Hospitals University NHS Trust

3. Mrs B complained about aspects of the care and treatment provided to her son, Mr C, at the Trust between 25 October and 5 November 2021.

Specifically, she complains the Trust: • missed opportunities to admit Mr C to hospital on 25 and 30 October, and 2 November • failed to actively prevent a pulmonary embolism (a blood clot in the lungs) • gave Mr C an injection on 5 November, following which he collapsed and died.

4. Mrs B says as a result of the claimed failings, her son died suddenly from a pulmonary embolism. She remains concerned that something in the injection given on 5 November caused her son’s sudden death. She says the Trust has been unable to confirm since what was in the injection, and she thinks he may have had an allergic reaction to the injection that led to his death.

5. Mrs B says the impact of Mr C’s death on her, her family and Mr C’s son has been terrible and has affected their grief and mental health. She says she has suffered from PTSD (post-traumatic stress disorder) and broken heart syndrome (a stress related condition that causes symptoms similar to a heart attack) and needed medical treatment several times since Mr C’s death.

6. Mrs B seeks service improvements and a financial payment of at least £10,000.

7. Mr C had chronic DVTs (deep vein thrombosis – blood clots in the deep veins of the legs) for which he was prescribed long-term blood thinners. He attended the Trust’s emergency department on 25 October due to leg pain and a rash on his leg. He was treated for cellulitis and investigated for possible pulmonary embolism (a blood clot in the lungs, which can be caused by a DVT). Mr C voluntarily left the department before his treatment finished.

8. On 30 October Mr C again attended the emergency department. The Trust recorded he had no signs of pulmonary embolism, prescribed blood thinners and discharged Mr C home.

9. Mr C attended an appointment with the Trust’s haematology team on 2 November. A scan confirmed he had a DVT and Mr C was advised he needed to take blood thinners for life.

10. On 5 November Mr C attended the emergency department again with continuing symptoms of leg pain. He was given an injection while waiting in the emergency department. The Trust says this was an injection of co-amoxiclav, an antibiotic containing amoxicillin, a type of penicillin. Mrs B says once given the injection, Mr C said he could not breathe and felt he was on fire. Mr C collapsed and died in front of her.

11. Mrs B complained to the Trust on 15 November 2021. She says Mr C was allergic to penicillin and thought he might have had an allergic reaction to the injection. The Trust says there was no record Mr C was allergic to penicillin. Mrs C says the Trust had no record of what was in the injection in her son’s healthcare records.

12. The Trust provided its final response to Mrs B’s complaint on 6 June 2022. At that point, it signposted Mrs B to the Ombudsman if she remained unhappy with its response to her complaint.

13. Mrs B says the post-mortem examination did not find a cause for her son’s death. An inquest held on 20 October 2022 found the cause of Mr C’s death was a pulmonary embolism.

14. Mrs B contacted the Ombudsman on 9 April 2024 and asked us to consider her complaint.

17. The law says a person with a complaint about the NHS in England needs to make their complaint to us within a year of the events or becoming aware of the issues raised. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

18. We have discussed this with Mrs B to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Mrs B.

19. Mrs B says after the Trust’s final response to her complaint, she had a long painful wait for the post-mortem results and the inquest. An inquest was held on 20 October 2022. At the inquest, the cause of death was decided as a pulmonary embolism. Mrs B also told us that following the inquest, she approached a number of solicitors, asking them to take on her case for legal action against the Trust.

20. Mrs B says she was unable to approach us until April 2024, as she was suffering from PTSD and broken heart syndrome, a rare condition that affects the heart after extreme emotional or physical stress. She says she needed medical treatment for this on several occasions.

21. We are sorry to hear Mrs B was so severely affected by witnessing her son’s death and by her bereavement, and she has understandably been through an extremely distressing experience. Nevertheless, Mrs B was able to explore her legal options in relation to her complaint during the time she says she was suffering from broken heart syndrome.

22. We can see Mrs B spent a significant time following the inquest proactively raising her concerns about what happened to her son through the legal system in the years following his death. Mrs B would have been able to contact us during this time to ask us to consider her complaint. We are not persuaded that she could not have approached us sooner due to the effects of the traumatic events she witnessed, as she was able to speak to solicitors about her concerns over an extended period of time after completing the local complaints process. For this reason, we have decided not to put our time limit to one side.

23. We recognise our decision may be disappointing to Mrs B. We thank Mrs B for bringing her concerns to us.

1. We have carefully considered Mrs B’s complaint about Portsmouth Hospitals University NHS Trust (the Trust). Mrs B’s 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. For this reason, we will not be taking further action on Mrs B’s complaint.

2. We recognise Mrs B will be disappointed with our decision. We have considered her reasons for bringing her complaint to us outside of the time limit, and explain the reasons why we are not putting the time limit aside below.