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Isle of Wight NHS Trust

P-003479 · Statement · Decision date: 28 April 2025 · View Isle of Wight NHS Trust scorecard
Complaint (AI summary)
Mrs F complained Trust A failed to inform her of her husband's sepsis and transferred him without her consent. She also stated Trust B provided inappropriate care and delayed informing her of his death.
Outcome (AI summary)
The ombudsman closed the complaint. Part of it was outside the time limit, and the communication aspect was not investigated further due to insufficient significant impact.

Full decision details

The Complaint

3. Mrs F complains Trust A told her Mr F had an infection but did not inform her Mr F had sepsis. Mrs F also says Trust A transferred her husband to another Trust in mainland England, Trust B, without letting her see him before he left. Mrs F questions the actions of Trust A and whether her husband was well enough to be transferred.

4. Mrs F complains Trust B failed to provide appropriate care and treatment for Mr F upon his admission. Mrs F also says the Trust failed to inform her about her husband’s death in a timely manner.

5. Mrs F told us if she had known her husband had sepsis, she would not have agreed for him to receive dialysis for his kidneys (this is a medical treatment used when someone's kidneys aren't working properly to help filter blood). Mrs F explains Mr F was on many drugs and being a diabetic, he did not need to be put through this.

6. As a result of both Trust’s actions Mrs F is left questioning whether more could have been done for Mr F and whether there was a missed opportunity to have more time with him. She told us of her great distress and upset at not being able to say goodbye to her husband and not being told of his death straight away.

7. To resolve her complaint, Mrs F is seeking service improvements to avoid this happening to others in the future.

Findings

Not being informed about Mr F having sepsis

10. Mrs F told us she is concerned Trust A did not tell her about Mr F’s sepsis diagnosis. She explains the Trust told her Mr F had an infection which it was treating with antibiotics.

11. Mrs F says if she had known his true diagnosis, she would have not agreed for him to have treatment for his kidneys. She explains that he went through this unnecessarily, given his condition. Mrs F told us she had seen what sepsis had done to people close to her.

12. Mrs F explains she only became aware of Mr F’s sepsis diagnosis when she found out about this in a report written after Mr F’s death, in June 2023. She said this caused her to question why she was not told this at the time it was identified.

13. It is our policy to only focus on the more serious complaints people bring to us, where they may have faced a big impact. For example, these may be about a potentially avoidable death or where someone has suffered pain over a significant period.

14. This means we are not looking into complaints where we can see there has been a lesser impact. Based on the impact Mrs F told us about this applies to this part of the complaint and we have decided not to consider it further.

Time limit decision

15. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We call this the date of knowledge. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We discussed this with Mrs F to understand the reasons why she did not bring her complaint to us sooner. We also considered the time each Trust took to respond to Mrs F’s complaint.

16. We considered the date Mrs F became aware of her reasons to complain about the care and treatment Trust A and Trust B provided to her husband. We believe Mrs F would have known about her concerns regarding both organisations close to Mr F’s death in September 2022. We accept this as Mrs F’s date of knowledge for her remaining concerns.

17. For her complaint to be in time, Mrs F would have needed to approach our Office by September 2023. As Mrs F’s complaint was not ready for us until April 2024, 7 months outside the time limit, we considered the reasons for the delay.

18. Mrs F raised her complaint with Trust A in February 2023, which first responded in June 2023; this took 4 months. Mrs F raised further concerns with Trust A in October 2023 and it provided its final response in November 2023. In total, this took 5 months.

19. Mrs F raised her complaint with Trust B in March 2023, which first responded in June 2023; this took 4 months. Mrs F raised further concerns with Trust B in October 2023 and it provided its final response in April 2024. In total, Trust B took 6 months.

20. NHS Complaint Regulations 2009 say the organisation investigating a complaint should respond within six months. We do not consider the time taken by the organisations unreasonable, considering the Regulations.

21. There were two periods when Mrs F did not pursue the complaints quickly and this led to a delay. For Trust A this was 8 months, from September 2022 to February 2023 and June 2023 to September 2023. For Trust B this was 9 months, from September 2022 to March 2023 and June 2023 to September 2023.

22. When asked about the periods from September 2022 to February and March 2023 and why she delayed raising her complaint to the Trusts after becoming aware of the concerns about her husband’s care, Mrs F said this was a very difficult time and she had a lot to arrange with her husband’s funeral. Mrs F explained that she needed time to process everything. Mrs F also told us her children were going to help her make the complaints but were working until December. Mrs F also shared with us it was then her wedding anniversary.

23. We accept there is good cause for this period of delay given the circumstances and sad death of Mr F. We are sorry to learn about this difficult time and can understand the period around their wedding anniversary would have been very distressing. We recognise this must have been a very difficult time for her and her family.

24. Mrs F approached us in September 2023. Her complaint was not yet ready for us because she had yet to complete local complaints processes. Mrs F returned to us in April 2024 when she received a final response from Trust A. We obtained a copy of Trust B’s final response in May 2024.

25. We asked Mrs F why she did not return to the Trusts in June 2023 when she knew she was unhappy with its responses. The Trusts had both explained she could return with any outstanding issues. Mrs F says she did not know how to. Mrs F says as far as she knew she had only a year to complain. Mrs F told us it was the Trust complaints team who explained if she was unhappy, she could take it further.

26. In June 2023 we can see Trust A and Trust B both provided Mrs F with information about our Office and the steps she could take if she remained unhappy with their responses. This included an invitation to contact each Trust if she wanted to discuss the responses further, along with information about our Office and its role.

27. We understand Mrs F’s complaints were not ready for us at that time. If Mrs F had come to us, or returned to the Trusts in June 2023 as suggested, we could have explained our position and asked Mrs F to return to Trust A and Trust B sooner with her remaining concerns. This may have meant the complaint remained in time.

28. We have carefully thought about the reasons Mrs F has shared with us for this period and do not think these sufficient to set our time limit aside. We think it would have been reasonable for Mrs F to have come to us sooner, in June 2023 so we could clarify the steps she needed to take if she had outstanding concerns. We have not seen strong reasons to put the time limit to one side and therefore will not be taking any further action.

29. It is clear from what Mrs F told us she has been through a very difficult time. We were very sorry to hear about what happened and offer our deepest condolences for her loss.

Our Decision

1. We have carefully considered Mrs F’s complaint about Isle of Wight NHS Trust (Trust A) and Portsmouth Hospitals University NHS Trust (Trust B). It is clear from what Mrs F has shared with us these events continue to cause her great upset and distress. We know how difficult this time has been for her and how much she has been affected by the sad death of her beloved husband, Mr F. We extend our sincere condolences for her considerable loss.

2. After careful consideration, we have decided not to consider the complaint further. This is because part of Mrs F’s complaint falls outside of our time limit. We have decided not to consider the other part of the complaint about communication. This is because we only investigate issues that have caused the most significant impact. We will explain more about this in our decision below.

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