King's College Hospital NHS Foundation Trust

SLAM Trust 4. Miss E complains about the following aspects of the care she received from this Trust in early 2016 and March 2022. She says: • the Trust restrained her and sedated her on the floor while she was pregnant • her belongings were stolen • another patient punched her in 2022.

5. Miss E says this caused emotional distress and physical pain to her. She would like acknowledgement, an apology, and a financial remedy.

L&G Trust 6. Miss E complains about the following aspects of the care she received from this Trust in March 2022. She says: • the buzzer did not work as it should have when she needed pain relief and wanted staff to assist her with getting out of bed • poor communication and record keeping meant her newborn baby did not receive milk • her newborn baby was forcefully removed from her to remove a drain against her wishes • the Trust separated her from her baby for more than six weeks • the Trust administered intramuscular (IM) injections unnecessarily • the Trust moved her to other wards without explanation • her belongings were damaged.

7. Miss E says this caused emotional distress to her. She would like acknowledgement, an apology, and a financial remedy.

King’s Trust 8. Miss E complains about aspects of the care she received from King's College Hospital NHS Foundation Trust in late 2015 and an incident in 2022. She says: • she attended hospital three times in 2015 but the Trust misdiagnosed her as having a mental health relapse when she had sepsis • a female member of staff punched her in 2022.

9. Miss E feels the misdiagnosis in 2015 led to her unborn child passing away. She says the incident in 2022 injured her. She would like acknowledgement, an apology, and a financial remedy.

10. We include this brief background to put the complaint into context. It is not intended to reflect all of the detail Miss E has provided about what were clearly challenging periods. It reflects information from Miss E and the complaint responses she received.

11. Miss E was pregnant with twins in 2015 but sadly one baby did not survive. She says she attended King’s Trust three times at the end of that year. She recalls being treated for sepsis then transferred to a Mother and Baby Unit (MBU). We understand in January 2016, Miss E was admitted to SLAM Trust under section 2 of the Mental Health Act.

12. In March 2022, Miss E gave birth at L&G Trust. On 27 March, L&G Trust placed Miss E under section 2 of the Mental Health Act. It had assessed her and concluded her care needs could better be served in a MBU than on a maternity inpatient ward. This led to Miss E being transferred to the MBU at SLAM Trust. We understand Miss E was at times taken from the MBU to A&E at King’s Trust.

13. Miss E first complained verbally to L&G Trust in September 2022 then made a formal complaint that November. She complained to SLAM Trust in December 2022 and complained to King’s Trust in March 2024. L&G Trust and SLAM Trust responded to the complaint. King’s Trust said the time limit for NHS complaints meant it could not investigate.

16. 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 Miss E to understand the reasons why she could not do so. We have also considered the time each organisation has taken to respond to Miss E.

17. Miss E first approached us in March 2024. She did not have a final response to all of her concerns yet so we did not consider her complaint to be ready for us until July 2024.

SLAM Trust

18. Miss E complained to the Trust in June 2016 about care she received that January.

She received the Trust’s response in late October 2016. The response told her to contact the Trust if she wanted advice on how to take matters forward through the complaints process.

19. We cannot see that Miss E did this. When she brought her complaint about 2016 to us, it was more than seven years outside of our time limit. We cannot see there was a good reason for waiting so many years following this. As a result, we cannot investigate this complaint.

20. Miss E’s next contact with the Trust appears to have been in December 2022. She was complaining about the care provided in March 2022 and received a response in February 2023. This timescale was in line with the NHS Complaint Regulations.

21. The Trust has no record of hearing from Miss E until her reply more than one year later, in March 2024. It then provided a further response in May. It sent other responses to Miss E’s correspondence, in June and after the complaint came to us.

22. The gap between Miss E receiving a response from the Trust in 2023 and replying is the key factor in the complaint being at least 14 months outside of our time limit. Had Miss E approached us after the 2023 response, or returned to the Trust sooner, the complaint would not have fallen so far outside of our time limit.

23. Based on the available information, we cannot say there is a good reason to put our time limit to one side and look at this complaint.

L&G Trust

24. Miss E disputes that was aware of the concerns she raised at the time of the events, in March 2022. Based on the points she has raised, we consider at the latest, she would have been aware there was an issue very soon after the events. When she brought this complaint to us in July 2024, it was at least 14 months outside of our time limit.

25. We understand Miss E formally complained to this Trust in November 2022. This was within the time limit for complaining to the NHS. She received what the Trust called a ‘verbal resolution’ in December, had contact with a midwife and got a formal response in May 2023. The response advised her to contact the complaints team in three months if she was happy.

26. Miss E says she contacted the Trust about the May 2023 response in June 2023 and waited a year for the final response. This is not consistent with what we have seen. The Trust told us Miss E made a further complaint via the Integrated Care Board (ICB) in March 2024. It responded to this in June and signposted her to us in July 2024.

27. The evidence indicates on both occasions, the Trust responded within the six month timeframe set out in the NHS Complaints Regulations. Had Miss E approached us after the 2023 response, or returned to the Trust sooner as it had advised, the complaint would not have fallen so far outside of our time limit.

King’s Trust

28. We would like to offer our condolences for Miss E’s loss in 2015. She would have been aware of concerns around this at the time. By the time she complained to us in 2024, her concerns about this period of care were more than eight years outside of our time limit.

29. We cannot see that she raised concerns to the Trust about an incident in 2022 when she made this complaint about care in 2015. When the Trust acknowledged Miss E’s complaint, it said her last recorded attendance was in December 2015 which suggests there may be no evidence from 2022.

30. The Trust’s decision not to investigate the complaint about care in 2015 reflects the NHS Complaints Regulations. While we appreciate Miss E may not have felt able to complain as soon as she had concerns, we cannot see there was a good reason for waiting so many years following this. As a result, we cannot investigate this complaint.

31. For the reasons set out above, we cannot justify putting the time limit aside to consider any of the complaints further. We appreciate this is not the outcome Miss E wanted. We hope we have clearly explained why we have decided not to investigate this complaint.

1. We have carefully considered Miss E’s complaint about three NHS Trusts: South London and Maudsley NHS Foundation Trust (SLAM Trust), Lewisham and Greenwich NHS Trust (L&G Trust), and King's College Hospital NHS Foundation Trust (King’s Trust).

2. We were very sorry to hear Miss E’s concerns about the care she has received. It is clear how important this complaint is to her and we do not underestimate how distressing she found her experiences. We do not wish to detract from this.

3. Unfortunately, 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.