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Medway NHS Foundation Trust

P-003522 · Statement · Decision date: 29 April 2025 · View Medway NHS Foundation Trust scorecard
Complaint (AI summary)
Miss A complained about her father's inappropriate discharge, delayed/incorrect equipment, inadequate meals, uncommunicated sepsis, unaddressed worsening condition, and poor staff communication.
Outcome (AI summary)
The ombudsman closed the complaint as it fell outside of their time limit for investigation.

Full decision details

The Complaint

4. Miss A complains about aspects of care and treatment Medway NHS Foundation Trust provided to her father, Mr A in May and June 2022. Miss A specifically says the Trust:

• inappropriately discharged Mr A in June 2022 when he was not fit to be discharged • delayed providing necessary equipment Mr A needed at home • did not deliver correct equipment to Mr A’s home • failed to provide alternatives for Mr A during mealtime • did not inform Mr A or his family he had sepsis and anaemia • did not treat her father appropriately when his condition worsened • did not provide adequate bedside care • failed to review Mr A’s medical records including those relating to his heart condition • denied Mr A medication he needed, including dietary and pain medication • had poor communication and staff were rude to Mr A and his family

5. Miss A also says Mr A did not feel safe to raise concerns about his care whilst an inpatient.

6. Miss A says her father died one day after being discharged from the Trust because it did not provide appropriate care and treatment. Miss A has also described the distress the Trust actions have caused her and her family.

7. To resolve her complaint, Miss A would like the Trust to be held to account for its failings.

Findings

10. The Health Service Commissioners Act 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 Miss A to understand the reasons why she did not bring her complaint to us sooner. We also considered the time the Trust took to respond to Miss A’s complaint.

11. Miss A complains about events that took place in May and June 2022, when her father was an inpatient at the Trust. When we spoke with Miss A, she told us she became aware of her concerns about the care and treatment he was receiving from the Trust in July 2022. Miss A says this was when she became involved in her father’s care and her concerns about it came to light. We accept this as Miss A’s date of knowledge for her concerns.

12. For her complaint to be in time, Miss A needed to bring it to us within 12 months of her date of knowledge, meaning by July 2023. As Miss A’s complaint was not ready for us until July 2024, 1 year outside the time limit, we considered the reasons for the delay.

13. Miss A raised her complaint with the Trust on 1 March 2023, which first responded on 11 August 2023; this took 5 months. Miss A raised further concerns with the Trust on 30 May 2024 and it provided its final response on 2 July 2024. In total, this took approximately 6 months.

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

15. We have identified a period when Miss A did not pursue the complaint quickly and this led to a delay. This was over 8 months, from August 2023 to May 2024.

16. Miss A received a response from the Trust in August 2023. In late February 2024, Miss A approached our Office. A few days later in early March 2024, we contacted Miss A to explain her complaint was not yet ready for us and explained the steps she needed to take to complete the Trust’s complaint process. We also discussed our time limit law and invited Miss A to return to us with this in mind, once she had completed the process and received a final response from the Trust. At this point, the complaint was already 7 months outside our time limit.

17. We can see Miss A did not return to the Trust until nearly two months later, in May with her further concerns. As we have explained, the Trust provided its final response in early July 2024. Miss A returned to our Office promptly after receiving this.

18. We asked Miss A about this period why she delayed approaching our Office and returning to the Trust with her remaining concerns.

19. Miss A explained she was not aware she could return to the Trust with her further concerns when she had received its response in August 2023. Miss A also told us she found it futile to return to the Trust with additional complaints, as she felt the response was merely justifying its actions. Miss A said it was not until she spoke to our Office in February 2024 that she understood this was the correct step she had to take.

20. Miss A told us she was not able to pursue her complaint quicker in this time due to her work commitments. Miss A explained she was busy at work from September and between December 2023 and January 2024 was moving in with her partner.

21. We have considered the information helpfully provided by Miss A and are of the view that the threshold for setting aside the time limit is not met. Miss A gave us her reasons for why she didn’t come to us sooner. We appreciate there were some periods after September 2023 until January 2024 when Miss A may have had other demands on her time, however we do not think these represented exceptional reasons to allow us to set the delay aside.

22. In August 2023 the Trust provided Miss A with information about our Office and the steps she could take if she remained unhappy with their responses. This included an invitation to contact the Trust if she wanted to discuss the response further, along with information about our Office and its role. It also directed her to our website which contains all relevant information about when a complaint is ready for us, along with information about our time limit and details about advocacy services that can help support people with their complaints. We think it was reasonable for Miss A to have independently reviewed this information at that time and be aware of this.

23. It is important to note that we reminded Miss A of our time limit during our conversation with her in early March 2024. Miss A did not provide any reason for not approaching the Trust again until late May 2024. Her complaint was already outside our time limit in February 2024 when she initially contacted our office. Therefore, Miss A was aware of the need to address her concerns promptly.

24. Miss A’s complaint has come to us significantly out of time. We have identified periods where we think it would have been reasonable for Miss A to have come to us sooner, before February 2024 so we could clarify the steps she needed to take if she had outstanding concerns, along with returning to the Trust earlier to raise her additional concerns.

25. We are sorry for any disappointment caused by our decision. We are grateful to Miss A for bringing her complaint to us and for speaking with us so openly about what happened. We understand this period was difficult for Miss A and we know how important her complaint is. We must apply our time limit fairly. For the reasons explained, we do not see good reason to set aside our time limit. We hope this statement clearly explains the reasons why we will not be considering this complaint further.

Our Decision

1. We were very sorry to learn of Miss A’s concerns about her father’s care. We recognise what happened continues to cause Miss A considerable ongoing upset and distress, and we extend our condolences to her for her loss.

2. After careful consideration, we have decided not to consider Miss A’s complaint further as it falls outside of our time limit.

3. We sincerely thank Miss A for sharing her experience with us. We are very sorry for any disappointment caused by our decision, which we explain in more detail below.

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