Harrogate and District NHS Foundation Trust

4. Ms M complains about aspects of care and treatment the Trust provided to her father, Mr M in late 2018 and 2019. Ms M says the Trust:

• failed to investigate and treat Mr M’s conditions, including sepsis • failed to investigate and treat Mr M’s chest and renal symptoms • delayed in providing Mr M with medication he needed • failed to obtain specialist input which would have allowed it to diagnose and treat Mr M appropriately • failed to properly communicate Mr M’s diagnosis • did not make the right decisions to care for Mr M, including those related to draining his lung • deliberately took no action to investigate Mr M’s symptoms • prevented her from carrying out power of attorney duties relating to Mr M’s medical needs • failed in its duty of care towards Mr M • did not follow hospital protocols for his conditions, including those related to palliative care.

5. Ms M says because of the Trust’s failures her father died from sepsis. She says this was entirely preventable and avoidable. She has told us of the catastrophic impact these events and losing her father has had on her.

6. Ms M also complains the Trust deliberately misused its complaint process to protect its staff and failed to be objective when Ms M raised concerns about her father’s care. Ms M says the Trust failed to uphold her concerns despite having evidence of the neglectful care its staff provided to Mr M. She also says the Trust has refused to address her complaint.

7. Ms M says because of its failure the Trust has condoned her father’s avoidable death. She also says it is putting other patients at risk by not addressing its failings and has undermined patient and family trust in the organisation. Ms M also says because of this; she is not assured by any further responses the Trust may provide to the Ombudsman. She has told us about the ongoing physical and emotional strain this process has had on her.

8. To resolve her complaints, Ms M is seeking an apology and assurance from the Trust it will address its poor practise.

11. 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 Ms M 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 Ms M’s complaint.

Concerns about Mr M’s clinical care and treatment

12. Ms M complains about events that took place in late 2018 and 2019, when her father was an inpatient at the Trust. We understand in March 2019, Mr M sadly died. We understand some of Ms M’s concerns predate Mr M’s death, however in the interests of proportionality, we accept March 2019 as Ms M’s latest date of knowledge for her concerns about the care and treatment the Trust provided to Mr M.

13. For this part of Ms M’s complaint to be in time, Ms M needed to bring it to the Ombudsman within 12 months of her date of knowledge, meaning by March 2020. As Ms M did not approach the Ombudsman until July 2024, over 4 years outside the time limit, we considered the reasons for the delay.

14. Ms M raised her complaint with the Trust in July 2019, which first responded in December 2019. From December 2019 to May 2021, we can see Ms M and the Trust continued to correspond about her concerns. A year later, in May 2022 Ms M returned to the Trust with additional issues, the Trust issued its final response to Ms M in July 2022.

15. NHS Complaint Regulations 2009 say the organisation investigating a complaint should respond within six months. With this in mind, we would not disadvantage Ms M for the period the Trust took to investigate Ms M’s complaint. That said, there were two periods when Ms M did not pursue the complaint quickly and this led to a delay of 3 years, from May 2021 to May 2022 and July 2022 to July 2024.

16. Ms M received a response from the Trust in May 2021. In May 2022 Ms M wrote back to the Trust with further concerns. We asked Ms M about this period and why she delayed returning to the Trust for a year.

17. Ms M gave us several reasons for this period of delay. Ms M acknowledges the Trust response in May 2021 signposted her to the Ombudsman. However, Ms M says she understood our process and because she had outstanding issues, felt there was little point in approaching the Ombudsman to be referred back to the Trust.

18. Ms M told us the Trust had already made it clear it would not accept responsibility or apologise for its failings. Ms M said she had seen the way it misused its own data to deny any responsibility. She said she assumed it would follow the same approach with the Ombudsman. Ms M decided she needed independent evidence to support her case and told us in June 2021, she set about achieving this. Ms M provided us with a detailed timeline of events from June 2021 to May 2022, this included exploring legal advice and obtaining a private review of her father’s medical records. In October 2021, Ms M says she approached the Care Quality Commission (the CQC).

19. From November 2021 to April 2022 Ms M told us she was facing difficulties with her own health. She explained she was also in the process of buying a house, moving and had a business to run. Ms M explained she reluctantly had to take this time to reorganise herself.

20. As we have explained, in May 2022 Ms M returned to the Trust with further concerns. Her complaint was already outside our time limit at this point. In July 2022 the Trust sent her its final response. We asked Ms M why she did not approach the Ombudsman until July 2024.

21. Ms M explained she understood her complaint was outside of our time limit and because of this, in November 2022 she decided instead to approach the General Medical Council (GMC); to refer concerns she had about the doctors involved in Mr M’s care.

22. Ms M told us in February 2023 she discussed her concerns with an advocate. She told us by this time, her health had been significantly impacted and was causing her considerable concern. Ms M described this affected her wellbeing and daily life. She told us she considered approaching the Ombudsman then, but due to her health, decided she was not able to proceed.

23. In June 2023, Ms M said she asked the GMC to review its decision. Ms M told us this was completed by January 2024.

24. We are sorry to learn of the difficulties Ms M faced during this period. We have considered the information helpfully provided by Ms M and are of the view that the threshold for setting aside the time limit is not met.

25. Ms M gave us her reasons for why she did not come to us sooner. We appreciate there were some periods when Ms M may not have been well enough to progress her complaint and had other demands on her time. However, we do not think these represented exceptional reasons to allow us to set the delay aside.

26. By Ms M’s own account there were periods during this time she was able to pursue her complaint, seeking independent clinical views and engaging with other organisations. Ms M explains she was already aware of our time limit at this point. We understand Ms M chose to pursue complaints with the CQC and GMC, as well as seeking legal advice.

27. Given the information available to Ms M, we think she could have been more proactive. We think it was reasonable for Ms M to take steps to consider what options were open to her to pursue her concerns. It also would have been open to her to use the support of her advocate and return to the Trust sooner than May 2022; this would have meant Ms M could have approached the Ombudsman sooner. For these reasons, we have not found good cause to waive our time limit for this part of Ms M’s complaint.

Concerns about Trust’s complaints procedure

28. Ms M told us the date she became aware of her reasons to complain about the objectivity of the Trust’s complaint procedure was in July 2023. Ms M carried out a review of the Trust’s correspondence in preparation for sending her complaint to the Ombudsman. Ms M acknowledged this took time but said it revealed how the Trust had chosen not to follow its complaint procedure. Ms M said it was then her concerns about this part of her complaint became apparent.

29. As we have explained in paragraph 14, Ms M knew she was unhappy with the way the Trust had investigated her complaint in May 2021. She told us she was considering returning to the Trust and approaching the Ombudsman then. However, in June 2021 she decided to obtain external independent evidence to support her concerns because she did not believe the Trust’s process was objective.

30. Ms M told us she had seen the way the Trust misused its own data and was not assured by its complaints process. We think the complaint she brings to us now, has at its heart, the same issue she was aware of in May 2021. We can see Ms M had completed the Trust’s complaints process in July 2022. In the interest of fairness, we accept this latest date as Ms M’s date of knowledge. This means for her complaint to have been in time, she would have needed to approach the Ombudsman by July 2023. As Ms M did not do so until July 2024, we have considered the reasons for the delay.

31. We can see Ms M approached he Trust with this part of her complaint in January 2024. The Trust responded to Ms M a month later, in February 2024.

32. 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.

33. Ms M explained why she delayed raising this part of her complaint until January 2024. She told us the GMC process took a significant amount of time. Ms M said she requested a review of the GMC’s decision in June 2023 and because she was not sure how long this would take, by January 2024 decided to raise her remaining concerns with the Trust.

34. In July 2024, when Ms M brought this concern to us, this was already one year outside of our time limit.

35. We do not consider the reasons Ms M gave for her delay in raising her concerns are enough justification for us to set aside our time limit. There was a significant gap where we think it was reasonable Ms M knew about her complaint handling concerns and could have raised these issues, but did not do so.

36. For this reason, we have decided not to consider the complaint further.

37. We understand how much this matter means to Ms M and thank her for sharing the details of her complaint. It is important we consider and act within the law and we hope this statement clearly explains the reasons for our decision.

1. We were very sorry to learn of Ms M’s concerns about her father’s care. We recognise what happened continues to cause Ms M 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 Ms M’s complaint further as it falls outside of our time limit.

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