West Hertfordshire Teaching Hospitals NHS Trust

3. Mrs F complains about aspects of the care and treatment provided to her husband, Mr F, at the Trust between 5 June and 19 July 2022. Specifically, Mrs F complains the Trust: • misdiagnosed her husband’s returning throat cancer as thrush, leading to a delay in diagnosis of and treatment for aggressive cancer • inappropriately discharged Mr F on 10 June without correct medication • failed to provide interventions such as PEG feeding as Mr F could not eat or drink • inappropriately discharged Mr F on 19 July while he was haemorrhaging blood • failed to provide appropriate personal care support to Mr F

4. Mrs F says the Trust treated her husband horrifically and she had to beg staff to help him. She says her husband was discharged from hospital stinking, dirty and dying, in pain and haemorrhaging blood. She says her husband should have been referred to a hospice instead of being discharged home. She says receiving palliative care from a hospice earlier would have made his final weeks less painful and distressing and allowed family to spend more quality time with him before he died. She says her family were all badly affected by what happened to her husband. She seeks justice for her husband who she says did not deserve to be treated how he was.

5. Mrs F seeks explanations for what happened and a financial remedy to support herself and her family with the distress they experienced over what happened to Mr F.

6. Mr F started having issues with swallowing in May 2022. He had previously been treated for throat cancer. On 5 June Mr F was admitted to the Trust, having been unable to eat or drink for a few weeks.

7. The Trust initially diagnosed Mr F with oral thrush. Mrs F says her husband felt his symptoms during this time were the same as when he had previously had throat cancer. Mr F remained in hospital until 10 June 2022, when he was discharged home.

8. Mr F had an MRI scan on 13 June. He was readmitted to the Trust on 20 June, and diagnosed with throat cancer. During the time at home between the two admissions, Mrs F says her husband was screaming in pain and could not swallow pain relief tablets.

9. Mr F was discharged home on 12 July. Mrs F says she begged the Trust not to discharge her husband as she thought he had an infection and was not well enough to return home. The next day Mr F was readmitted to the Trust after a seizure at home and was diagnosed with pneumonia.

10. Mr F was discharged home again on 19 July. Mrs F says her husband was haemorrhaging blood and severely unwell, and not fit to be at home. The following day an ambulance was called and the ambulance crew said he needed to be in a hospice. Mr F was admitted to a hospice on 22 July and sadly died on 24 July 2022.

11. Mrs F complained to the Trust on 15 February 2024. The Trust responded to Mrs F’s complaint on 28 June 2024. Mrs F then asked us to consider her complaint on 28 July 2024.

15. The law sets out that complaints about NHS services in England must be made within 12 months of the date of the event complained about, or the date the person became aware of the issues they complain about.

16. The law also 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.

17. Mrs F asked us to consider her complaint two years after the time of the events, and one year outside of our time limit. We have discussed this with Mrs F to understand the reasons why she could not come to us earlier. We have also considered the time the Trust took to respond to Mrs F.

18. Mrs F told us she became aware of her cause to complain when Mr F sadly died on 24 July 2022. By law, she would have needed to bring her complaint to us by 25 July 2023.

19. Mrs F complained to the Trust on 15 February 2024, 18 months after the time of the events complained about, and six months outside of the time limit for making a complaint about NHS services in England. The Trust responded to Mrs F’s complaint in June 2024, and Mrs F asked us to consider her complaint in July 2024.

20. We have not seen anything to make us think the complaint has gone outside our time limit because of the time the Trust took to provide the response.

21. We explored with Mrs F the reasons for the delay in making her initial complaint to the Trust. Mrs F says after her husband’s funeral she was unable to function, and she was told she had post-traumatic stress disorder (PTSD). She says she was unable to sleep and constantly relived events every day. Mrs F says when she started to recover from the shock of what had happened, she felt guilty for not fighting harder for her husband’s needs and this prompted her to make her complaint.

22. We are sorry to hear Mrs F was so severely affected by what happened to her husband during the last few weeks of his life. We acknowledge she has understandably been through an extremely distressing experience.

23. We have taken into account that bereavement does not have a set timeline, and people may react differently to grief. Mrs F did not raise her complaint to the Trust until 18 months after the events. We think there was an opportunity for Mrs F to have sought help and support from an advocacy organisation, which would have helped her to raise a complaint sooner.

24. It is clear it has been a difficult time for Mrs F. Even taking into account the impact of the grieving process on Mrs F, we do not think Mrs F’s reasons justify the extent of the delay in bringing her complaint to us. Unfortunately we are unable to set our time limit aside in this case and we will not be considering her complaint further.

25. It is important we consider and act within the law and we regret any further upset this decision may cause. We thank Mrs F for bringing her concerns to us.

1. We have carefully considered Mrs F’s complaint about West Hertfordshire Teaching Hospitals NHS Trust (the Trust). Mrs F’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 F’s complaint.

2. We recognise Mrs F 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.