South Tyneside and Sunderland NHS Foundation Trust

3. Mrs A complains about the care provided to her sister, Ms B, by the Trust from 10 August to 14 November 2022. Specifically:

• Ms B had left knee surgery on 10 August 2022 even though she was not fully mobile having had right toe surgery on 25 March 2022 • Nurses did not report Ms B’s confusion and deterioration in physical health for at least three days between 28 and 31 October 2022, to medical staff • Nurses did not report Ms B’s lack of urine output and the fact that it was tea-coloured to medical staff from 31 October to 14 November 2022 • Medical staff did not act appropriately upon clinical signs of Ms B having renal failure from 31 October to 14 November 2022 • Ms B was not supervised closely enough when she was confused to prevent her from pulling out some of her lines from 31 October to 14 November 2022 • Ms B’s health passport was not filled in.

4. Mrs A says that Ms B suffered a great deal of trauma for many months with her physical and mental health because of having a non-emergency, elective procedure which the Trust has acknowledged was unnecessary. Mrs A says the complications that Ms B suffered due to the Trust’s negligence not only resulted in her terrible suffering but eventually led to her death. Mrs A says the impact of this on her and her family has been extremely traumatic. She has been unable to go about her everyday life and is still undergoing therapy for post-traumatic stress disorder.

5. As a set of outcomes, Mrs A wants an apology from the Trust for its failings and relevant staff to be retrained, service improvements to prevent other families suffering in this way, further explanation about her sister’s care, and a financial remedy.

6. Ms B was 58 years old with learning difficulties and mental incapacities. As a result, Mrs A says she had always lived with a family member, who cared for her. For eight years, until December 2019, Ms B lived with Mrs A and was happy in her surroundings. Mrs A says Ms B was then befriended by someone and moved away to live with them, against the wishes of her family. Mrs A says that Ms B was persuaded not to keep in touch with her family. Despite numerous attempts to contact her, this was to no avail.

7. Unfortunately, on 18 November 2022, Mrs A says she was informed by the Trust that Ms B had died a few days earlier. Mrs A says it became apparent after considering Ms B’s medical records that she had been admitted to hospital on 10 August 2022 for elective surgery to repair a tendon in her knee. Mrs A says Ms B’s pre-admission assessment was incomplete and she suffered similar complications to those suffered when she had previous toe surgery.

8. Mrs A says that Ms B’s condition deteriorated, and she developed respiratory and renal failure spending over three months in hospital. During this period, Mrs A says that Ms B’s condition gradually worsened physically and mentally to the point where she became confused and very drowsy. She sadly died on 14 November 2022 after a cardiac arrest. The cause of death on Ms B’s Death Certificate is sepsis, but Mrs A says she had no clinical signs of this and had not been treated for it.

10. 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 Mrs A to understand the reasons why she could not do so. We have also considered the time the Trust has taken to respond to Mrs A.

11. We appreciate that Mrs A was estranged from Ms B at the time of her death on 14 November 2022, but Ms A acknowledges that she was informed of her sister’s death a few days later on 18 November 2022. Therefore, Mrs A has acknowledged to us that she was aware of a problem on 18 November 2022 as she was informed that Ms B had died, and her death was unexpected. Even though Mrs A had not been in touch with Ms B for a few years, no doubt this tragic news would have been a great shock for Mrs A and the rest of her family. Understandably, there would have been a period of mourning after Ms B died with her family trying to process what had happened.

12. Mrs A wanted some further information from the Trust about the circumstances around Ms B’s death, but she was only given basic information. The Trust said it could not release further detailed information such as Ms B’s medical records as Mrs A did not have authority from the next of kin or other authority such as Letters of Administration.

13. Mrs A was advised by the Trust to make a complaint which she did on 12 March 2024. The Trust replied on 28 March 2024 reiterating its previous advice. As the registered next of kin was non-cooperative, Mrs A was advised by her solicitor to apply for Letters of Administration and once these were received, she would have the required authority to pursue her complaint with the Trust.

14. Unfortunately, Mrs A did not get Letters of Administration until September 2023. We recognise this must have been frustrating for Mrs A as the Trust would not deal with her complaint or any request for further information without such authority. Up until this point, we consider the delays in Mrs A submitting a complaint since Ms B’s death in November 2022 can be accounted for by Mrs A’s bereavement and the Trust’s stance regarding the required authority which took Mrs A several months to obtain.

15. Nevertheless, we consider that by September 2023, Mrs A now had the required authority to pursue her complaint with the Trust, but she did not do this promptly. Instead, Mrs A chose to firstly request copies of Ms B’s medical records so she could establish what had happened to her sister when she was in hospital. This information was not received until November 2023 and consisted of some 17000 pages. Mrs A also said she was awaiting the findings of a mortality review by the Trust which was not available until January 2024. This delayed Mrs A in resubmitting her complaint to the Trust until 19 January 2024.

16. We understand why Mrs A did this as she wanted to find out more about what had happened to Ms B, but we do not consider it was a necessary step for her to take in the context of resubmitting her complaint to the Trust that had already been significantly delayed by a lack of required authority. This is demonstrated by the fact that Mrs A had already submitted her original complaint to the Trust in March 2023 without sight of Ms B’s records or the mortality review.

17. The Trust replied to Mrs A’s resubmitted complaint of 19 January 2024 promptly with a detailed response dated 12 March 2024. Mrs A told us she was unhappy with elements of the Trust’s response. In many similar situations, complainants would go back to the Trust for further clarification of any outstanding points or approach the Ombudsman for advice. There is no evidence Mrs A took either of these steps. Instead, Mrs A decided to request advice from her solicitor about the Trust’s response.

18. Over the next six months, Mrs A says she had to deal with multiple legal staff as her solicitor kept changing. This delayed the advice she was seeking. When she eventually got her advice, Mrs A says the solicitor told her they were only interested in a potential clinical negligence claim rather than providing advice about the Trust’s complaint response which is what she wanted.

19. It is unfortunate that Mrs A had to deal with multiple staff at the firm of solicitors she was using and ultimately, they could not give her any advice about the complaint response received from the Trust as their main business is legal matters rather than providing advice about NHS complaint responses. We appreciate there may have been genuine misunderstanding on Mrs A’s part as she thought the solicitors were going to advise her about the complaint response, but we do not consider it should have taken six months to clarify this.

20. We did not see Mrs A’s complaint until September 2024 which was six months after the Trust’s only substantive response to her complaint. If Mrs A was unhappy with the complaint response received in March 2024, we consider she should have gone back to the Trust for further clarification or come to the Ombudsman more promptly.

21. From our consideration of the timeline of events in this case, we consider there were two unnecessary delays caused by Mrs A’s actions that are not fully accounted for by the explanations she has provided. The first delay is four months between September 2023 and January 2024 when Mrs A could have resubmitted her complaint to the Trust sooner than she did. The second delay is six months between March 2024 and September 2024 when Mrs A could have brought her complaint to the Ombudsman sooner than she did. These two unnecessary delays have left Mrs A’s complaint approximately ten months out of time.

22. In our view, If Mrs A had resubmitted her complaint to the Trust in September 2023 when she obtained Letters of Administration (which she could have done), and the Trust had come back to her promptly (which it did do when she eventually resubmitted), her complaint to the Ombudsman may have been received in-time or at least much sooner than it was. If this had happened, we may have had stronger grounds to waive the time limit in this case. Given the explanation and analysis provided in this statement, we consider that Mrs A’s complaint is out of time for our further consideration.

1. We have carefully considered Mrs A’s complaint about the care provided to her sister, Ms B, by the Trust.

-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.

2. We acknowledge the sad and difficult circumstances around Mrs A’s complaint about the care provided to Ms B by the Trust, and we recognise that Mrs A will be disappointed by our decision that her complaint is out of time.