University Hospitals Sussex NHS Foundation Trust

3. Mrs N complains doctors at the Trust wrongly discharged her husband, Mr N, from accident and emergency (A&E) on 24 April 2022. She says this discharge was inappropriate due to her husband’s blood oxygen saturation at the time, his family history of heart problems and the discharge summary mistakenly stating he was admitted to hospital.

4. She also complains on 5 May the Trust’s specialist heart clinic diagnosed Mr N with angina and sent him away without telling him he needed urgent intervention. She also complains the heart clinic did not make the referral for an urgent X-ray to look at her husband’s blood vessels (an angiogram) promptly or mark it as urgent.

5. Mrs N says because of what happened her husband died later that month. She says her husband’s death has been devastating, and she and her children have lost their financial support.

6. As an outcome to her complaint she would like an answer to her concerns. She would also like service improvements to stop the same thing happening again and a financial remedy.

7. On 24 April Mr N visited A&E with a several week history of chest pain, an aching left arm and shortness of breath. Doctors were satisfied the problem was not critical so sent him home with a referral to the outpatient heart clinic. He visited the heart clinic 11 days later and doctors diagnosed him with stable angina. This is chest pain that usually happens during physical activity.

8. Mr N went on holiday abroad shortly after and sadly died whilst he was away. The postmortem found severe coronary heart disease was his underlying cause of death. Coronary heart disease is when a build-up of fatty substances in the arteries leading to the heart interrupts blood supply.

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 N to understand why she did not bring her complaint to us sooner.

11. Mrs N contacted the Trust by email on 6 July 2022 and explained she had received her husband’s postmortem verdict. Her email said it was wrong for A&E to discharge her husband due to his blood oxygen levels, and she was unhappy it had not done an angiogram.

12. She felt A&E should have given her husband a procedure to keep his arteries open (a stent) which she believes would have saved his life. In her email Mrs N also complained about the Trust’s heart clinic. She was unhappy it did not perform an angiogram, and only sent him home with a spray to relieve his symptoms.

13. She asked to meet with clinical staff at the Trust so they could give her answers about Mr N’s care.

14. Staff from the Trust met with Mrs N on 22 September and spoke to her over the phone on 6 October. Mrs N told the Trust she accepted the explanations staff gave and was happy it no longer needed to send a written response to her concerns.

15. Mrs N returned to the Trust in October 2023. She said she had spoken to a solicitor and got some more information due to her ‘gut feeling’ that something had gone wrong. Mrs N said she had her husband’s post-mortem report from abroad which found he had an enlarged heart and fluid build-up in his lungs caused by heart failure.

16. She said this was new information and wanted the Trust to investigate her concerns.

17. At this point the Trust decided to send Mrs N a final written response to her complaint. It took some time to prepare this and sent its response on 30 April 2024. The response explained staff cared for Mr N appropriately. It added if she remained unhappy then she could approach us. She did so in October, six months later.

18. Although the date of events is 24 April and 5 May 2022, it appears Mrs N first believed something went wrong when she got her husband’s post-mortem verdict in July.

19. For Mrs N’s complaint to have been in time, we would have needed to receive it by July 2023. By the time we received Mrs N’s complaint in October 2024 it was 15 months outside our time limit. We have spoken to Mrs N about this delay and examined the reasons for it.

20. Mrs N says it took a long time to approach us due to the time spent trying to resolve her complaint locally and waiting for the Trust to respond.

21. The Trust spent from 6 July to 20 November 2022 providing explanations that Mrs N was initially happy with. When she returned to the Trust on 3 October 2023 it took the Trust until 30 April 2024 to provide its final written response.

22. There is evidence Mrs N chased the Trust regularly whilst it investigated the issues she raised. However, the time it took for the Trust to provide answers was ultimately outside of her control. Raising the problem locally was an effective way to try and resolve her concerns, and necessary to approaching us with a properly made complaint.

23. We therefore consider the time spent in local resolution caused a reasonable delay and have set these periods aside.

24. However, that still leaves significant delays not explained by local resolution. This is split into two periods. Specifically: • between when Mrs N felt her concerns were resolved and when she returned to the Trust (October 2022 to 6 October 2023) • between the Trust’s final response and when she approached us (30 April and October 2024).

25. Mrs N said the time to get her husband’s post-mortem report delayed her escalating her complaint. We recognise Mr N died abroad, and there are barriers to getting post-mortem information in these circumstances.

26. Having considered the post-mortem report it does not reveal any new information that Mrs N was not aware of when she first contacted the Trust in July 2022. The issues she put to the Trust at the time are fundamentally the same as she has brought to us. Therefore, the principal reason Mrs N’s complaint falls outside our time limit is due to the period she spent not pursuing her complaint between October 2022 and 2023 as she considered it resolved.

27. We appreciate Mrs N reflected on what happened and decided to pursue matters further, but that is not a compelling reason for us to set the time limit aside. She was clearly unhappy in July 2022 and should have escalated the problem accordingly in October 2022 if she remained concerned. However, she did not do so and we can see no persuasive reason why.

28. Furthermore, there is no explanation for the six-month delay in approaching us after the Trust’s final response in April 2024. With this in mind, we cannot justify the time taken to approach us and cannot put aside the time limit set out in law.

29. Although this means we will not look Mrs N’s concerns further, we acknowledge how upsetting this issue has been for her. We understand the distress she has gone through and our decision does not take away from her experience.

1. We have carefully considered Mrs N’s complaint about University Hospitals Sussex NHS Foundation Trust (the Trust). We have decided the complaint falls outside of our time limit and there is no good reason for us to put it aside to consider the complaint further.

2. We recognise the heartbreaking circumstances of Mrs N’s complaint and understand the impact these events have had on her day to day life.