United Lincolnshire Teaching Hospitals NHS Trust

The Trust 3. Mrs M complains about the following aspects of care the Trust provided to her mother from August 2022 onwards. She says it: • took too long to do tests on her mother’s liver • did not take action after identifying a growth on her mother’s liver • did not carry out a head scan during any of her mother’s admissions until March 2023 • did not inform her mother she had brain cancer until after she had read this in her discharge letter.

4. Mrs M says the Trust’s actions meant her mother’s cancer spread and she lost the opportunity to have treatment. She considers her mother’s death in November 2023 avoidable.

5. Mrs M would like the Trust to acknowledge its failings, apologise, and take action to prevent others having a similar experience. She would also like us to consider making a financial recommendation.

Marie Curie 6. Mrs M says Marie Curie staff did not insert a cannula correctly at the end of her mother’s life on 27 November 2023 and did not flush the line to check the insertion. She is concerned her mother’s end of life medication was not administered as it should have been.

7. Mrs M says these issues caused her mother to suffer significantly in the last hours of her life as she did not have pain relief until her final minutes. She says her mother did not die with dignity and she cannot forget this. This has led to flashbacks and nightmares, and has prevented her working.

8. Mrs M would like Marie Curie to acknowledge its failings, apologise, and take action to prevent others having a similar experience. She would also like us to consider making a financial recommendation.

9. Mrs R had been diagnosed with cancer following investigations at the Trust in 2023. She was at home and at the end of her life in late November. In the evening of 27 November, Mrs M asked for a home visit to help manage her mother’s symptoms.

10. Marie Curie’s response indicated Mrs R received medication between 3.47am (when the team arrived) on 28 November and 4.24am (when the team left the house). It said 5.42am was therefore too soon to administer medication and noted the Community Nursing Team attended at 8.50am. Mrs R sadly died that day.

The Trust

13. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. The date they became aware is their ‘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 have discussed this with Mrs M to understand the reasons why she could not do so. We have also considered the time the Trust has taken to respond to Mrs M.

14. Mrs M feels the Trust was a significant factor in the complaint being out of time. We can see she came us promptly after its response, having waited three months for it. Given the six month timeframe in the NHS Complaint Regulations, the Trust responded in an acceptable period.

15. Arguably, Mrs M did not complain to the Trust within the 12 month period set out in the NHS Complaint Regulations. She accepts her date of knowledge was, at the latest, March 2023 for each aspect of her complaint. She said she needed to focus on her mother as she was told she had six months to live in April 2023. We recognise how challenging this time was for her.

16. Following Mrs R’s death in November 2023, Mrs M complained to the Trust in July 2024. While she had received her mother’s records at the start of 2024, she did not need those to know she had concerns.

17. Mrs M had received Marie Curie’s response signposting to us in February. We signposted her to the Trust after she contacted us in May and June 2024.

18. Given Mrs M had been able to complain to Marie Curie (in January 2024), we consider it reasonable to say she could also have complained to the Trust by then. Had she done so, the complaint would not have been so far outside of our time limit and potentially could have been in time.

19. For the reasons set out above, we cannot justify putting the time limit aside to consider the complaint further.

Marie Curie

20. Mrs M accepts Marie Curie has identified things went wrong and taken action as a result of her complaint. She wanted Marie Curie to make a financial payment in recognition of the impact her experience had on her. We gave Marie Curie the opportunity to consider this and it decided a payment would not be appropriate. We therefore considered if we could justify investigating the complaint.

21. Our Severity of Injustice scale contains six different levels of injustice that a complaint could fall into, which increase in severity (from 1 to 6).  This complaint appears to fall within Level 2 of our scale. This covers cases involving relatively minor failings which did not cause significant pain or suffering to the deceased, but they have exacerbated bereavement.

22. Mrs M says her mother experienced hours of avoidable pain at the end of her life, until the final minutes when her end of life medication was administered. We do not underestimate how troubling it was for her family while they were waiting for support.

23. From what we have seen, it appears Mrs R may have been without pain relief for up to approximately two hours. This fits within Level 2 of our scale. We hope it is clear this description is not intended to diminish Mrs R or Mrs M’s experience. Based on the available information, the failings were relatively minor and there was no lasting, significant pain.

24. We need to use our resources to investigate the most serious cases, alongside cases that will have the biggest impact on improving public services for everyone. We are reassured by the acknowledgement and reflection on learning in Marie Curie’s complaint response. With that in mind, it would not be proportionate for us to investigate this complaint further.

25. We appreciate this is not the outcome Mrs M wanted and we would like to offer our condolences for her loss. We hope we have clearly explained why we have decided not to investigate this complaint.

1. We have carefully considered Mrs M’s complaint about the care the Trust and Marie Curie provided to her mother, Mrs R. We were very sorry to hear her concerns about the Trust’s actions in the last year of her mother’s life and Marie Curie’s care in her final hours.

2. The complaint about the Trust 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. We have decided it would not be proportionate for us to investigate the complaint about Marie Curie. We have explained our reasoning in this decision statement.