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A practice in the East Riding of Yorkshire area

P-003752 · Statement · Decision date: 31 July 2025
Complaint (AI summary)
Mr A complained about a seven-hour ambulance delay and a GP practice's failure to review medication, which he believed contributed to his wife's stroke and death.
Outcome (AI summary)
The ombudsman closed the complaint because it was submitted outside the one-year time limit and no valid reason was given to waive this.

Full decision details

The Complaint

4. Mr A complains about the Ambulance Trust and the seven hours wait his wife Mrs A experienced on 12 June 2022.

5. He says that the delay meant his wife stayed in an uncomfortable position on the floor for a prolonged period as he was unable to move her. This caused him significant distress. He says that he thought his wife was going to die while waiting. This panicked him and he was distraught.

6. He also complains that the Practice failed to complete a medication review in June 2022 and continued to prescribe Apixaban despite his wife suffering side effects.

7. He says the actions of the Practice contributed to the haemorrhagic stroke his wife suffered on 12 June 2022 and to her death 24 days later on 6 July 2022.

8. He tells us both organisations actions contributed to his wife’s death and her death was avoidable. It has had a massive impact on his physical and mental health, and he has struggled to understand what went wrong. He said he has been left traumatised by her death.

9. He wants an apology, service improvements and a financial remedy to put things right.

Findings

12. 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 explored this with Mrs O to understand the reasons why Mr A could not do so. We have also considered the time the Ambulance Trust and Practice has taken to respond to Mr A.

13. Mrs O says that she complained on behalf of Mr A to the Practice on 13 September 2022. She then complained to the Ambulance Trust on 16 September 2022. The Practice had a telephone call with Mr A on 14 September 2022 and then held a meeting on 15 September 2022, including Mrs O via a conference call. The Ambulance Trust sent its serious incident report on 28 February 2023.

14. Mrs O says that she asked the Practice for a written response after the conference call and chased the Practice for one around every two to three weeks after. She said that she contacted us in February 2024 asking to bring Mr A’s concerns.

15. We told her she needed a written response to the Practice complaint. Once she had one, this would allow her to raise her concerns with us. We also sent a copy of our complaint form. She says that she contacted the Practice about the final response, and it provided one on 12 April 2024, apologising for the delay in its response.

16. Our records show that Mr A signed the complaint form on 16 July 2024, and we received the form on 2 October 2024.

17. We discussed with Mrs O the impact Mr A’s concerns have had on him. She says that the Practice was treating Mr A for depression at the time he raised his concerns so it should have known the impact that this was having on his mental and physical health.

18. We discussed why Mr A did not bring his concerns to us when they received the serious incident report from the Ambulance Trust. She said that Mr A was not in the right headspace at the time. She says that he would not go out of the house and refused to talk about the complaint. She says he has a lot of underlying anger about Mrs A’s death and the actions of those involved. She said once they received the Practice’s written response, this took a great toll on Mr A’s mental health.

19. She says that they took some time to confirm that they wanted to bring the concerns to us and then spent some time completing the complaint form and gathering their evidence together. Mrs O also explained her own difficulties which prevented her in bringing the complaint to us sooner. She also said that she was not initially aware of our service.

20. We appreciate the impact that Mrs A’s death had on Mr A, the deep distress this caused and the significant effect this had on his mental health. We appreciate that it is difficult for a person going through a bereavement to raise their concerns, and the upheaval that comes with it. We also appreciate that this can, at times, delay a person raising their concerns.

21. From the information we have seen, Mr A raised his initial concerns with the Ambulance Trust and the Practice in a timely manner and well within the requirements of the law.

22. The Ambulance Trust provided its response in time. The Practice held its meetings in a timely manner and said that they thought that this was enough to finalise its complaints process. We can conclude that the Practice is responsible for some of the delay in this case.

23. We cannot disregard the fact that the Trust sent its serious incident report in February 2023, and Mr A remained aware of his concerns throughout 2023 and early 2024 when Mrs O contacted us to start our complaints process. Mr A was able to pursue his complaint in the months after receiving Mrs A’s death certificate (completed in July 2022). Had contact been made with us earlier than it was, Mr A would have been able to pursue his complaint with us sooner rather than later. Had he done so, his complaint may not have been made out of time.

24. We consider it would have been possible for Mr A to contact us sooner than February 2024 and possible that he could have submitted the complaint form to this office sooner than October 2024. This is why we have decided not to set aside the time limit. This means that we will not consider this complaint further.

25. We recognise this is not the decision Mr A was hoping for and are sorry for any upset this causes. We hope we have clearly explained our reasons for it.

Our Decision

1. We have carefully considered Mr A’s complaint about the Ambulance Trust and the Practice. We were sorry to hear of his concerns about his wife, Mrs A’s, experience before she died. After considering the relevant information, we have decided that the complaint falls outside of our time limit.

2. We recognise that Mr A tried to resolve his concerns with the Ambulance Trust and the Practice and encountered some delays that were outside of his control. We appreciate that Mr A was bereft and the delay he experienced added to what was already a difficult time. We also recognise the significant impact Mr A still experiences after his wife’s sad death and the concerns he has about both organisations involved.

3. We consider that Mr A could have brought his concerns to us sooner than he did. Had he done so, the complaint may not have fallen outside of our time limit.

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