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Central and North West London NHS Foundation Trust

P-003801 · Statement · Decision date: 12 August 2025 · View Central and North West London NHS Foundation Trust scorecard
Transfer, discharge and aftercare Risk assessment Care and discharge planning Clinical negligence harms learning
Complaint (AI summary)
Mr W complained the Trust unsafely discharged his mother and failed to manage her choking risk, or respond appropriately during a choking episode, contributing to her death.
Outcome (AI summary)
The complaint was closed. The ombudsman decided not to investigate further due to ongoing legal action and an inquest into Mrs P's death.

Full decision details

The Complaint

3. Mr W complains about the care and treatment Central and North West London NHS Foundation Trust provided to his mother, Mrs P, between April and July 2024. Specifically, he complaints the Trust: • discharged his mother when it was unsafe to do so on 18 April 2024 • did not manage his mother’s choking risk or respond appropriately when his mother had a choking episode on 19 July 2024.

4. Shortly after discharge, Mrs P had to be taken back to hospital by the police and sectioned. Mr W explains she was a risk to herself and others. Regarding the incident on 19 July 2024, Mrs P has sadly since died. Mr W says his mother’s death was avoidable. This caused extreme distress for him and his family.

5. Mr W would like the Trust to make service improvements and provide a financial remedy.

Findings

8. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mr W to understand his circumstances and the outcomes he is seeking. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

9. We understand Mr W is currently in the process of taking legal action. As set out above, the law sets out somebody should take legal action in the first instance before coming to us.

10. We recognise Mr W is seeking a mix of outcomes, and how important these are to him. As part of this, Mr W is seeking a financial remedy. Legal action may be best placed to look to achieve a more significant financial remedy. We acknowledge he is also seeking service improvements, which may be a byproduct of legal action.

11. As Mr W has told us he would like to pursue legal action, we think this is reasonable at this time. Mr W has also explained to us inquest proceedings are currently ongoing. This would also be a reason for us not to consider the complaint at this time. We hope this process helps Mr W in seeking more information about his mother’s death and achieving the outcomes he is seeking.

12. Mr W knows at the end of the above processes, if his circumstances change or it does not achieve all outcomes he is seeking, he may be able to return for us for our consideration.

13. We hope we have clearly explained the reasons for our decision, to not consider Mr W’s complaint further at this time. We thank him for taking the time to contact us.

Our Decision

1. We have carefully considered Mr W’s complaint about the Trust. We were extremely sorry to learn about the reasons for Mr W’s complaint and would like to extend our sincerest condolences to him. We have decided not to consider the complaint further at this time, as Mr W is pursing legal action. There is also an inquest ongoing.

2. We understand how important Mr W’s complaint is to him and thank him for taking the time to contact us.

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P-002871 · 31 Jul 2024
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