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The Hillingdon Hospitals NHS Foundation Trust

P-003817 · Statement · Decision date: 16 May 2023 · View The Hillingdon Hospitals NHS Foundation Trust scorecard
Complaint (AI summary)
Miss F complained her mother fell out of bed, possibly due to absent bed rails, which Miss F believes led to her mother's death. Trust responses were conflicting.
Outcome (AI summary)
Closed. Miss F's complaint was brought outside the Ombudsman's time limit, and no further action was taken.

Full decision details

The Complaint

4. Miss F complains her mother fell out of bed on 30 April 2020 while under the care of the Trust. She says the Trust’s complaint responses give conflicting information about whether the bed had rails in place or not.

5. Miss F believes the fall led to her mother’s death. She told us the information the Trust gave about the incident caused her distress because she has not had a clear account of what happened. She would like the Trust to apologise for what happened and change its policies, so no other family has a similar experience.

Findings

8. 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.

9. Miss F complains about what happened at the end of April 2020. This means that when she brought the complaint to us in February 2022, the complaint was ten months outside of our time limit.

10. We looked at the complaint file and the communication Miss F had with the Trust. We asked Miss F for some more information about this to understand the reasons why she could not bring her complaint to us sooner.

11. We can see Miss F made a complaint to the Trust on 1 May 2020, after her mother’s fall. On 20 May the Trust confirmed in an email to Miss F that because of the seriousness of the complaint, her concerns were being dealt with by a Serious Incident Report (SIR). The complaint team agreed this was the best way to deal with her concerns. The Trust also said that once the investigation was complete and the report had been shared, Miss F would have the opportunity to meet with a clinician to address any outstanding concerns.

12. After the approval of the investigation and action plan, the Trust shared a copy of the SIR with Miss F on 24 August 2020. The Trust then continued to answer the outstanding questions she raised until February 2021 (six months after sharing the SIR). It then offered a video meeting to discuss any other concerns she had. Miss F rejected the offer saying she would prefer to meet face-to-face. The meeting took place on 19 October 2021, and the Trust shared the meeting notes with her on 3 November.

13. Miss F made a complaint to the Trust about the content of the SIR on 7 February 2022, 18 months after getting the report. Although she had been in contact with the Trust to ask questions about the information, there is no evidence to suggest she was unhappy with the findings or that she wanted to raise any other complaints, until she contacted the complaints team.

14. This leaves a gap of about three months from when Miss F received the meeting notes to her making a complaint about the content of the report.

15. On 8 February, the complaints team told Miss F it was not able to log her concerns as a complaint because it had already completed an investigation. But if she stayed unhappy with this outcome, she could approach us. On 9 February, Miss F brought her complaint to us.

16. Miss F says she did not approach us sooner because she wanted to complete the Trust’s complaints process first. She says she was in the process of gathering more information, such as her mother’s medical records, and she could not meet with the Trust because of government visiting restrictions. She says that once she had the records, she needed time to review them. We understand how upsetting she found this process.

17. We have not seen good enough reason to put our time limit to one side. We consider there were missed opportunities to bring the complaint to us on 24 August 2020 and again on 3 November 2021. We think it would have been reasonable for her to have reviewed all the information and approached us sooner.

18. We looked at the SIR and the action plan the Trust shared with Miss F on 24 August 2020. This is a detailed report that addresses the concerns raised by Miss F about whether the bed rails were up or down and details what actions the Trust will take to prevent this happening again.

19. We also considered the time the Trust took to respond to the complaint. The Trust produced the SIR and action plan within four months.

20. The regulations say that organisations should complete an investigation and send the complaint response within six months. The Trust did this. We have not seen anything to make us think the complaint was delayed by the Trust’s complaint handling.

21. At the beginning of the process, we can see the Trust told Miss F she will have the opportunity to speak with the Trust after getting the SIR. Miss F did not initially request a meeting but asked additional questions about her mother’s care that the SIR did not cover. But these questions were not raised in the form of a complaint because Miss F did not say what she thought may have gone wrong with her mother’s care.

22. Although it did take a long time to arrange the meeting, we have not seen evidence to say this was due to any failings by the Trust. This was during the COVID-19 pandemic and the government had put visiting restrictions on hospitals. Had Miss F not wanted a face-to-face meeting, the meeting could have taken place in March to May 2021, meaning Miss F would have had the opportunity to approach us sooner, and within the time limit, if she remained unhappy.

23. For the reasons explained above, we have decided not to put our time limit to one side.

24. We are very sorry to hear about how upset Miss F has been and how she has been affected. We understand how much this complaint means to her and thank her for sharing the details. It is important we consider and act within the law and we regret any further upset this decision may cause. We hope this statement clearly explains the reasons why will not be considering the complaint further.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Miss F’s complaint about the care and treatment the Hillingdon Hospitals NHS Foundation Trust (the Trust) gave to her mother, Mrs F, in 2020. We are sorry to hear how much these events upset her.

2. We have decided not to consider the complaint further because Miss F brought her concerns to us outside of our time limit.

3. We thank Miss F for taking the time to tell us about her concerns. We recognise this decision will be disappointing and regret any distress this may cause. We explain our decision in this statement.

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