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Northern Care Alliance NHS Group

P-003819 · Statement · Decision date: 26 September 2023 · View Northern Care Alliance NHS Group scorecard
Complaint (AI summary)
The Trust failed to manage her husband's nutrition/hydration, delayed medication, and missed sepsis signs, leading to his avoidable death.
Outcome (AI summary)
The complaint was not investigated further as it fell outside the 12-month time limit.

Full decision details

The Complaint

4. Mrs F complains about aspects of care and treatment Northern Care Alliance NHS Foundation Trust (the Trust) gave to her husband, Mr F, in February 2020. She says the Trust:

• did not properly manage Mr F’s nutrition and hydration • delayed giving him medication • missed the signs that he had sepsis and did not treat him quickly enough.

5. Mrs F says her husband lost his life because of the Trust’s actions. She says this was avoidable and has caused extreme distress and suffering for her and her family.

6. Mrs F would like the Trust to make service improvements and make a financial payment to her.

Findings

9. The law says a person needs to make their complaint to us within a year of becoming aware of a need to complain. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to.

10. Mrs F’s complaint is about events that happened in February 2020. Mrs F was aware she had a need to complain at this time and when her husband sadly died. For her complaint to have been in time, Mrs F would have needed to bring the complaint by February 2021.

11. Our records show Mrs F contacted us about her complaint in December 2022 and completed a complaint form in February 2023. This was two years outside of our time limit. We spoke with Mrs F to understand the reasons why she could not bring her complaint to us sooner. We have also considered the time the Trust took to respond to her complaint.

12. Mrs F says she first raised her concerns with the Trust verbally at the time (February 2020) and thought the Trust would contact her. Mrs F says she chased this up with the Trust in June 2020, late 2020, mid-2021 and January 2022.

13. We understand Mrs F says she struggled getting a response from the Trust. We are mindful of this and empathise with the situation she was in. When we look at the time involved, there are gaps of around six months between each time Mrs F followed up her complaint with the Trust. This went on for nearly two years in total, and she says she still heard nothing back. We think it would have been reasonable for Mrs F to have chased this sooner or to have come to us sooner after having difficulties with the Trust.

14. Mrs F also explained that in mid-2020 she had chronic depression and went to hospital for another condition. She says this contributed to delays with her complaint.

15. We are sorry to learn about Mrs F’s health problems at this time. It is understandable that these circumstances made it more difficult to progress her complaint. Because Mrs F was able to contact the Trust we do not think there was anything stopping her from coming to us for help, or from chasing the Trust without there being gaps in between.

16. We have carefully considered the difficult circumstances Mrs F experienced across this two-year period and we do not see good reason to put our time limit to one side.

17. We have also seen delays in the complaint coming to us after Mrs F got a final response from the Trust. The Trust responded in April 2022 and we got Mrs F’s complaint form over ten months later, in February 2023.

18. Mrs F says after she got the Trust’s response she wrote to us at the wrong address. We recognise this may have been the case but we did not hear anything more from Mrs F until six more months after this.

19. There was then a further two-month delay in sending us the complaint form to allow us to progress the complaint. We appreciate the circumstances and accept Mrs F’s explanation that her first correspondence went to the wrong address. These would not be exceptional reasons for us to justify putting the time limit to one side.

20. It is clear from the information provided how much distress the events caused Mrs F. When we have considered the time taken, while we note Mrs F was contacting the Trust at points, there are several periods of time where there are significant gaps that cannot be explained.

21. We are grateful to Mrs F for bringing her complaint to us and speaking with us about what happened. We must apply our time limit fairly. We do not underestimate how difficult this period was for Mrs F. Our decision is not meant to take away from these difficult events.

Our Decision

1. We have considered Mrs F’s complaint about the care her husband had before his death in February 2020. We extend our sincere condolences to Mrs F and her family and recognise the events continue to cause her distress.

2. After careful consideration, we have decided not to consider the complaint further because the complaint falls outside of our 12-month time limit. We explain the reasons for this below.

3. We know from the information Mrs F sent us how important this complaint is to her and how much this experience has had an impact. We are very sorry to hear about Mrs F’s distress and we appreciate the details she kindly shared with us.

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