A practice in the Essex area

4. Mr D complains he visited the Practice 14 times between January 2018 and October 2020 with the same symptoms and it did not diagnose him correctly.

5. Mr D says the Practice diagnosed him with acid reflux and the medication did not help. He says his GP said there was nothing more they could do for him. In October 2020, after begging for help, he was referred to a specialist who diagnosed gallstones.

6. Mr D said because of the delayed diagnosis and treatment, he was admitted to hospital for six weeks on 13 February 2021 with severe pancreatitis (inflammation of the pancreas), which had life-changing consequences. He explains a pancreatic cyst was pressing on his lungs and stomach and he had to be tube fed. He says he is at risk of type one diabetes, he lost two stone, and the events were upsetting and distressing.

7. Mr D wants the Practice to accept it failed to diagnose and treat him. He would like the Practice to recognise the impact this had on him and to make service improvements to stop this happening again.

9. 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. We spoke to Mr D to understand the reasons why he did not come to us sooner.

10. The events Mr D complains about took place between January 2018 and October 2020. Mr D was aware of a problem in October 2020 when he was diagnosed with gallstones and on 13 February 2021 when he was admitted to hospital for surgery.

11. Mr D sent his complaint to NHS England on 4 February 2022. NHS England sent its complaint response to him on 23 August. Mr D came to us on 23 December 2022.

12. Part of the delay was caused by Mr D not making his complaint to NHS England until 4 February 2022. We asked Mr D why he did not complain to NHS England sooner, after he was diagnosed in October 2020 and admitted to hospital on 13 February 2021.

13. Mr D said there were several reasons. He said he was relieved that after three years he finally had a correct diagnosis. He said October 2020 was the height of the pandemic and his problem was not important compared to what else was going on. He felt a complaint was not appropriate when every day thousands of people were dying of COVID-19.

14. Mr D also said nobody explained how serious his condition was and how he was at increased risk because of how long he had been suffering from gallstones. He says he chased up having an operation twice, before being admitted to hospital.

15. Mr D said he felt a complaint was necessary after he had been hospitalised on 13 February 2021. He explains it was only after speaking to a consultant that he understood how serious his condition was, and that it was because of the Practice’s poor care.

16. Mr D said there was a delay from 13 February 2021 to 4 February 2022 because he was hospitalised for six weeks and was fed by a feeding tube. He says before the pandemic he had spent 17 years going to the gym and made an effort to look after himself. When he left hospital at the end of March 2021 he could not walk properly and was not in a fit state physically or emotionally to tackle a complaint. Mr D also said complaining was not his priority - getting better and surviving what had happened was.

17. We also asked Mr D why he did not come to us sooner. He got a complaint response from NHS England on 23 August but did not come to us until 23 December 2022.

18. Mr D said he needed to consider his options and if he wanted to continue with his complaint. He explained for the sake of others in a similar position in the future, he felt he needed to complain so the same mistakes do not happen again.

19. We appreciate this has been a traumatic experience for Mr D and understand it had a life-changing impact on him. We also understand the pandemic was a stressful time.

20. We have considered our approach to the time limit during the pandemic. Between 26 March and 30 June 2020, we decided to stop accepting health complaints so we did not put extra pressure on the NHS during a time of national emergency. Our decision to do this was shared publicly on our website and on social media. We explained that once this period ends, we would consider this period of delay fairly when looking at our time limit.

21. We told complainants that if they brought cases to us within two months of our decision to restart our work, we would take this pause into account. We advised them to regularly check our website and social media for updates on when to submit their complaints to us. After 1 September 2020, we returned to considering cases as normal. We are not aware of anything that would have stopped Mr D from complaining to NHS England sooner.

22. We appreciate that Mr D was not discharged until March 2021. At this time, we think Mr D could have complained to NHS England instead of waiting until February 2022. If Mr D did not feel he was able to do this on his own, he could have got support from an advocacy service. The delay in complaining to NHS England had a knock-on effect on the delay in bringing his concerns us.

23. We are also think Mr D should have come to us after he got NHS England’s response on 23 August 2022, instead of waiting another four months.

24. For these reasons, we cannot put our time limit to one side. Our decision is not made without recognition of the stressful circumstances Mr D faced.

1. We have carefully considered Mr D’s complaint about a practice in the Essex area (the Practice).

2. We are sorry to hear about Mr D’s concerns and we understand this has been a traumatic time for him.

3. We have decided not to investigate the complaint further as the events Mr D complains about are outside of our 12-month time limit, and we have not seen good reasons to put the time limit to one side.