Leeds Teaching Hospitals NHS Trust

Complaint about the Practice

4. Ms and Mrs G complain the Practice did not immediately refer Mr G to hospital as an emergency when he was seen on 13 and 14 July 2016.

5. They tell us Mr G had recently been diagnosed with aortic dissection (AD is a tear in the main artery from the heart) before those appointments and had he been referred to hospital, his sad death that month could have been avoided.

6. They tell us the family is devastated by the loss. Further distress and upset was caused by the knowledge that Mr G suffered a painful and avoidable death.

7. Ms and Mrs G want the Practice to acknowledge its mistakes, apologise for them and improve its service. They also want the Practice to pay them financial compensation.

Complaint about HDFT

8. Ms and Mrs G complain HDFT’s doctors did not accurately diagnose AD when Mr G first attended hospital in February 2016. This diagnosis was made around two months later in April 2016.

9. They complain the delayed diagnosis meant treatment was not provided sooner and this contributed to Mr G’s death in July 2016.

10. Ms and Mrs G want HDFT to acknowledge its mistakes, apologise for them and improve its service. They also want HDFT to pay them financial compensation.

Complaint about LTH

11. Ms and Mrs G complain that LTH’s doctors did not to treat Mr G’s AD and penetrating ulcer (PU) in June 2016 and instead decided to monitor it.

12. They say LTH’s doctors did not appropriately monitor Mr G’s AD and PU which put him at unnecessary risk. They say had doctors decided to treat Mr G at an earlier stage, and monitor his condition more closely, it may have saved his life.

13. Ms and Mrs G want LTH to acknowledge its mistakes, apologise for them and improve its service. They also want LTH to pay them financial compensation.

Complaint about YAS

14. Ms and Mrs G complain about YAS’s ambulance response on 15 July 2016. They complain: • the ambulance did not arrive within eight minutes, which is the target for immediate and life threatening emergencies • ambulance staff did not provide appropriate treatment and there was a 45-minute delay in providing an AutoPulse machine (a device used to do cardiopulmonary resuscitation or CPR) • paramedics did not recognise the ‘tearing and ripping pain’ in Mr G’s chest were symptoms of AD.

15. Ms and Mrs G want YAS to acknowledge its mistakes, apologise for them and improve its service. They also want YAS to pay them financial compensation.

16. Mr G sadly died in July 2016. After his death, Ms and Mrs G waited for the inquest (an investigation into a death) to finish before making their complaint with the four NHS organisations involved in his care. The complaints process finished in July 2021 and they approached us in July 2022.

18. The Health Service Commissioners Act 1993 (the law) says a person needs to make their complaint to us within a year of becoming aware of the problem they want to complain about.

19. After carefully considering Ms and Mrs G’s complaint, we have decided it falls outside of our 12-month time limit. We have not seen good reason for us to put the time limit to one side.

20. Ms and Mrs G complain about four separate NHS organisations and the treatment they provided to Mr G in 2016. They tell us the lack of appropriate treatment contributed to his sad death in July 2016. They first complained in July 2017 following the end of an inquest and the complaints process ended in July 2021.

21. We can see Ms and Mrs G were aware of the problems with Mr G’s care after his death in July 2016. This means by the time they approached us in early July 2022, their complaint fell outside of our time limit by around five years.

22. We have not reviewed the complaints process between July 2017 and July 2021 in detail as we can see there was a significant delay in Ms and Mrs G approaching us once the complaints process ended.

23. LTH provided its final response on 1 July 2021. This meant Ms and Mrs G now had final responses from all four organisations and their complaint was ready for us to consider.

24. We did not receive their complaint until just over 12 months later, on 9 July 2022. We asked Ms and Mrs G why it took over a year to submit their complaint to us.

25. They told us:

• they did not accept the responses they received from the NHS organisations. They felt it was important to provide their own comments on those responses to highlight to us the discrepancies or issues they felt should be of importance to us • they struggled to complete their comments as they lacked medical knowledge • reviewing the medical records and other evidence to support their submission to us caused further distress while they were still grieving • they worked full time and their business was affected by the COVID-19 pandemic • Ms G’s mother-in-law sadly died and she needed to support her husband while he was grieving. She also tells us she and her husband caught COVID-19.

26. We acknowledge Ms and Mrs G had a challenging time, but we do not consider it is reasonable for them to have taken 12 months to approach us once they received their final response.

27. There was no requirement for them to provide a review of the complaint responses and clinical records to highlight to us where they felt the failings in care happened. We understand they wanted to make their complaint as clear as possible, but this could have been achieved by completing our complaint form and discussing the complaint with us.

28. They could also have provided any additional supporting information after their complaint form and final responses had been submitted to us. Had they taken this approach, it would likely have significantly reduced the delay in us receiving their complaint.

29. We appreciate the impact of the COVID-19 pandemic upon their business will likely have caused stress and upset to Ms G, but we must balance this against the significant delay in us receiving their complaint.

30. The effects of COVID-19 will likely have been unpleasant, but Ms G has not told us those effects were so serious that they stopped her being able to submit the complaint in a reasonable time.

31. We understand Ms G supported her husband while he grieved for his mother, but we do not see this should have meant the complaint was delayed for over a year.

32. We can also see YAS’s complaint response noted, ‘there are time limits for taking a complaint to the Ombudsman…’. We would expect Ms and Mrs G to have sent their complaint to us around the time they received their final response.

33. Ms and Mrs G could have used an advocate to help them if they were having problems preparing their complaint. We can see they had used an advocate earlier in the complaints process, so were aware of this service.

34. While we appreciate their advocate later took a job role in the NHS and was no longer available, they could have asked another advocate which may have helped them to bring their complaint to us sooner.

35. We have also considered whether Ms and Mrs G’s explanations had a greater impact together which could provide good reason for the time it took to approach us. We do not see the reasons they provided are enough to allow us to put the time limit to one side due to the considerable delay between July 2021 and July 2022.

Summary

36. As we have already set out, by the time the complaints process ended a significant amount of time had already passed since the events took place. So it was vital that any complaint was brought to us without any further delay.

37. Our view is that there was a 12-month delay in Ms and Mrs G bringing their complaint to us once the complaints process had concluded.

38. This means we are unable to look into their concerns. We recognise how important this complaint is to them, and this is not the outcome they hoped for. Although our decision may be disappointing, we hope they are assured that we have carefully considered their explanations for the delay and that we have explained the reasons for our decision clearly.

1. We have carefully considered Ms and Mrs G’s complaint about Leeds Teaching Hospitals NHS Trust (LTH), Harrogate and District NHS Foundation Trust (HDFT), Yorkshire Ambulance Service NHS Trust (YAS) and a GP practice in the Leeds area (the Practice). We are sorry to hear Ms and Mrs G’s concerns about the care Mr G received before he died.

2. Ms and Mrs G’s complaint falls outside our 12-month time limit. We have carefully considered why they could not have approached us sooner. We can see that there were some delays which were avoidable. We have not seen any evidence to suggest Ms and Mrs G were prevented from approaching us during this time. This means we cannot consider the complaint further.

3. We recognise how deeply Ms and Mrs G have been affected by Mr G’s death. We do not underestimate how difficult this time has been for them. Although we are unable to look into their concerns further, we thank them for taking the time to bring their complaint to us.