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University Hospitals Sussex NHS Foundation Trust

P-003880 · Statement · Decision date: 8 September 2023 · View University Hospitals Sussex NHS Foundation Trust scorecard
Transfer, discharge and aftercare Drugs / medication Drugs / medication Nursing care Care plan failures Delayed Recognition of Deterioration
Complaint (AI summary)
The Trust allegedly delayed Mrs M's discharge, failed to identify/treat her vertigo and chest infection, and did not provide adequate food/fluids.
Outcome (AI summary)
The complaint was closed as it fell outside the ombudsman's one-year time limit, with no sufficient reason to waive it.

Full decision details

The Complaint

4. Miss M complains that in May and June 2018 the Trust:

• delayed discharging Mrs M to a rehabilitation centre and blocked transfers to centres suggested by the family • failed to identify Mrs M’s historical diagnosis of vertigo (a symptom of feeling very dizzy) and give appropriate medication to treat it • failed to give medication to treat Mrs M’s chest infection • did not give Mrs M enough food or fluids despite being asked to by her family.

5. Miss M says her mother did not co-operate with the occupational health therapist because of her vertigo which added to her delayed discharge. She says Mrs M’s condition deteriorated the longer she stayed in hospital and she developed urinary tract infections (UTIs), delirium and pneumonia (inflammation of the lungs usually caused by an infection). She also says Mrs M’s cognitive function (ability to process thoughts) deteriorated which she thinks was the start of dementia. Miss M says she has been left very distressed by Mrs M’s death and she lost trust and confidence in the Trust.

6. Miss M would like the Trust to acknowledge its failings and to make service improvements.

Background

7. In April 2018, Mrs M was admitted to hospital after a fall that caused a minor head injury. In May she was readmitted after another fall and in June she developed pneumonia and a UTI. She was discharged from hospital in late June to a care home.

8. Soon after the discharge, Miss M started to raise concerns about the care the Trust gave her mother. She told the Trust she felt her mother’s condition had deteriorated while under its care, and when she was discharged she was in a worse condition than when she was admitted. A month after she was discharged, Mrs M sadly died.

9. The Trust sent its response to Miss M’s concerns on 10 September.

10. In August 2019, Miss M wrote to the Trust and said she was not happy with its response. She told the Trust she had more concerns and she was going to bring her complaint to us. In November we told Miss M she needed to complete the Trust’s complaints process by taking her extra concerns to the Trust first.

11. The Trust contacted Miss M in April 2020 and said it could not complete its investigation into her concerns because of the COVID-19 pandemic. The Trust asked Miss M to contact it at the start of July to reopen her complaint.

12. In August 2022, Miss M contacted the Trust and asked it to give an update. The Trust first told her too much time had passed and because she had not returned to it in July 2020, it could not send a response to her concerns. In September, the Trust agreed to send a response. The Trust sent its final response on 6 December and Miss M came to us in January 2023.

Findings

15. The law says we should not investigate a complaint if it is brought to us more than one year after the person first became aware of their reason to complain, unless we consider there is good reason to.

16. Miss M told us it was during her mother’s time in hospital in May and June 2018 that she became aware of her reason to complain.

17. This means Miss M needed to make her complaint to us by June 2019.

18. Miss M first raised a complaint with the Trust on 26 June 2018. The Trust sent its response three months later in September. The Trust told Miss M she could ask for a meeting with the staff involved if she had any more questions or if she thought it would be helpful. It also told her she could come to us if she was unhappy with its response.

19. In August 2019, Miss M wrote to the Trust and apologised for the time it had taken her to reply. She said she was unhappy with the response and felt there were issues that had not been addressed. She told the Trust she intended to bring her complaint to us. The Trust acknowledged Miss M’s letter and said it would wait to hear from us.

20. At the end of August 2019, Miss M brought her complaint to us. In November we wrote to her to explain her complaint was not ready for us because she had not completed the Trust’s complaints process. She had concerns that needed to be raised with the Trust first.

21. The law does not say we must only consider a complaint when the local complaints process has been completed, but we have a responsibility to make sure the Trust has had the opportunity to try to resolve things before it comes to us as the final stage of the complaints process.

22. We made enquiries to make sure Miss M was able to follow her complaint up with the Trust.

23. In April 2020, the Trust wrote to Miss M and told her it could not investigate her complaint because of the COVID-19 pandemic. It told her it needed to put patient care first and it asked her to bring her complaint back to it in July.

24. Miss M contacted the Trust in August 2022 and asked it for an update. The Trust sent its final response in December and Miss M came to us in January 2023. This means we got Miss M’s complaint three years and seven months outside of our time limit.

25. We can see two periods of time that delayed progress with the complaint. These are:

• 11 months between the Trust’s first complaint response in September 2018 and her reply letter to the Trust in August 2019 (first delay) • 25 months between July 2020 (when the Trust said Miss M should return with her complaint) and her contacting the Trust again in August 2022 (second delay).

26. We discussed this with Miss M to understand her reasons for the delays.

First delay

27. Miss M told us she experienced much grief when her mother died. She said although she was originally able to raise her concerns, her mother’s death had a big impact on her. She also told us other close family members had died and her mother’s death caused a reaction in her that meant she could not cope well day to day. She said she replied to the Trust’s letter as soon as she felt able to. We recognise how difficult this must have been for Miss M.

Second delay

28. Miss M told us she did not contact the Trust in July 2020 because she was aware of the seriousness of the COVID-19 situation. She says she felt she was acting in good faith and being considerate by not contacting the Trust and letting it return to a level of ‘business as usual’. She also told us she was living in Australia at this time and the COVID-19 situation was very different to the UK. She said she was very anxious and concerned about her son and his young family in the UK.

29. Miss M explains she thinks it was unreasonable and unfair for the Trust to close her complaint without contacting her again. She felt it was unlikely the Trust would have been able to handle her complaint even if she had returned to it in July 2020.

Our view

30. We are sorry to hear about how greatly Miss M was affected by the death of her mother. We recognise the experience was traumatic for her. We also recognise how the COVID-19 pandemic was an uncertain time for everyone and this brought feelings of anxiety and worry.

31. With the first delay, we understand how difficult it is to lose a loved one. There are often important matters to deal with like arranging a funeral and getting the estate in order. On top of this, the grief and emotion that comes with the death of a loved one can mean making a complaint is not a priority or even possible at the time.

32. We understand and accept Miss M’s reasons for the first delay.

33. But, we do not think Miss M’s reasons for the second delay are strong enough to allow us to put our time limit to one side. This is because we need to see exceptional circumstances.

34. We understand Miss M was acting in good faith when she chose not to return to the Trust in July 2020 because of the COVID-19 pandemic. But, the Trust told her twice by email in April 2020 that it was not able to simply reopen complaints when the COVID-19 pandemic was under control. It asked Miss M to return to the complaints team in July 2020 when it would hopefully be able to investigate. While Miss M felt she was doing the right thing at the time by not doing this, the Trust had asked her to go back to it at that time.

35. If Miss M had contacted the Trust in July 2020 and it was unable to handle her complaint, it would have told her and advised her on the next steps.

36. While we recognise how the pandemic was an uncertain and anxious time for many, we consider the 25-month delay between July 2020 and August 2022 to be too long to wait. This was a long delay where Miss M could have progressed her complaint quicker. While we realise this may be disappointing for Miss M, it is important we consider and act within the law. We regret any upset this decision may cause.

Our Decision

1. We have carefully considered Miss M’s complaint about aspects of the care University Hospitals Sussex NHS Foundation Trust (the Trust) gave to her mother, Mrs M, in May and June 2018.

2. We have decided Miss M’s complaint falls outside of our one-year limit and we have not seen good enough reasons to put this to one side. We are sorry to hear the details of Miss M’s complaint and we understand how difficult this experience has been for her and her family.

3. We explain the reasons for our decision below.

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