9. The Health Service Commissioners Act 1993 is the law which gives us our powers to investigate complaints about NHS Services. Section 9(4) of this Act says that we cannot consider a complaint that comes to us more than one year after the date the complainant first became aware of the problem(s).
10. We do have some discretion to put this time limit to one side if we see good reasons for the delay. Our Service Model guidance sets out how we should exercise this discretion, including what factors we should consider. We consider the time taken for the person to complete the organisation’s complaints process and any personal circumstances which may have prevented them from raising a complaint sooner.
11. These events took place on 23 August 2022. We are satisfied Mrs T was aware of most the clinical concerns outlined in this complaint at the time they took place. This is because, sadly, her mother died that day and her death was unexpected.
12. Mrs T became aware of the issues with the documentation of her mother’s care in March 2023, when she received the medical records.
13. Mrs T approached our service on 10 January 2025. This means her complaint came to us 17 months outside the 12-month time limit, for most of the clinical issues, and 10 months outside the time limit for her complaint about the documentation of her mother’s care. Because these aspects of her complaint came to us outside the time limit, we have considered whether we have good reasons to put the time limit to one side.
14. Mrs T’s husband initially contacted the Trust regarding these matters in September 2022. She then raised a complaint with the Trust in October 2022 as she believed this was necessary to obtain her mother’s medical records. Following this she was in regular contact with the Trust, but did not pursue the complaint. She received her mother’s medical records in March 2023 and raised a complaint with the Trust on 12 September 2023.
15. There was a long delay of 13 months in raising the complaint with the Trust. Between September 2023 and June 2024, the Trust was investigating her concerns and issuing responses to these. We are satisfied that the period between September 2023 and June 2024 is reasonably explained by engagement with the Trust’s complaints process.
16. Following the Trust’s final response, which was sent on 20 June, Mrs T then approached our service on 10 January 2025. The Trust’s response had signposted Mrs T to our service. This was a further delay of seven months.
17. There are two periods of significant delay, amounting to a delay of 20 months in total. We, therefore, asked Mrs T whether there were any personal circumstances which prevented her from bringing her complaint to us sooner.
18. The periods of delay we have considered are:
• 23 August 2022 to 12 September 2023 (13 months) • 20 June 2024 to 10 January 2025 (7 months)
19. Mrs T provided an explanation for these periods of delay via email. We outline our consideration of these below.
20. Mrs T says that when she first requested her mother’s medical records, she hoped this would resolve her concerns and she would not need to raise a complaint. She adds she did not realise the time limit would commence before she received these records.
21. Whilst we recognise that not everyone will be aware of the time limits for complaining and/or when the time limit starts, Mrs T and her husband were both in contact with the Trust’s complaints team from as early as September 2022. It was open to them to enquire with the complaints team about time limits and whether waiting for her mother’s medical records could have an impact on taking their concerns further.
22. Obtaining her mother’s medical records was also not required for raising a complaint. Mrs T could, for example, have raised a complaint at the same time as requesting her mother’s records and withdrawn the complaint if, on receipt of the records, her concerns had been resolved.
23. There was also a further delay of six months between Mrs T receiving her mother’s medical records and raising a complaint with the Trust. She would have known quite soon after receiving these that the medical records had not resolved her concerns, especially as this complaint did not relate to a long or complex period of care. We have not seen a robust explanation for this delay.
24. Mrs T also says her mother was a resident in a supported living facility and she had to vacate her flat after her death. She says she had no help to do this and she had to store her mother’s possessions in her home. She says she had young children and had to prioritise clearing her mother’s belongings and creating a safe space for her children.
25. We empathise with how difficult this experience must have been, especially given how unexpected her mother’s death was. We can understand Mrs T’s priority may not have been raising a complaint when faced with these circumstances. That said, we can see Mrs T contacted the Trust and raised a complaint in October 2022 when attempting to access her mother’s medical records. Because of this, we cannot reasonably conclude that from October 2022 these circumstances were preventing her from raising a complaint. We can also see that Mrs T was in regular contact with the Trust in the following months to chase these records. This further supports that these circumstances were no longer a factor which could be preventing her in raising a complaint.
26. Mrs T also told us she partially amputated her thumb on 20 August 2023. She says this was her right thumb and she is right-handed. She explained this prevented her from undertaking activities and she was unable to type quickly with her left hand or write at all whilst recovering from this.
27. She adds that this injury happened at a time when her household was hosting elderly relatives. She explains they were vulnerable due to having dementia and stayed with her family on multiple occasions during the periods of delay in raising a complaint.
28. We can see Mrs T raised a complaint on 12 September 2023, is which just over three weeks after the partial amputation. For this reason, we cannot reasonably conclude this injury prevented her from raising a complaint for a prolonged period of time.
29. We understand that caring for older relatives with dementia can be very stressful and would understandably take priority. That said, this cannot reasonably explain the extent of delays which have occurred in this case. Many people who approach our service have caring responsibilities, including adults and children with additional needs who are fully dependent on the complainant for all care. Whilst this can cause some delays, we are not satisfied that this explains a cumulative delay of 20 months.
30. Mrs T also explained that prior to her mother’s death she had sold her mother’s home to support her transition to the assisted living facility. She says that there were a number of legal difficulties surrounding this sale and that these had not been resolved by the time her mother had died. Due to this she says there was family conflict surrounding the Probate for her mother’s estate.
31. Whilst we understand this was stressful and would have been a focus for Mrs T, she was able to raise a complaint in October 2022 and pursue her mother’s medical records via email over a period of months. Given she demonstrated her ability to raise, focus on, and pursue this course of action at that time, we cannot reasonably conclude these prevented her from pursuing her complaint. Had she not withdrawn the complaint at this time, she could reasonably have received a final response and approached our service far sooner.
32. In addition, Mrs T explained she had a period of ill health that led to investigations for cancer. She explains that her tests were negative, but the chest pain caused difficulty in completing day-to-day tasks. She also adds that her young child experienced respiratory problems and was diagnosed with asthma, which was difficult to navigate.
33. Whilst we can understand this may cause some slight delay, amounting at most to a couple of months, we cannot reasonably conclude this accounts for the full delay of 20 months.
34. Mrs T adds she was consulting with her family members during the complaints process and that this took time. We have accounted for this during the period of time we have said is fully explained by complaint handling. We can see from her emails to the Trust that she was engaging with family members and that this did not take an extensive period of time.
35. We also note that Mrs T has raised a complaint about the Trust’s handling of her complaint. This part of her complaint came to us within the 12-month time limit.
36. We do not consider we could reach a meaningful outcome for Mrs T on this part of her complaint. This is because we would be unable to consider any of the merits of the clinical issues raised, meaning we could not be able to reach a conclusion on whether the Trust had been honest in its responses to her.
Conclusion 37. Mrs T’s complaint came to us two years and five months after she became aware of her concerns about her mother’s care. The law says people must approach our service within 12 months, which means her complaint came to us 17 months outside this time limit.
38. Sometimes there are good reasons for delays, and we can apply our discretion where we can clearly see it would not be reasonable to have expected the person to approach our service sooner. In Mrs T’s case, we cannot reasonably conclude the delay was unavoidable. For this reason, we are taking no further action.
39. We are also taking no further action on her complaint about the Trust’s handling of her complaint about its service. This is because there is no prospect of being able to reach a meaningful conclusion when we cannot consider the clinical matters raised.
40. We recognise these events were deeply shocking and distressing to Mrs T and her family, and our decision in no way detracts from the impact of these events.