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Sheffield Teaching Hospitals NHS Foundation Trust

P-003917 · Statement · Decision date: 26 September 2025 · View Sheffield Teaching Hospitals NHS Foundation Trust scorecard
Drugs / medication Nursing care Delayed Recognition of Deterioration
Complaint (AI summary)
Ms R complained the Trust failed to provide adequate care for her brother, Mr S, including not giving antibiotics, fluids, or blood thinners, and insufficient observation. She believed this led to his avoidable death.
Outcome (AI summary)
The complaint was closed. The ombudsman decided not to investigate further because the complaint fell outside its time limit, finding no sufficient reason to set the limit aside.

Full decision details

The Complaint

4. Ms R complains the Trust failed to provide adequate care for her brother, Mr S, in October 2022. She says the Trust:

• did not give her brother antibiotics, intravenous fluids or blood thinners • did not observe him properly during his admission

5. Ms R says her brother’s deterioration and death may have been avoidable if the Trust had provided appropriate care. She says this has caused her and her family significant distress. She also says she has lost trust in the NHS and now feels anxious about the standard of care she and her family might receive in the future.

6. To resolve her complaint, Ms R would like a financial payment.

Findings

9. The law gives us our powers to investigate complaints about NHS services in England. Section 9(4) of this Act says we should not investigate a complaint if it is brought to us more than one year after the person became aware of the issues, unless we consider it reasonable to do so.

10. If a complaint comes to us outside of the 12-month time limit, we must consider whether to put the time limit to one side. In doing so, we consider the complainant’s reasons for the time they took and the time it has taken the organisation to investigate and respond.

11. Ms R complains the Trust failed to provide adequate care for her brother Mr S in October 2022.

12. When Ms R completed her complaint form to us, she documented 30 October 2022 as the date she became aware she had a reason to complain. This is what we call her date of knowledge (DOK).

13. For Ms R’s complaint to have been made within our time limit, she would have needed to bring the complaint to us by 30 October 2023, within 12 months of the DOK.

14. Ms R submitted her complaint to us on 13 February 2025, nearly one year and four months outside our 12-month time limit.

15. We spoke with Ms R to understand why she was unable to bring her complaint to us sooner. We also considered the time it took the Trust to respond. The timeline and our considerations are set out below.

16. From the information provided, we note that Ms R complained to the Trust on 26 May 2024. This was one year and seven months after her DOK. This means at the point Ms R first complained to the Trust, she was already outside of our time limit. We spoke with Ms R to explore the reasons for this delay.

17. Ms R says shortly after her brother died on 30 October 2022, her partner had a bad accident in December and was admitted to hospital where he remained until he was discharged at the end of January 2023. After his discharge from hospital, she explains she provided extensive care to him.

18. Ms R says she provided daily care to her partner until he was well enough to be independent, around June 2023. Between January and June 2023, Ms R says she struggled to have the energy to make her complaint as she was caring for her partner, working full-time and grieving for her brother and also her mother, who sadly died in January 2021.

19. We understand the reasons why Ms R did not complain whilst she was grieving and also caring for her partner following his accident, up to June 2023. We recognise this must have been an incredibly difficult time for Ms R and we understand that raising her complaint was not her priority at that time.

20. We spoke with Ms R about the reasons why she did not complain when things had changed, once her partner had recovered sufficiently in June 2023. Ms R says she did not complain after June 2023 because she was experiencing depression and could not think of anything else. She said that losing her youngest brother was a shock and that it was not until May 2024 that she felt able to address the matter and raise a complaint to the Trust.

21. While we understand the reasons Ms R has given for not complaining before June 2023, from that point it took a further eleven months for her to raise her concerns with the Trust. During this period, although we acknowledge that her circumstances remained difficult, Ms R was able to continue working and engage with aspects of day-to-day life.

22. If Ms R felt that making a complaint herself was too difficult at the time, she could have considered accessing a free health advocacy service, which could have supported her or made the complaint on her behalf.

23. The Trust responded to Ms R’s complaint four months later, on 18 September 2024. We recognise it does take time for an organisation to investigate and respond to any complaint it receives. This is in line with the regulations, which say organisations should respond within six months. We think this was sufficiently timely, and do not see this four-month period equates to a delay.

24. After Ms R received the Trust response in September 2024, there was a further five-month delay until February 2025 before she returned to the Trust and asked it for a meeting. When speaking with us about the reason for this delay, Ms R explained she felt there wasn't going to be any response she would be happy with. She said she contacted the Trust in February 2025 as she felt she owed it to her brother. She says she was not conscious of time at that point.

25. In response and without delay, the Trust offered to meet with Ms R to discuss her outstanding concerns. Ms R declined this offer, telling us she felt she would not get the answers she was looking for from the Trust and for that reason had come to us.

26. We acknowledge that Ms R felt disheartened after receiving the Trust’s response and this led to a lack of engagement. However, by the time she did respond, a further five months had elapsed. This represents an additional delay we must take into account. We have not been provided with a good reason for this and we can see no barriers that would have prevented her from pursuing her complaint sooner, either by re-engaging with the Trust or by coming to us.

27. At the point Ms R first complained to the Trust, her complaint was already beyond our 12-month time limit. We have identified two periods of delay where we think Ms R could have acted sooner. For the reasons we have explained, we have decided not to set our time limit aside.

28. From speaking with Ms R, it is clear what happened to Mr S had a profound impact on her life, and we know how important this complaint is to her. We are very grateful to Ms R for bringing her complaint to us and for speaking with us so openly about what happened.

Our Decision

1. We have carefully considered Ms R’s complaint about the Trust. We are very sorry and deeply saddened to read about the death of her brother, Mr S. We extend our sincere condolences to Ms R and her family for their loss.

2. We have decided not to consider Ms R’s complaint further. This is because the complaint falls outside of our time limit. We carefully considered the reasons Ms R gave for this and we do not see sufficient reason to set our time limit aside. We explain the reasons for this decision in this statement.

3. We recognise and are grateful for the time and effort that has gone into making this complaint. Our decision in no way diminishes the seriousness of the concerns raised or the distress these events have caused Ms R and her family.

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