East Kent Hospitals University NHS Foundation Trust

4. Mrs E complains about aspects of care and treatment provided by the Trust to her father, Mr D, in April 2020. She says:

• The Trust failed to accurately diagnose Mr D, following his surgery, and provide an appropriate course of treatment.

• The Trust poorly managed Mr D’s sepsis, failing to keep accurate documentation.

• Trust staff showed a lack of awareness of venous thromboembolism (blood clots), leading to failures in Mr D’s diagnosis and subsequent treatment.

• The Trust failed to refer Mr D’s case to the coroner, despite his death occurring within two weeks of two major abdominal procedures.

5. Mrs E says the care and treatment provided by the Trust ultimately led to her father’s death. She says its actions left him alone, in fear and distress, during the weeks leading up to his death, and that this has caused Mrs E, and the rest of Mr D’s family, a great deal of distress. Mrs E says she has been unable to work due to depression and anxiety, and she is currently in counselling.

6. As an outcome, Mrs E would like an acknowledgment of mistakes and explanation of the events leading up to her father’s death. She would also like a financial remedy.

7. On 1 April 2020, Mr D underwent elective surgery to remove a cancerous tumour. Within 24 hours of the surgery, he developed a fever. Trust staff noticed Mr D had very low oxygen levels and so suggested using a breathing support machine.

8. Mr D was considered too unwell to remain at the original hospital and was transferred to an alternative hospital’s Emergency Department (ED), within the same Trust. Following treatment with antibiotics, Mr D’s condition slightly improved. Based on information from the ambulance crew, who said Mr D may have COVID-19, he was placed in the COVID-19 section of the department and later moved to a COVID-19 surgical ward.

9. A medical assessment was then performed by Trust staff. A doctor suspected a post-operative infection, which was confirmed by CT scan. Mr D then underwent a surgical revision (repeat or correction of original surgery) and washout (clean of infected area).

10. Due to COVID-19 policy at the time, patients required three negative tests before transfer to a non-COVID-19 ward. Mr D was moved after approximately one week but later developed a cough and was returned to the COVID-19 ward. He subsequently required oxygen, though he remained clinically stable during this period.

11. On 13 April 2020, Mr D tested positive for COVID-19. Shortly after, on 14 April 2020, he suffered a sudden collapse in oxygenation and very sadly died within 15 minutes.

12. Mr D’s family believes this abrupt deterioration more closely resembles a pulmonary embolism, citing his known cancer, recent surgery, and ongoing but stable oxygen requirements. They also say no investigation was conducted into a possible venous thromboembolism (blood clot) despite Mr D having multiple risk factors, and that there was no reference to this in the medical notes or death certificate, which listed only COVID-19 and bowel cancer.

14. The ‘Health Service Commissioners Act 1993’ (the Act) 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 do so. We have discussed this with Mrs E to understand the reasons why she could not bring her complaint to us sooner. We have also considered the time the Trust has taken to respond to Mrs E.

15. Following Mr D’s death, his grandson (Mrs E’s nephew) complained to the Trust on behalf of the family, on 19 April 2020. He complained about the diagnosis and decision-making surrounding Mr D’s care and requested an explanation of the events that led up to Mr D’s death. He also asked the Trust to learn from the mistakes he felt were made in relation to Mr D’s care and treatment and put in place service improvements to prevent them happening again in the future.

16. Mrs E told us, although her nephew was dealing with the complaint initially, she took over the handling of the complaint eventually. We know from speaking with Mrs E, although her nephew started the complaint initially, she and her family were aware they had a reason to complain when Mr D died. This means they were aware they had reason to complain in April 2020. With this and the Act in mind, it means Mrs E and her family needed to bring their complaint to us by April 2021, unless there was good reason they could not do so.

17. We understand it took a considerable amount of time to complete the Trust’s complaint process, and we have taken this into account when considering Mrs E’s complaint.

18. Mrs E and her family received a response to their complaint in March 2022 and first contacted us in March 2024. We can see the Trust’s response, in March 2022, gave Mrs E details on either returning to it if she was dissatisfied, or, approaching us. This means that when Mrs E first contacted us in March 2024, this was two years after the Trust had responded and nearly three years outside of our time limit.

19. When Mrs E approached us in March 2024, we decided her complaint was not ready for us at that time. This is because the Trust had offered to look again at her concerns if she was not happy with the answers it had given her. The Act sets out our role is the final stage of the complaints process and, given the fact the Trust had invited Mrs E to return to it if she had outstanding concerns, we did not think the complaints process had been exhausted.

20. We advised Mrs E to return to the Trust with her outstanding concerns, and reminded her to return to us promptly if, when it responded, she remained dissatisfied. In our email to Mrs E, we explained we had a one-year time limit and would need to consider this if she returned to us when she had received a final response from the Trust.

21. On 2 December 2024, we were contacted by Mrs E’s MP. We have asked Mrs E whether she returned to the Trust when we told her to do so in April 2024 and what the reasons were for the delay in progressing the complaint between March 2022 and March 2024, and between April 2024 and December 2024. Mrs E told us that no one had told her or her family they were able to bring their complaint to us and she only found out about us by completing her own research. As set out previously, we can see in the Trust’s letter dated 7 March 2022 it explained she could approach us if she remained dissatisfied, so we cannot see this is a strong reason for delay.

22. With regards to the reasons for Mrs E’s delay between us advising her to return to the Trust in April 2024 and approaching us via her MP in December 2024, she told us she does not remember receiving a response from us. She says she waited a few months before contacting her local MP, who then referred her complaint to us.

23. We can see that if Mrs E was unhappy with the Trust’s response in March 2022, it was open to her to bring the complaint to us much sooner than March 2024. Beyond telling us she was not aware of our Office, she has not provided any other reason for what is a lengthy period of delay. Neither can we see any strong reason for the delay in returning to us after April 2024, with or without the support of an MP.

24. With the above in mind, we cannot see that Mrs E has provided strong reasons to allow us to set our time limit aside. On that basis, we have decided not to consider this complaint further. We acknowledge our decision may be disappointing for Mrs E and we do not wish to undermine what she has told us about the events of her complaint and the very sad loss to her and her family. We hope we have clearly explained how we reached our decision in this case.

1. We have carefully considered Mrs E’s complaint about East Kent Hospitals University NHS Foundation Trust (the Trust).

2. We are sorry to hear about the circumstances surrounding Mrs E’s complaint. We recognise the upset and distress she and her family have faced because of the loss of their father, Mr D, and how this has profoundly affected them.

3. Having looked very carefully, we can see Mrs E’s complaint falls outside of our one-year time limit and we are unable to set the time limit to one side, based on the evidence available to us. We recognise our decision will likely be disappointing for Mrs E, given how long she has been seeking answers to the concerns she has raised, and we explain the reasons for our decision below.