University Hospitals of Leicester NHS Trust

4. Mr H complains clinical staff at the Trust wrongly inserted an ascitic drain into his mother, Mrs F’s ovarian cyst on 11 April 2022. He tells us his mother sadly died of an infection on 14 April and explains this infection was a direct consequence of the wrongly inserted ascitic drain.

5. Mr H says he is devastated to lose his mother and is further distressed that a routine procedure went wrong and caused her avoidable death.

6. Mr H wants the Trust to acknowledge its mistakes, apologise for them and improve its service. He also wants the Trust to pay him a financial remedy.

7. Mrs F contacted the Trust’s oncology clinic on 6 April 2022. She had been receiving cancer treatment and felt her condition had worsened the previous day. Her doctor arranged an urgent clinical appointment for 8 April.

8. On 8 April the doctor arranged an ultrasound for Mrs F which would allow an acute oncology nurse to insert an ascitic drain to remove excess fluid (ascites) which was thought to be causing her worsening condition.

9. An ultrasound is a scan which uses sound waves to create images of the body. An ascitic drain is a medical procedure where a needle is inserted into the abdominal cavity to remove ascites.

10. The ascitic drain took place on 11 April. Following this procedure, Mrs F felt unwell, so doctors admitted her for further tests. A subsequent computed tomography scan (CT scan) found the ascitic drain had gone into an ovarian cyst rather than the pocket of ascites.

11. A CT scan uses X-rays and a computer to create detailed internal images of the body. An ovarian cyst is a fluid filled sac which can form on the ovaries.

12. The next day, Mrs F felt increasingly unwell. Doctors suspected a respiratory infection and treated her with antibiotics.

13. Mrs F’s condition continued to deteriorate in the following days. She sadly died on 14 April.

14. Mr H complained to the Trust on 24 June and got its response on 22 September. He approached our Office on 14 March 2025.

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

17. Mr H became aware of the issues he now complains about on 14 April 2022. This is the date a doctor discussed his mother’s serious deterioration and apologised that the ascitic drain had gone into his mother’s ovarian cyst.

18. We received Mr H’s complaint about the Trust on 14 March 2025. This means the complaint reached us one year and eleven months outside of our time limit.

19. We cannot investigate complaints brought to us outside our time limit unless we think there is a good reason to do so. We first considered the time it took the Trust to respond to Mr H’s complaint.

20. Mr H complained to the Trust on 24 June 2022 and received its response on 14 September 2022. It offered to further discuss matters with Mr H if he wanted and also made him aware that if he remained dissatisfied, and wanted to escalate his complaint, he could approach our Office.

21. In total it took the Trust around 11 weeks to provide its response. This was prompt, and well within the six months stipulated in the NHS Complaints Regulations (2009).

22. We do not consider the time it took the Trust to respond to Mr H’s complaint presents a good enough reason to set aside the time limit.

23. We can see Mr H did not go back to the Trust following its 14 September 2022 complaint response. He appears to have taken no further action in his complaint until he approached our Office on 14 March 2025.

24. We asked Mr H why it took so long for him to approach our Office after he received his response from the Trust.

25. Mr H tells us he was not aware our Office had a time limit. He says he was still grieving for his mother and did not know what he should do to further his complaint. He adds that it was not an easy decision to make.

26. We acknowledge the Trust did not make Mr H aware of our time limits in its response. While we appreciate Mr H’s comment that he did not know about our time limit, this is not a reason for us to set it aside. Mr H, or anyone supporting him at the time, could have checked either by calling us, visiting our website or doing an internet search where this information is freely available.

27. We recognise Mr H has been through a great deal over the past few years and we do not wish to diminish his experience. Having carefully considered his reasons, we are not convinced this should justify the sizeable delay in Mr H bringing his complaint to our Office.

28. If Mr H felt unable to complain to our Office himself, he could have considered using an advocate to assist him or represent him. Using an advocate to bring the complaint to our Office could, for example, have eased the additional upset and distress this process may have caused.

29. For the reasons set out above, we are unable to consider Mr H’s complaint further. It is clear Mr H’s bereavement has deeply affected him, and we are sorry we are unable to assist him in the way he would like us to. Although our decision may be disappointing, we hope he is assured that we have carefully considered his explanations of delay and that we have explained the reasons for our decision clearly.

1. We have carefully considered Mr H’s complaint about the Trust. We are sorry to hear Mr H’s concerns about the care his mother, Mrs F, received before she died.

2. Mr H’s complaint falls outside our time limit, and we have decided there is no good reason for us to put this aside. This means we cannot consider the complaint further.

3. We recognise how deeply Mr H has been affected by his mother’s death. We do not underestimate how difficult this time has been for him. Although we are unable to look into his concerns further, we thank him for taking the time to raise them with us.