University Hospitals Sussex NHS Foundation Trust

4. Mr G complains about the care the Trust provided his mother, Mrs G, between 3 February and 2 April 2023. He raises specific concerns that it:

• treated his mother on an open ward where she caught COVID-19 • did not fast-track her for continuing health care funding when they knew she was at end of life • discharged her to a nursing home whilst she had aspiration pneumonia • did not inform him his mother had a diagnosis of cerebrovascular disease and vascular dementia.

5. Mr G says the Trust should have transferred his mother to a ward and given her a longer course of antibiotics instead of discharging her. He considers its actions allowed her health to deteriorate, led to her premature death and meant she missed the opportunity to die at home with her family and friends.

6. In bringing the complaint to us, Mr G would like the Trust to accept responsibility for what went wrong and carry out service improvements to prevent this from happening to others. He would also like it to pay him a financial remedy in line with level six of our scale.

7. What follows is a brief background to the complaint. We have not included all details as both parties are aware of these.

8. Mrs G went into hospital on 3 February 2023 with pneumonia, delirium and an unsafe swallow that had been deteriorating over the last few months.

9. On 14 February clinicians began discussing the possibility of home-based end-of-life care with Mr G. Clinicians considered she should be on palliative care.

10. On 22 February Mr G advised he and his mother agreed she should receive all active treatments including intravenous (IV, through the vein) antibiotics and fluids. He also wanted staff to readmit his mother to hospital if she developed another aspiration pneumonia.

11. On 27 February staff sent a referral for a package of care. This did not begin as Mrs G tested positive for COVID-19 on three occasions between 4 and 6 March.

12. Mrs G tested negative for COVID-19 on 7 and 8 March. She remained unwell and needed oxygen and IV fluids and became delirious to the point where clinicians were worried she had a stroke. They ruled this out during the admission.

13. On 20 March an occupational therapist discussed an end-of-life package of care with Mr G and sent a referral for this the same day. The package of care was due to start on 5 April, Mrs G sadly died on 2 April before this could begin.

16. The NHS guidance on complaining explains (section 7) that a complaint must be made not later than 12 months after the date on which a person knew of a reason to complain.

17. The Health Service Commissioners Act 1993 (the law) says a person needs to make their complaint to the Ombudsman within a year of becoming aware of the problem they wish to complain of. By law, we are prevented from investigating complaints brought to us after one year, unless we consider there is a good reason to justify why the complaint was not raised within twelve months.

18. We begin by considering each stage of the complaint and identify any delays. We engage with the complainant to understand the reasons for any delays, this allows us to understand the time taken for the complainant to take action to make their complaint, and the circumstances that caused their delay so we can assess reasonableness. We also consider the delays of the organisation.

19. There is no exhaustive list of reasons that could delay a complaint or a timescale to meet, we take this consideration on an individual case by case basis. Where we identify delays, if we consider the reasons with justification, we may then go on to consider waiving the time limit as the Ombudsman has this discretion to do so.

20. Having explained the process, we next go onto establishing a summary of the delays. We have identified the following periods of time and delays in the complaint process.

Timeline of the complaints process

21. Mrs G was in hospital for around eight weeks between February and April 2023. We understand that each of the issues Mr G raises occurred at different times. Mrs G sadly died on 2 April. Therefore, we taken this (2 April 2023) as the date by which Mr G knew a problem to complain about had occurred. We refer to this as the ‘date of knowledge’.

22. Mr G made a formal complaint to the Trust in writing on 14 April 2023. This was well within the NHS requirement to complain within a year to the organisation.

23. The Trust then took until 24 June 2024 to issue its first response. This was a period of around 14 months. In this response it acknowledges the delay and that it did not keep him informed of the reasons for this.

24. Mr G returned to the Trust with outstanding concerns on 19 July, almost a month after receiving its first response.

25. The Trust issued its final response on 12 October 2024, less than three months after it received Mr G’s outstanding concerns.

26. Mr G brought his complaint to the Ombudsman on 12 March 2025. This was a delay of five months from receipt of the Trust’s response.

27. Based on the dates provided, specifically from the date of knowledge (when Mr G knew of a reason to complain) to be within the twelve-month Health Service Commissioners Act requirement, Mr G should have submitted his complaint to the Ombudsman by 3 April 2024. We received Mr G’s complaint by 12 March 2025. This shows the complaint is out of time by 11 months.

Delays in complaint handling by the Trust

28. The NHS Regulations (2009), state if a complaint is not resolved within six months the organisation should then write to the complainant and explain what is occurring and what they are doing to address matters.

29. The Trust concluded its investigation and issued a written response on 24 June 2024. This was around eight months outside the six-month target for response and therefore was a delay.

30. It then issued its final response on 12 October 2024, around three months after receiving Mr G’s outstanding concerns. This was within the six-month target for response and was therefore not a delay.

Delays in progressing the complaint by Mr G

31. Mr G complained to the Trust around ten days after his date of knowledge. This was well within the timeframes set out in NHS guidance. The Trust took around 14 months to issue its first response. We recognise that meant he could not bring his complaint to us in time. It then took a further three months to issue its final response.

32. When a complaint comes to us outside of our time limit, we consider whether the person making the complaint we prevented from bringing this to us sooner. Mr G brought his complaint to us on 12 March 2025. This was a delay of five months after receiving the Trust’s final response.

33. We asked Mr G why he waited to bring his complaint to us. He said he was not aware he could pursue his complaint with us until he spoke to a medical professional in February 2025. He says after speaking with this person, he was he was under the impression he had six months after receiving the Trust’s final response to bring his complaint to us.

34. He says he had to go into hospital in November 2024 and February 2025 due to having blood clots in his left leg. He says a doctor told him not to sit for too long or on hard chairs. He tells us his computer is on a desk with a hard chair, and he rarely used this during the period of delay.

Considerations of reasons for delay

Not being aware of us or our timescale

35. Mr G said he was not aware he could continue pursuing his complaint with the Ombudsman until a medical professional made him aware of this in February 2025. He also tells us he was under the impression he had six months after receiving the Trust’s final response to bring his complaint to us.

36. Having looked at the Trust’s responses from June and October 2024, we can see both say ‘if you remain unhappy with out response to your complaint and would like to take the matter further, you can contact the Parliamentary and Health Service Ombudsman. The Ombudsman makes final decisions on complaints that have not been resolved by the NHS. It is important you make your complaint as soon as you receive our final response as there are time limits for the Ombudsman to look into complaints.’ We consider this makes it clear that Mr G could pursue his complaint with us.

37. Mr G says he was unaware of our time limit and did not know he could pursue his complaint with us. We recognise he may have been unaware of our exact time limit. We do not consider he was unaware he could pursue his complaint with us as both responses clearly state we make final decisions on complaints that have not been resolved by the NHS.

Health concerns

38. We recognise that Mr G experienced blood clots during the period of delay. He tells us a clinician advised him not to sit in one position for too long or on hard chairs. He says this impacted his ability to bring his complaint to us as his computer is on a desk with a hard chair. We do not consider being unable to use a computer prevented Mr G from bringing his complaint to us sooner.

39. As an organisation we are able to make reasonable adjustments. These can include assisting someone with completing our complaint form if they are unable to do this. Both complaints responses contain details of our helpline. Had Mr G used this, we could have supported him in completing a complaint form over the phone, regardless of his ability to use a computer.

Conclusion

40. We acknowledge that the Trust’s handling of the complaint contributed to an eight-month delay and accept that this prevented Mr G from bring his complaint to us sooner. It is likely that we would have set aside our time limit had we received the complaint shortly after Mr G received the Trust’s final response in October 2024.

41. Mr G had our contact details from June 2024 and could have sought advice from us whilst waiting for the Trust to respond. He could also have used these to bring his complaint to us upon receiving its final response in October 2024. We recognise there were factors outside of his control such as the Trust’s delays and his limited ability to use a computer. These do not demonstrate that he was unable to approach us sooner.

42. On this basis, we consider that the complaint was brought to us significantly outside our time limit and we have not seen exceptional circumstances that would justify setting this limit aside.

43. We are thankful for Mr G bringing his complaint to us.

1. We have carefully considered Mr G’s complaint about the care his mother, Mrs G, received from University Hospitals Sussex NHS Foundation Trust (the Trust). We are sorry to hear about his mother’s death and the significant impact this loss has had and continues to have for him.

2. The complaint falls outside of the legal time limit to bring a complaint to the Ombudsman. Though we have some discretion to consider and waive the legal time limit where exceptional circumstances justify delays, on this occasion we have not seen reason to justify this.

3. We recognise our decision will be disappointing for Mr G and hope the information in this statement clearly explains our decision and the Ombudsman’s legal duty to consider the time limit on complaints received.