20. The Ombudsman’s powers are set out in the Health Service Commissioner’s Act (HSCA) 1993. Section 9(4) of this legislation says a person needs to make their complaint to us within a year of becoming aware they have a need to complain. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.
The Practice and Trust A
21. We have set out both the Practice and Trust A together, as the time limit consideration is the same for both organisations. This will be explained below.
Date of events and knowledge for the Practice
22. Miss L complains from December 2020 to June 2021, Mr O attended the Practice and reported symptoms he was experiencing, including a headache. She says the Practice failed to adequately investigate his reported symptoms.
23. Miss L explained there were several consultations during this time where they were unhappy with the GP advice. For example, she says they constantly prescribed medication, none of which helped ease his headaches.
24. She explained Mr O asked about having a scan. This was because he was sure there was something seriously wrong with him, and concerns the medication was not working. She said the GP was dismissive and told him they would treat the pain first.
25. On 17 May, Mr O phoned the Practice as the pain relief medication was not helping. The GP informed him they had done a referral for a scan and prescribed otomize ear spray (used to treat infections and inflammation).
26. Following the referral, scans took place and further investigations, and it was confirmed on 23 July 2021 Mr O had cancer. Miss L raises concerns that due to the delay in referring him and not taking his symptoms seriously, this led to a delayed cancer diagnosis, and in turn delayed treatment.
27. We consider Miss L was aware of the issues at the very latest 23 July 2021. We call this her ‘date of knowledge’.
Date of events and knowledge for Trust A
28. Miss L complains Lewisham and Greenwich NHS Trust (Trust A) incorrectly diagnosed Mr O with ‘likely temporomandibular joint dysfunction’ (issues with the jaw, such as jaw pain, difficulty moving your law, jaw locking) and advised incorrect treatment (dental work).
29. She says this led to a delay in the correct diagnosis and correct treatment, as the correct diagnosis was cancer.
30. Miss L explained Mr O reported headaches to Trust A, yet it advised dental work which he paid for. Following the dental work, he experienced excruciating pain, and later realised he did not need this treatment because the correct diagnosis was cancer.
31. As mentioned above, it was confirmed on 23 July 2021 Mr O had cancer. Therefore, the date of knowledge was on this date as they realised the diagnosis given by Trust A was incorrect and, in turn, the dental treatment was unnecessary.
Our consideration
32. For Miss L’s complaint about the Practice and Trust A to be made in time, she would have needed to complaint to us within 12 months of her date of knowledge, which is 23 July 2022.
33. Our records show Miss L complained to us on 11 February 2025. This means Miss L’s complaint was made to us approximately two years and seven months outside of our 12-month time limit. We spoke with Miss L to understand the reasons why she could not bring her complaint to us sooner. We also considered the time the Practice and Trust A took to respond.
34. Miss L complained to NHS England (before it became the ‘ICB’) on 12 January 2023. She complained about the Practice, Trust A, and Trust B. We asked Miss L for the reason behind the delay in complaining.
35. She said it was difficult to do anything about it at the time because she wanted to focus on caring for Mr O and helping him. She said she also had to manage a full-time job alongside the caring responsibilities and wanted to spend as much time with him as she could.
36. We understand this must have been a very distressing time for Mr O and Miss L and can see why this would have made it more difficult to complain.
37. We asked Miss L about the delays caused after Mr O’s death on 25 June 2022. She said there were a lot of adjustments at this time, as she was grieving and did not expect for Mr O to die when he did. She explained she spoke to Mr O’s children about potentially making a complaint, and they didn’t want to.
38. She added it was such a long period of care and wanted to ensure she got everything right. She also informed us the organisations took a long time to respond which was also partly the reason for the delay.
39. We understand there are points where her caring responsibilities for Mr O, and grieving would have understandably made it more difficult to pursue her complaint. We understand this to have been such a difficult time and are sorry to hear about this.
40. We consider there was approximately eighteen months between Miss L’s date of knowledge and complaining about the Practice and Trust A to NHS England. We consider there is not strong reason for us to justify putting the time limit to one side, as (for example) Miss L could have approached an advocate to assist her in complaining if she was facing difficulties doing so.
41. We have considered Miss L’s reasons in that the Practice and Trust A took a while to respond.
42. The Practice responded on 25 April 2023 and Trust A responded on 24 July 2023, however the ICB did not send her the responses until 17 December 2024. We can see this is a long period of time, from complaining to receiving the response which must have been frustrating. We consider the time it took the ICB to send the responses to her accounts for part of the delay.
43. Miss L chased the ICB and it responded on 21 February 2024 apologising for the delay. It said that the Practice had responded, and it was awaiting a response from Trust A (from our review of the complaint file, this needed to go through internal checks before it could be shared).
44. It explained it could prepare the response from the Practice and Trust B and send it to her directly. It also asked if she would like it to ask Trust A to send its response directly to her. It asked her to confirm if she would like it to do this.
45. Miss L did not respond to this email until 11 December, expressing her concerns with the length of time the investigation was taking. We think that it is reasonable to say Miss L could have asked the ICB to send the Practice’s response to her, following receipt of this email. We also think she could have asked it to ask Trust A to send its response to her directly.
46. We also think that Miss L could have contacted us with her frustrations and difficulties in the length of time the investigation into her complaint was taking. We consider her reasons account for part of the delay and understand that the complaints process took a significant amount of time.
47. Taking away the time it took between Miss L complaining to the ICB and in receiving the response (which took one year and eleven months), Miss L’s complaint is still eight months outside of our time limit.
48. We do not consider Miss L’s reasons strong enough to set the time limit to one side. We think her reasons account for only part of the delay. We think Miss L could have approached an advocate, or contacted us if she was having difficulties getting a response from the Practice, Trust A or the ICB. Also, she could have asked the ICB to send the Practice’s response following the email in February. She also could have asked it to ask Trust A to send the response to her directly.
49. Miss L took a further two months to approach us after the response from the ICB, as she approached us on 11 February 2025. Miss L said it took some time to collate all the documents and ensure the details were correct. We consider the response provided our contact details (including a telephone number). We think due to the length of time passed, she could have contacted us via telephone to inform us on her intention to complain.
50. We understand it is not easy making a complaint and understand her caring responsibilities and wanting to spend as much time with Mr O would have made it more difficult to complain.
51. We do not see good reason for the significant period of time that passed, to set the time limit aside. There were various points between 23 July 2021 and 11 February 2025 where Miss L knew she had reason to complain.
Guy’s and St Thomas’ NHS Foundation Trust
Date of events and knowledge 52. Miss L complains Guy’s and St Thomas’ NHS Foundation Trust (Trust B) did not adequately monitor and maintain Mr O’s dignity during his stay in hospital which led to a fall on 13 June 2022. She has explained to us staff were supposed to assist him with mobility however no one was there to help. She said Mr O must have tried to mobilise himself, which led to his fall.
53. Miss L sent images of Mr O following his fall. We were sorry to see the impact this had on him and the injuries he sustained. This must have been very distressing for him and family.
54. Miss L also says staff did not inform her he was on end-of-life care.
55. Mr O was admitted to Trust B on 7 June 2022. He then had the fall on 13 June 2022. Miss L informed us the fall happened a few minutes before she arrived on the ward. We think her date of knowledge for this part of her complaint was on 13 June 2022, as she realised Mr O had a fall on the same day.
56. She explained she felt there was a lack of care and staff were negligent in their responsibilities during Mr O’s stay on the ward. This indicates she was aware of the issues during the time it happened.
57. Miss L explained to us Mr O was transferred to a hospice on 22 June 2022, and staff at the hospice informed her on 25 June 2022 he was on end-of-life care. She explained at no point during Mr O’s admission at Trust B did staff inform her about this.
58. We therefore think Miss L’s date of knowledge for this part of her complaint is 25 June 2022, when staff informed her, he was on end-of-life care.
59. To summarise, we consider the first date of knowledge for issues surrounding his fall was on 13 June 2022, and regarding the communication issue about end-of-life care was on 25 June 2022.
Reasons for delay
60. Miss L gave the same reasons as already outlined in our report, for reasons behind the delay.
61. The issues happened on 13 and 25 June 2022, and she raised her complaint to us on 11 February 2025. Miss L’s complaint is therefore approximately one year and eight months outside of our time limit for Trust B.
62. The issues raised happened shortly before Mr O’s death on 25 June 2022. We understand this would have been a very difficult time and understand why Miss O did not complain straight away, as she was grieving.
63. Miss L complained about Trust B to NHS England on 12 January 2023. There was approximately a seven-month delay from the issues occurring and in raising a complaint to NHS England. We think the reasons she gave account for some of the delay.
64. We have carefully considered this part of the delay, and think Miss L could have contacted an advocate if she was facing difficulties in complaining herself, during this difficult time. Due to this, we do not consider her reasons strong enough to account for a seven-month delay.
65. Once she raised the complaint to NHS England, Trust B responded on 5 July 2023. This means it took approximately six months to respond. However, Miss L did not receive this response until the ICB sent it to her on 17 December 2024. This means the complaints process took one year and eleven months.
66. When we look at the time involved, there are gaps between Miss L complaining and receiving a response of one year and eleven months. This is a significant period of time to not hear anything back.
67. As explained earlier in our report, the ICB sent Miss L an email on 21 February explaining that it had received responses from the Practice and Trust B. It asked for her confirmation if she would like it to send it to her. Miss L did not respond to this email until 11 December when she expressed further frustrations with the length of time she had been waiting for a response.
68. We consider Miss L could have asked the ICB to send Trust B’s response to her, which would have likely led to her receiving the response sooner than she did. We acknowledge this was a significant period to wait for responses and understand this must have been frustrating at an already difficult time.
69. We think it would have been reasonable for Miss L to have pursued this sooner or come to us sooner if she had difficulties receiving a response.
70. We have carefully considered the difficult circumstances Miss L experienced across this one year and eight-month period. We do not see good reason for the significant period of time passed, to set our time limit to one side. We think she would have approached us, or asked the ICB to send Trust B’s response following its email in February.
71. We also consider there was a further delay, from receiving a response in December 2024 to approaching us in February 2025. We appreciate it is not easy making a complaint. The responses directed Miss L to us and informed her of a time limit and provided our contact details.
72. We think Miss L could have approached us sooner than she did, considering the length of time that had already passed. We accept it would have taken some time to prepare her complaint form. She could have telephoned us as our contact details were provided, to inform us of her intention to complain.
Summary of our decision
73. We have carefully considered the reasons for the delays identified above. We recognise how difficult it must have been for Miss L to pursue the complaint in the circumstances at various points. We were sorry to hear about how hard this was and the difficulties she went through.
74. It is clear from the information provide how much distress the events described has caused. We are so sorry to hear about this. When we have considered the time taken, we think it would have been reasonable for her to have complained to us sooner.
75. We have not identified sufficient reasons to enable us to put our time limit to one side, for her complaint about the Practice, Trust A and Trust B. We will therefore be closing the complaint and taking no further action,
76. We thank Miss L for bringing her complaint to us and speaking with us about what happened. We must apply our time limit fairly. We do not underestimate how difficult this period was for Miss L and recognise how important her complaint is to her. Our decision is not intended to detract from these difficult events. We wish her all the best for the future.