NHS in England Closed After Initial Enquiries Search on PHSO website

University Hospitals of Liverpool Group

P-004310 · Statement · Decision date: 20 November 2025 · View University Hospitals of Liverpool Group scorecard
Complaint (AI summary)
Mr A complained the Trust's Emergency Department failed to provide an asthma team assessment after his attacks and didn't consider his raised blood levels, causing anxiety.
Outcome (AI summary)
The ombudsman closed the case without further consideration, as the complaint regarding the asthma team was submitted out of time.

Full decision details

The Complaint

4. Mr A complains about University Hospitals of Liverpool Group (the Trust) and the care it provided him on 29 June 2023 following three asthma attacks. He says the Trust’s Emergency Department (ED) referred him to its asthma team for an assessment, but there was no one from the team available to assess him. He also complains he had raised blood levels, and the ED doctors did not take this into account.

5. As a result of his experience, he says the Trust’s actions left him infected. He says it could have been dangerous, and this made him anxious.

6. Finally, he complains about the way the Trust handled his complaint. He says it had several opportunities to respond to this particular issue, but he feels it has not been accountable for the actions of its staff nor willing to learn from his experience.

7. As an outcome of his complaint, Mr A would like the Trust to apologise for his care on 29 June 2023 and explain why the asthma team never turned up. He would also like it to introduce service improvements.

Background

8. On 29 June 2023, Mr A contacted the Trust to report he was unwell following a holiday and the asthma clinician he spoke to over the phone suspected his health concerns were asthma related. They advised him to come to the Trust and ask for someone from the asthma team to see him.

9. Mr A went to the Trust and was triaged by a nurse who then contacted the asthma team. Following this, Mr A waited for over six hours (“give or take”) and nobody from the asthma team came to see him. He says the Trust told him to go home, but the Trust recorded he discharged himself.

10. Mr A never heard back from the asthma team following his trip to the Trust.

11. With the help of an advocate, he complained to the Trust on 9 August. He complained about: • The asthma team not seeing him when he went to the Trust, as they advised, • The triage nurse did not identify he had an infection after checking his blood, • The Trust asked him to leave after he asked for reasonable adjustments for the seating due to his back condition, • It did not believe he needed medication, despite him showing its staff a medication list on the ‘My GP’ app, and, • PALS did not provide any reasonable adjustments after he told it he had learning difficulties and would not record his concerns as a verbal complaint.

12. The Trust responded to his complaint on 31 October.

13. Regarding the asthma team’s absence, it said there was no explanation as to why the asthma team did not see him and apologised for his experience and its asthma team not seeing him.

14. Regarding his raised blood levels, it said an Emergency Department doctor (the doctor) did see his blood levels when he attended, but concluded it was not likely there was an infection as there was significant abnormality in his blood. They highlighted his white blood cells were in the upper limit and there was no rise in inflammatory markers. Taken together with Mr A’s chest examination and his normal oxygen saturation, the doctor was reassured he did not have an infection.

15. The Trust referred Mr A to our office if he was still unhappy. However, he was dissatisfied with its response and requested it reopen his complaint on 16 January 2024.

16. However, the Trust reviewed the case again on 13 February 2024 and felt the local resolution process had been exhausted. It signposted Mr A to our office again.

17. Mr A requested a local resolution meeting on 5 March 2024 and asked that it be held in August. It was arranged for 17 September.

18. The meeting went ahead on 17 September, and the Trust acknowledged that it was unable to explain why the asthma team had not seen Mr A when he attended. It agreed to follow up this matter, but the asthma team did not respond to Mr A until 13 January 2025. Its response was very brief and said it believed its staff had acted correctly.

19. On the same day, Mr A told the Trust he was still unsatisfied with the response and tried to reopen his complaint again. However, the Trust advised him its involvement was over, and he needed to come to our office to progress his complaint.

20. Mr A brought his complaint to our office on 21 January 2025.

Findings

23. We are unable to investigate complaints that do not meet our time-bar policy. We must consider the time limit for every case. For health service complaints, the aggrieved must refer the matter to our office in writing within 12 months from the day they first became aware they had a reason to complain (as set out in section 9 of the Health Service Commissioners Act 1993).

24. It is our view that Mr A’s complaint about the events that occurred on 29 June 2023 are out of time. This is because his date of awareness was also on 29 June 2023. Therefore, our office should have received his complaint by 29 June 2024, but we did not receive it until 21 January 2025 (almost six months later and 18 months after the event complained about).

25. Our office does have the power to exercise discretion, but we would only do this in scenarios where the complainant could not bring their complaint to our office sooner. For example, the organisation took a long time responding to their complaint.

26. We spoke to Mr A on 31 October. He gave the following reasons for not complaining sooner: • He blamed the Trust for the delays, saying it delayed the local resolution period to ‘run the clock’ on his complaint.

• He blamed his advocate, as they did not advise him to come to our office after the Trust’s complaint response on 31 October 2023 • He said his advocate did not help him bring his complaint to our office • He said he came to our office while the Trust delayed his case • He said he has learning difficulties, which impacted his ability to come to our office sooner and why he put all his faith into his advocate

27. In this case, the Trust did not take a long time responding to Mr A’s complaint. He complained to the Trust on 9 August, and it responded to him on 31 October (just under three months). The Trust responded to all the points raised and clearly listed each of Mr A’s complaints as subheadings with its responses beneath.

28. We appreciate why Mr A was unsatisfied with the Trust’s response, as the Trust could not tell him why the asthma team did not see him. However, our office could have investigated this further. Instead, Mr A decided to continue trying to escalate his complaint with the Trust despite its clear signposting to our office on 31 October 2023 and 13 February 2024. He should have followed the Trust’s instruction, and it was his own agency that delayed the case coming to our office.

29. He says it was his advocate who advised him to return to the Trust. Whilst we do not dispute this, we cannot ignore the fact that this was Mr A’s complaint, not his advocate’s. We have seen nothing to suggest Mr A lacked the capacity to make his own decisions and he was under no obligation to follow his advocate’s advice. The evidence shows the Trust had been clear on what steps he needed to take to escalate his complaint (namely, to bring his concerns to our attention). Ultimately, Mr A’s decision to follow his advocate’s advice rather than that given to him by the Trust, although somewhat understandable, is what led to his complaint falling foul of our legislation.

30. We have noted Mr A’s comment that he contacted our office during the time the Trust was dealing with his complaint. Unfortunately, we can find no record of him contacting us about these specific concerns. However, our records show that, in November 2023, he contacted us about a different complaint (involving a different Trust). At the time, we gave Mr A general advice about our time-limits. This is further evidence that he was made aware of both our legislation and our expectations.

31. In any event, a telephone conversation with our office would not have met the requirements of our legislation. As we have explained earlier, under the relevant legislation, he was required to make the complaint in writing.

32. We recognise that Mr A has learning difficulties which may impact on his ability to make a complaint in writing (and may explain his reliance on an advocate). However, we again need to refer here to the separate complaint mentioned earlier.

33. Our records show that, when Mr A approached us with that complaint, he explained the difficulty he may have in making his complaint in writing. We therefore agreed (in December 2023) that, with his permission, we would take details of his complaint by telephone and transcribe these into a written document which he could then authorise. Our records show this task was undertaken successfully and his other complaint was progressed as normal. This serves as evidence that Mr A was aware of our processes and how we could help him if he was having trouble in bringing his concerns to us.

34. Looking at matters in the round, we are satisfied Mr A was aware of the need to bring a complaint to us within the required timeframe and was able to do so effectively. Because of this, we can see no good reason to set our time-limit aside in this instance.

35. We are sorry to hear about the health concerns Mr A has had, and we can appreciate the events around 29 June 2023 were frightening for him, especially in light of his asthma and risk.

36. We realise this is unlikely to be the outcome Mr A was looking for when he approached us. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it. We would like to thank Mr A for bringing his concerns to our attention.

Our Decision

1. We are sorry to hear about the experience Mr A had with University Hospitals of Liverpool Group (the Trust), and we can appreciate he was very anxious about his health following his asthma attacks. We are grateful for the time he has taken to correspond with us to help our understanding of his complaint.

2. Having looked at Mr A’s case, we have decided not to consider it further. We have found that his complaint about the asthma team is out of time for our office to consider.

3. We appreciate why this complaint is important to Mr A and we will explain our decision in more detail below. We hope our explanation provides him with reassurance about how carefully we have considered his complaint before reaching our decision.

Other Decisions About University Hospitals of Liverpool Group

P-004629 · 14 Jan 2026
Miss K complaints the Trust failed to diagnose her mother’s heart failure during an admission. Her mother, Mrs B sadly …
Closed After Initial Enquiries
P-004468 · 15 Dec 2025
Mrs E complains about aspects of care and treatment her sister, Miss A received from The Trust. She says the …
Closed After Initial Enquiries
P-004262 · 14 Nov 2025
Daughter complains that poor communication regarding her father's deterioration meant she lost the chance to spend valuable time with him …
Upheld
P-003812 · 13 Aug 2025
Mrs G complains about how the Trust carried out her knee replacement and managed this post operatively.
Closed After Initial Enquiries
P-003536 · 13 Mar 2025
Mrs R complains about the Trust’s treatment of her late sister. She says it failed to detect liver cancer, to …
Partly Upheld
View all decisions for this organisation →