University Hospitals Birmingham NHS Foundation Trust

3. Mr B complains about the care and treatment the Trust gave his father, Mr A, between the dates of 14 March and 17 March 2023. Specifically, he complains the Trust:

• did not act as it should in relation to falls management, leading to a fall on 14 March which he believes caused a stroke on 15 March • did not act in line with guidance following the fall • left a sedative capsule in his father’s mouth which caused a choking hazard and may have caused the fall • placed restrictions on his father without appropriate assessments and Deprivation of Liberty Safeguards (DoLS, - legal checks to protect people who lack capacity when their freedom is restricted in hospital).

4. Mr B says the overall impact is the emotional and psychological distress caused to his family by witnessing Mr A’s condition worsen, without appropriate intervention. The impact of the restrictions was that his father was deprived of his liberty and the family experienced considerable distress, anxiety, and loss of trust in the care system

5. As an outcome to his complaint Mr B wants service improvements and a financial remedy.

6. Mr A’s wife (Mr B’s mother) Mrs A originally made the complaint to the Trust on 28 May 2024. This was over 14 months after the issues outlined in the summary of the complaint.

7. The Trust acknowledged Mrs A’s complaint on 7 June 2024, and provided a full response to the issues she had raised on 3 September 2024.

8. Mr B brought the complaint to this office on 28 April 2025.

11. The law says a person needs to make their complaint to us within a year of becoming aware of the problem (we call this the date of knowledge). We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

12. When Mrs A made her complaint to the Trust in May 2024 it was already two months outside our time limit and 14 months after the date of knowledge. We asked Mr B to explain why he, or his mother, had not brought the complaint to the Trust sooner.

13. Mrs A was aware that she had cause to complain about care and treatment at the time Mr A was an inpatient, in March 2023. We know this was the case because Mr B told us about the things that had happened in hospital, and that these things had raised concerns for him, as well as his mother.

14. Mr B told us his mother had not made the complaint sooner because she had a history of post-traumatic stress disorder (PTSD), and her experience of what happened affected her mental health. He said she did not feel able to bring the complaint sooner than that. We were sorry to hear about the impact her experience had on her.

15. Mr B told us he was supporting his mother through this difficult time, and she was accessing help from her GP. We asked if there was a reason he was not able to bring the complaint to the Trust instead. He told us that he did not want to ‘step on [his] mother’s toes’, and it would not have seemed right. He told us he was also grieving himself at this time.

16. We respect the choices Mr B made, and can understand why he did not want to intrude. We understand the impact of grief, which is experienced differently by everyone.

17. We do think it would have been reasonable for Mr B to have taken some action to prevent the complaint from falling outside the time limit. Advocacy organisations are there to help in such circumstances, and we think Mr B could have sought such support to help him or his mother make the complaint at this emotional time.

18. We also considered the time the Trust took to make its response. The regulations say the organisation investigating a complaint should send the complaint response within ‘the period of six months commencing on the day on which the complaint was received’.

19. We can see this happened as the Trust replied within three months of receiving the complaint, on 3 September 2024. For this reason we have not seen any indications of delays on the part of the Trust.

20. The Trust response explained the right to bring the complaint to the Ombudsman. It also explained ‘There is a time limit for making your complaint to the Ombudsman so you should do this as soon as possible.’

21. Mr B brought the complaint to the Ombudsman on 28 April 2025. This was over one year outside our time limit and almost eight months after the Trust response.

22. We asked Mr B the reason Mrs A had not brought the complaint to us soon after the response as advised. We asked if there was any reason another family member could not have brought the complaint sooner.

23. Mr B told us the response affected his mother’s mental health. He said there was no reason why he could not bring the complaint, he had waited until she was better to discuss it and then he had contacted the Ombudsman.

24. As outlined in paragraph 17, there are advocacy agencies available to help people to bring their complaint. The Trust told Mrs A about these advocacy organisations when it acknowledged her complaint in June 2024. We think it would have been reasonable for Mr B to seek the support of an advocacy organisation, to avoid the complaint falling even further outside our time limit.

25. To conclude, Mr B’s complaint about his father’s care and treatment was brought to us significantly outside our time limit. We do not think the explanations he has given are reason enough to set our time limit to one side.

26. We were very sorry to learn about what happened, and the impact this had on Mr B and his family. We understand how important the complaint is to him and his mother, and we are grateful to them both for sharing their concerns.

27. It is important we act within the law, and that we apply our current approach and process fairly and consistently. We are sorry for any upset this decision may cause. We hope this statement clearly explains the reasons why we will not be considering the complaint further.

1. Mr B’s complaint falls outside our time limit. We carefully considered his reasons for not bringing the complaint to us sooner. We did not think these were sufficient reason to set aside our time limit and so we will take no further action.

2. We thank Mr B for taking the time to tell us about his upsetting experience. We were sorry to read about the ongoing impact of this on him and his family. We hope this statement explains the reasons for our decision.