12. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.
13. We have discussed this with Mr D to understand the reasons why they could not do so. We have also considered the time the Trust has taken to respond to Mr D’s complaint.
14. Mr E was admitted to the Trust’s urology department in August 2022 with symptoms of urinary retention (bladder does not completely empty which can cause complications including an infection) and an enlarged prostate (a condition causing urinary symptoms and discomfort). The Trust completed a physical examination of Mr E’s prostate and noted it was soft.
15. During a follow up appointment in November 2022, the Trust carried out a PSA test. The blood result was reported on 15 November showing a result of 529.17 (the normal result for a PSA is below 5). The Trust missed this result.
16. The family explain Mr E started to lose weight rapidly during this time and his general health deteriorated.
17. Mr E was admitted to the Trust’s emergency department (ED) on 2 March 2023 with shortness of breath and deterioration. The Trust then referred him to the urology team on 7 March 2023, where clinicians recognised the PSA result from November 2022. A registered nurse informed Mr E of his prostate cancer diagnosis on 7 March 2023.
18. During his admission, clinicians gave Mr E an enema without a call bell which left him unable to call for help from the nursing team.
19. Mr D and his sister made a formal complaint on 7 May 2023. They attended a local resolution meeting (LRM) with the Trust on 21 June 2023. The Trust posted a recording of the meeting to the family in November 2023.
20. Mr D and his sister made a further complaint to the Trust on 14 December 2024. The Trust responded to this on 3 March 2025.
21. Mr D told us his date of knowledge was initially 7 March 2023, when his father was informed of his prostate cancer diagnosis. His second date of knowledge was during his father’s admission when he was left unsupported after taking an enema.
22. We consider Mr D had reasons to formally complain from 7 March 2023 onwards. Given Mr D and his family were focussed on their father’s treatment, we are not critical of the fact that he did not formally complain at this point. We consider Mr D’s date of awareness of the main crux of his complaint was when his father had died, which was around 14 April 2023.
23. This means for Mr D to be within our time limit, he should have complained to us by around April 2024. He complained to us in May 2025. This means his complaint is outside our time limit by around one year and one month.
24. In total the Trust took one year and seven months to investigate and respond to this complaint. During this time, we can see there were periods of time where nothing happened to progress the complaint, specifically between August to December 2024 and from March to May 2025.
25. Mr D told us during the LRM on 21 June 2023, the Trust suggested Mr E’s GP would have been notified of his PSA test results in November 2022. The Trust also explained that it would be discussing this complaint at a higher level and any learning identified would be shared with the family.
26. Mr D says he arranged a meeting with their father’s GP to rule out if it needed to be included in the complaint. Following a meeting with the GP in August 2024, it confirmed it had not received the PSA test results in November 2022.
27. Mr D told us that despite chasing the Trust they did not receive any further information regarding its internal investigations. During this time the family also requested a copy of their father’s medical records, which they received in August 2024. The family then took over three months to make their second complaint to the Trust in December 2024.
28. In the Trust’s final response dated 3 March 2025, it says the complaint will be shared at the urology governance meeting for learning and Mr D says the family were waiting for further information regarding this. As the Trust shared no further information with the family, they decided to bring the complaint to us in May 2025, which is a further two-month delay.
29. We recognise it was important for the family to rule out any complaint against their father’s GP. We also appreciate they were waiting for the Trust’s medical records and a further response from it regarding its own internal investigations. We are therefore not critical of the period of delay from November 2023 to August 2024.
30. We are very sorry to hear about Mr D’s complaint. We recognise the circumstances leading to his father’s death has had a profound impact on him and his family. Mr D explained members of his extended family are being treated for prostate cancer and have been living with this condition for many years. He says the fact his father was not given the opportunity to commence treatment is distressing for him. We are sorry to hear the lengthy local resolution process caused the family frustration and compounded their grief.
31. We have carefully considered Mr D’s explanation for the delays. We consider the family could have brought their second complaint to the Trust sooner. Also following receipt of the Trust’s final response on 3 March 2025, Mr D could have brought this complaint to us sooner. There are not, therefore, strong reasons to explain the delay from August to December 2024 and from March to May 2025. In these circumstances, it is difficult not to come to the view the family could have complained to us earlier. We therefore cannot see strong grounds to set aside the time limit.
32. Whilst we do not diminish the impact this complaint has had and continues to have on Mr D and his family, the regulations which govern our work state, a complainant must complain within one year when they first become aware they have a reason to complain. From the information we have seen, we consider Mr D could have brought his complaint sooner to us.
33. We consider the delay in bringing this complaint to us is too long for us to set to one side. We have decided not to consider it further.
34. We thank Mr D for bringing his complaint to us.