Warrington and Halton Hospitals NHS Foundation Trust

4. Dr D complains about aspects of care and treatment her father, Mr D, received from the Trust in mid October 2023.

5. Specifically, she said the Trust: • ignored her father's pain levels and denied him appropriate pain management • did not make a timely referral to the palliative care team.

6. She also said a Trust nurse made racist comments towards her father and misled the Trust about her concerns over her father’s care.

7. Dr D told us that as a result of the claimed failings, her father was left in extreme pain. She told us she believes his treatment was ‘inhumane’. She said her father suffered in his final days and that she and her family have been left deeply traumatised.

8. She is looking for an apology, service improvements and a significant financial remedy.

9. Mr D’s memory, thinking, language and decision making skills had declined between August and October 2023. He had a series of investigations including blood tests, a chest x-ray, an ultrasound of his kidneys, and a computerised tomography (CT) (a scan of the inside structures) of his head. The Trust did not believe there was treatment plan available.

On the 13 October 2023, a Trust consultant met with Dr D. The Trust said it would stop any invasive (putting medical instruments e.g. cannula, into the body) and distressing interventions, including blood tests and cannulation. The Trust started Mr D on a palliative care pathway after speaking with Dr D. It prescribed medication to support Mr D at the end of his life.

10. Mr D’s cannula became dislodged in the night. Trust staff followed his care plan and did not re-insert it.

11. On 14 October, the Trust on-call doctor stopped Mr D’s intravenous medications.

12. On the same day, the Trust prescribed and administered 3 doses of oxycodone (for severe pain) through injection.

13. On 15 October, the Trust prescribed and administered 3 more doses of oxycodone through injection.

14. On the evening of the same day, the Trust on-call medical team were asked to start a syringe driver. A syringe driver is a small pump used to administer medication under the skin, to manage symptoms.

15. On 16 October, at 1.08am, the Trust began using the syringe driver.

16. On 16 October, the Trust palliative care team received Mr D’s referral, after contact from the ward staff. The team did not pick up the referral sooner, as the team do not work over the weekend.

17. On 23 October, Mr D sadly died.

19. We use relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. In this case we have referred to the Health Service Commissioner’s Act 1993 (the Law).

20. 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. We have discussed this with Dr D to understand the reasons why she could not bring her complaint to us within this time frame. We have also considered the time the organisation has taken to respond to Dr D.

21. Dr D became aware she had reason to complain in October 2023.

22. In order for her complaint to be within the 12-month time consideration she should have brought her complaint to us by October 2024, at the latest. She brought her complaint to us in May 2025. The complaint is seven months out of time.

23. There is a gap of three months between when Dr D became aware of the concern and when she complained to the Trust. She states this is due to grief. There is a further gap of seven months between her receiving a response from the Trust and bringing the complaint to the Ombudsman.

24. Dr D told us she was waiting for the Grant of Probate (GOP) before bringing her complaint to us. It was not necessary for Dr D to have the GOP before bringing her complaint to us.

25. Dr D told us been deeply affected by her father’s experiences at the Trust and the process of complaining was not clear. We recognise that the death of a loved one can be a very difficult time.

26. Dr D complained to the Trust in January 2024. The Trust issued its final response in April 2024. Local resolution took three months to complete.

27.

28. Dr D has not provided any additional information as to why she waited one year and one month after receiving her final response from the Trust, before bringing her complaint to us in May 2025.

29. We recognise that the death of a loved one can be very difficult. We do not underestimate the impact this had on Dr D. Considering all the information provided, there was a delay of one year and one month after Dr D received the Trust’s final response. When she received the Trust response, she was still within our 12-month time consideration. We are not satisfied the reasons Dr D has provided for the delay, are enough for us to put our time limit to one side.

30. We recognise how difficult it is to make a complaint. We would like to thank Dr D for bringing her concerns to us.

1. We have carefully considered Dr D’s complaint about Warrington and Halton Hospitals NHS Foundation Trust (the Trust). We were sorry to hear about the treatment her father, Mr D received in mid October 2023.

2. The complaint falls outside of our time limit, and we have decided there is no good reason for us to put our time limit aside to consider it further.

3. We recognise that the death of a loved one can be very difficult. We do not underestimate the impact this had on Dr D. Taking into account all the information provided, there was a delay of seven months between Dr D receiving the Trust final response and bringing the complaint to us. We are not satisfied the reasons Dr D has provided for the delay, are enough for us to put our time limit to one side.