MRI scan after first seizure
25. In relation to this issue, we consider this aspect of the complaint is not yet ready for us to consider as it has not been raised to the Trust.
26. Mrs O complained there was a delay in the Trust completing an MRI scan on her husband after he had his first seizure/fall on 4 December 2020.
27. Mrs O said the discharge letter Mr O came home with, in December 2020 after the Trust had treated him, stated he had a head CT scan. Mrs O stated there was no mention of an MRI scan. Mrs O explained she contacted the hospital immediately regarding this. She stated it was difficult to get hold of the doctor to review his symptoms as well as to request and MRI scan. She confirmed she was calling the hospital about this as soon as Mr O came home, for him to have an MRI scan.
28. From the evidence available we can see Mrs O raises several concerns with the Trust between 19 September 2023 and 24 October 2023 about the care and treatment the Trust has provided to her husband. She raises these concerns to the Trust PALs and complaint departments. Within Mrs O’s correspondence at this time there is no reference to her concerns about the Trust delaying in completing an MRI scan after Mr O ’s first seizure on 4 December 2020.
29. Mrs O is in further contact with the Trust in February 2025 about her complaint. We have seen on 10 March 2025, the Trust send a complaint summary to Mrs O. The Trust provided its final response addressing the concerns raised in the complaint summary. Mrs O’s concerns about the Trust’s delay in completing the MRI are not agreed within the complaint summary. The Trust do not address this issue within its final response.
30. We acknowledge Mrs O’s comments that she attempted to contact the Trust at the time of the event to raise her concerns about her husband not having an MRI. From the evidence available to us, we do not know who Mrs O contacted at this time. We have not seen any evidence she followed this up as a formal complaint to the Trust. We do not dispute Mrs O’s version of events. Her concerns at the time appear to have just been raised to clinical staff, and not as a formal complaint to the Trust.
31. From the evidence we have seen when Mrs O raises her complaint to the Trust in October 2023 and February 2025, there is no reference to her complaint point about the Trust delaying in completing the MRI scan. Within the Trusts response, this is not an issue it has addressed.
32. Based on the above we are satisfied this is not an issue Mrs O has previously raised to the Trust as a complaint for it to address and respond to Mrs O about.
33. As Mrs O has not raised this issue with the Trust, it is not something we can investigate at this stage. In line with our guidance, we should allow the Trust the opportunity to respond to this issue.
34. We will therefore not look to investigate this component further at this stage. Mrs O would need to return to the Trust with this issue.
35. We appreciate this may be frustrating for Mrs O of having to return to the Trust, we need to ensure the complaint is ready for us to investigate. We need to allow the Trust the opportunity to respond and try to resolve the complaint first before we look to investigate this element of her complaint.
Treatment after Mr O seizures
36. 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 Mrs O to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Mrs O. Having done this, we have decided there is no good reason for us to put our time limit aside to consider it further.
37. Mrs O complains the Trust delayed in reviewing, and treating her husband after his seizures/falls on 4 December 2020 and 18 March 2021.
38. The events Mrs O complains about happened between December 2020 and March 2021. We asked Mrs O when she became aware she had a reason to complain about this issue, she confirmed in December 2020, immediately after her husband was first discharged by the Trust. She explains he was not the same person after his first seizure/fall.
39. Based on the above Mrs O’s date of knowledge regarding this issue is December 2020 to March 2021. For the complaint to be in time, Mrs O would have needed to complain to us by at least March 2022. Mrs O’s complaint to us was ready for us to consider on 20 May 2025. Therefore, she has made her complaint around three years outside of our time limit.
40. During my contact with Mrs O regarding her complaint she has explained she contacted the Trust straight away regarding this issue. She stated her pleas for help in 2020 to the hospital went unanswered as her calls went straight to voicemail. She explained the voicemail referred her to the website, which she stated looked untrustworthy at the time. She stated they went through years of this.
41. She also confirmed this was also when the covid-19 pandemic happened. Mrs O explained it was not until the hospital opened to the public, could she go and get a PALs leaflet with the details on she could trust. She stated this was in September 2023.
42. Mrs O further explained her husband was not allocated a consultant until Spring 2023, so prior to this there was not one to contact at the time. She stated she did not speak to a consultant until Spring 2023.
Reviewing the MRI scan
43. Mrs O complained the Trust delayed in reviewing the MRI scan it completed on Mr O in October 2021.
44. The Trust completed the MRI scan on Mr O in October 2021. Mrs O says the Trust did not give them the results of the scan until March 2023. She explained this was after many calls from herself and her family to the hospital.
45. The events Mrs O complains about happened between October 2021 and March 2023. Therefore, the events have been ongoing for some time. Mrs O confirmed she had made several telephone calls to the Trust during this period. It was only after these calls she says the Trust gave them the scan results.
46. Mr O had an appointment at the Trust on 10 May 2022, which is after he had had the MRI scan. On the basis Mr O had the scan by this appointment it is reasonable to conclude Mrs & Mr O would have been aware they had not been given the results of the scan at this appointment. Given this we can be satisfied Mrs O’s date of knowledge for this issue would have been around this time, May 2022.
47. For the complaint to be in time, Mrs O would have needed to complain to us by at least May 2023. Therefore, she has made her complaint around two years outside of our time limit.
48. Mrs O explained it is inexcusable there was such a delay in running the first MRI after 4 December and it is unacceptable there was such a delay in giving the results to the family. Mrs O says she first raised the complaint to the Trust in September 2023.
49. Mrs O stated there was no communication from the Trust during this period. She stated her husband did not have a neurological doctor allocated at the time, as her husband was on the waiting list.
Communication
50. Mrs O complains there was a lack of communication with the family about her husband’s condition and treatment since December 2020.
51. The events Mrs O complains about happened between December 2020 and February 2023. Therefore, the events have been ongoing for several years.
52. We appreciate this issue has been ongoing for Mrs O and her family for some time. It is evident the family have been unhappy with the lack of communication from the start from the Trust, since Mr O first attended at the hospital.
53. As the issues Mrs O complains about first started in December 2020, she would have known they had a reason to complain about the matter at this time. We asked Mrs O when she became aware she had a reason to complain about this issue, she confirmed in December 2020.
54. Based on the above Mrs O’s date of knowledge regarding this issue is December 2020. For the complaint to be in time, Mrs O would have needed to complain to us by December 2021. Therefore, she has made her complaint around three years and five months outside of our time limit.
55. Mrs O explained due to the Covid-19 pandemic she was not allowed to visit her husband at the hospital, so was unable to advocate for him in his vulnerable state.
56. She stated there was no communication from the Trust. She explained she was calling the switchboard at the hospital, where it constantly told her that her husband was on the waiting list to see the neurology doctor. She confirmed this appointment did not take place until February 2023.
57. Mrs O further explained PALs were very difficult to deal with. She stated it took a long time to find the correct department. She said the Trust were not answering her calls, so it was very difficult to send confidential documents. She explained this went on until she went to the hospital and she got the PALs leaflet around September 2023.
Our decision
58. We are very sorry to learn of the events that have led Mrs O to complain to us. We appreciate this will have been a very difficult and frustrating time for Mrs O and the family. We are sorry to hear of the deterioration of Mr O since his first seizure/fall in December 2020.
59. The law says a person needs to make a complaint to us within a year of becoming aware they have a reason to complain. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.
60. The complaint has come to us outside of the time limit. We have considered if we should set aside the time limit on this occasion and if the reasons Mrs O has provided, show a justifiable reason for the entire period of delay in them raising a complaint with us.
61. From the complaint correspondence we can see Mr O writes to the Trust on 19 September 2023, where he requests copies of all the scans completed. As this was just a request for scans, we do not consider this was a formal complaint raised. Mr O sends a further letter to the Trust on 12 October 2023, where he raises concerns about negligence due to a delay in investigation, review and treatment and not receiving a copy of the second MRI scan.
62. On 13 October Mr O sent a further letter to the Trust where he raised concerns about not being provided the second MRI scan, the cause of the seizures being unknown, there being a history of epilepsy on the discharge summary and the family’s concern his head injury is untreated. Following this the Trust respond to say it cannot accept the document as a complaint and will need some context in writing.
63. We can see Mr O sends a further letter to the Trust on 23 October about the delay in investigation and not having any treatment for the head injury, delay in the Trust reviewing the MRI scan, a forgery on the second MRI scan and stating Mr O does not have a history of epilepsy. We have also seen the same concerns were emailed to the Trust on 24 October 2023.
64. There does not appear to be any further response from the Trust following Mr O ’s further letter on 24 October 2023. We can see Mrs O chases up the Trust on 4 March 2024 regarding the complaint. We note on 18 September Mrs O contacts her MP about the issue and her MPs office explain they will chase this on 3 October 2024.
65. Mrs O first approached PHSO on 4 February 2025. Her case was closed at this time as she had not received a final response from the Trust, and the local resolution process was still ongoing.
66. We understand on 4 February 2025 Mrs O sent a further complaint letter to the Trust, regarding her concerns. We have seen on 10 March 2025 the Trust sent a summary of complaint to Mrs O, following a telephone discussion. The agreed summary was.
• delay in reviewing the MRI scan from 9 October 2021 • the discussion of the findings on the MRI scan from 10 April 2023 were not clearly explained and what radiology said • false diagnosis of epilepsy • lack of follow up appointments since May 2023 • delay in PALS response
67. The Trust provided its response to Mrs O’s complaint, on 12 May 2025, addressing the above points.
68. The Trust did not initially respond to Mrs O’s complaint that she initially raised in October 2023. The Trust did not provide its response until 18 months later, on 12 May 2025. We note this was after Mrs O raised a further complaint to the Trust on 5 February 2025. We consider there was a significant delay in the Trust responding to Mrs O’s complaint, with the local resolution process going on longer than we would expect.
69. When Mr and Mrs O first raised the complaint to the Trust in October 2023 this was still significantly outside of our time limit. With it being over one year (December 2020 to May 2022) from when they first knew they had a reason to complain about all the issues concerns. As such the time taken for the local complaints process to be completed is not a strong enough reason to put the time limit to one side.
70. We appreciate since Mr O had his first fall/seizure it has been very difficult for him and the family to get information and understand what treatment and investigations the Trust has completed. We understand it must have been very frustrating to Mr O and his family.
71. We acknowledge Mrs O’s reasons for not raising the complaint sooner to the Trust or PHSO. We recognise since Mr O had his first seizure/fall, Mrs O has explained she has attempted to contact the Trust about his treatment, but he was not allocated a consultant until later on. We also appreciate during the time the Trust was seeing Mr O, it was when the Covid-19 pandemic was happening.
72. The issues Mrs O complains about have been ongoing since December 2020. Based on this they would have known they had a reason to complain for several years. It is not until three years later when Mrs O first contacts PALs or the complaints team to raise her concerns.
73. We appreciate Mrs O stated she contacted the Trust straight away after her husband first had the seizure/fall but was unable to get through to anyone. We understand how frustrating this would have been.
74. We also note Mrs O’s concerns about not being able to visit the hospital due to the pandemic or trusting its website. We appreciate Mrs O’s concerns about this. We do recognise due to the Covid-19 pandemic it would have made communicating with the Trust more difficult for Mrs O.
75. On the Trusts website it details how to contact PALs and also how to raise a formal complaint if PALs cannot resolve it. There are links to email addresses, address details and an online complaint form to complete. We consider these details were available to Mrs O while the pandemic was ongoing and when her husband was under the care of the Trust. Based on this we can be satisfied she could have raised her complaint earlier using these details. We also consider she could have used these details if she was not able to speak to anyone directly at the Trust, through its switchboard.
76. We acknowledge Mr O may not have had a consultant allocated. We do not consider this would have prevented Mrs O raising a complaint to PALs or the Trusts complaints team.
77. Given the length of time the matter had been ongoing we consider it would have been reasonable for Mrs O to have raised the complaint earlier.
78. In line with the law, we are not able to look at historical issues that have been ongoing for several years. It would be unfair to all the parties to do this as people’s recollection of events would not be clear. Also records and evidence may not still be available because of the time that has passed.
79. We have carefully considered the time limit in line with our legislation, and we have considered the reasons Mrs O has given for the delay in coming to us.
80. Based on the information provided, Mrs O’s complaint is around two to three years outside of our time limit. We have not seen strong reasons to set aside our time limit in this case. We consider Mrs O could have approach us sooner, regarding these issues. For these reasons, we should decline these parts of the complaint as out of time.
Summary
81. We realise this is unlikely to be the outcome Mrs O was looking for when she had approached us. We were sorry to hear of the circumstances which led to her complaint, and we do not underestimate how difficult and worrying this whole experience was for her husband, herself and her family. We are sorry to hear of the impact this has had on them.
82. We hope our decision clearly explains the reasons why we will not be considering the complaint further. We would like to thank Mrs O for bringing her concerns to our attention.