Chesterfield Royal Hospital NHS Foundation Trust

4. Mr X complains about aspects of care and treatment, his mother, Mrs X, received from the Trust, in January 2024 when she went to A&E with Atrial Fibrillation (a type of heart rhythm problem where the heartbeat is not steady).

5. Specifically, Mr X said the Trust: • did not involve the family, when it chose not to prescribe anti-coagulation medication on 13 January 2024 • failed to identify Mrs X had suffered a stroke, whilst in A&E on 29 January 2024

6. Mr X told us the impact of the claimed failings is the family may have decided to request Mrs X received the anti-coagulation medication. He believes not being able to make this decision led to his mother having two strokes and a heart attack.

7. He said he feels guilty for not reminding his mother and the Trust about blood thinners.

8. Mr X said he believes that his mother had an avoidable distressing end to 97 years of life, ending on sedation and pain killers through a syringe driver.

9. He is looking for the Trust to acknowledge the failing in his mother’s care and treatment. He would also like service improvements.

10. Mr X has told us Mrs X went to A&E in January 2024 with Atrial Fibrillation. A Trust doctor mentioned anti coagulation medication but this was not discussed again. The Trust discharged Mrs X two days later. Mr X told us the Trust did not discuss Mrs X’s stroke and bleeding risk with her or her family. The Trust did not prescribe the anti-coagulation medication to Mrs X.

11. The Trust admitted Mrs X again two weeks later when she went to A&E with atrial fibrillation.

12. Mr X has told us that Mrs X’s family recognised signs that she had suffered a stroke (when blood stops flowing to a part of your brain) in A&E and had informed Trust doctors. The Trust completed tests late the following afternoon and said Mrs X had a bleed on her brain (a type of stroke). The Trust discharged Mrs X on 31 January 2024 with an End-of-Life package of care. Mrs X was residing in a nursing home when she suffered a further stroke on 5 March 2024.

13. Sadly, on 3 June 2024, Mrs Xdied.

14. 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).

15. 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 Mr X to understand the reasons why he could not do so. We have also considered the time the Trust has taken to respond to Mr X.

16. Mr X told us he became aware he had reason to complain in January 2024. To be within our 12-month time consideration, he should have brought his complaint to us by January 2025. Mr X did not bring his complaint to us until June 2025. Mr X’s complaint is five months outside our 12-month time consideration.

17. Mr X complained to the Trust in February 2024. The Trust sent its final response in November 2024. Local resolution took nine months.

18. The Trust response is clear that it will not respond to further questions related to his complaint and referred Mr X to PHSO. Mr X wrote to the Trust on 9 December. As detailed in its letter dated 22 November, the Trust did not respond. Mr X’s letter was about Mrs X’s care and treatment, discussing points already raised.

19. Mr X initially brought his complaint to PHSO in February 2025. We told Mr X that we required additional information to investigate his complaint. He said he would send this.

20. On 8 June, Mr X emailed PHSO to ask for an update on his complaint, and to advise us of a new email address. We advised him that we had not received the documents we requested after his initial contact in February. Mr X said he had sent the documents to us. He told us he had sent them to a non-monitored email address. He apologised for his error.

21. In reviewing Mr X’s reasons for the delay, we are not satisfied we have seen good reason to put aside the time limit. Mr X received the final response in November 2024. He had two months to bring his complaint to us before the 12-month time limit, in January 2025. He brought his complaint to us in June 2025.

22. We understand how difficult it can be to make a complaint. We would like to thank Mr X for bringing his concerns to us.

1. We have carefully considered Mr X’s complaint about the Trust. We were sorry to hear of the issues Mr X had with the care and treatment provided to his mother, Mrs X.

2. We appreciate this was a very distressing time for both Mr X and Mrs X. We are grateful for the time and effort Mr X spent bringing the complaint to our attention.

3. After considering the relevant information, we have decided the complaint falls outside the time limit. We have seen no good reason for us to put our time limit aside to consider it further