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University Hospitals Birmingham NHS Foundation Trust

P-004537 · Statement · Decision date: 22 December 2025 · View University Hospitals Birmingham NHS Foundation Trust scorecard
Complaint (AI summary)
Miss L complained the Trust failed to treat a gastrointestinal perforation during surgery, provided inappropriate aftercare, and delayed treatment for a gastric ulcer.
Outcome (AI summary)
The ombudsman closed the complaint because it fell outside the 12-month time limit, and no sufficient reason was provided to waive this.

Full decision details

The Complaint

4. Miss L complains about the care and treatment she received from the Trust. She says:

• during surgery in August 2021 the Trust failed to treat her gastrointestinal perforation • the Trust failed to provide appropriate aftercare following surgery in August 2021 • following the development of a gastric ulcer in September 2022 the Trust did not provide timely treatment

5. Miss L said the Trust not treating her perforation during surgery meant she suffered with acid reflux, she struggled swallowing, and she developed a gastric ulcer. Miss L said the Trust not providing appropriate aftercare caused her to experience rapid weight loss and it severely affected her physical and mental health. Miss L said the Trust not providing timely treatment to a gastric ulcer meant her health continued to deteriorate. Miss L said this experience has been devastating for her and has caused her needless pain, stress, depression and mental distress.

6. By bringing this complaint to us Miss L would like an apology, acknowledgement of failings, service improvements and a financial remedy.

Findings

9. 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.

10. The Trust performed surgery in August 2021 and Miss L has told us it did not treat her gastric perforation which was the reason for the surgery.

11. Miss L has told us she became aware the Trust had failed to treat her gastric perforation in approximately October 2022. Miss L said she was referred to a different consultant at the Trust in September and was seen the following month. Miss L said the consultant informed her the operation had not been carried out correctly.

12. We think a consultant informing Miss L the surgery was not carried out correctly would have reasonably made Miss L aware she was unhappy the Trust had not resolved her gastric perforation. We therefore think Miss L should reasonably have been aware of the need to complain in October 2022.

13. For this part of Miss L’s complaint to be in time, Miss L would have needed to bring her complaint to us by October 2023.

14. Miss L said the Trust also failed to provide aftercare following her August 2021 operation. We think the latest Miss L would have reasonably became aware the Trust failed to provide aftercare following surgery would be November 2021. Miss L said the Trust told her she would have a follow-up review (the Trust has acknowledged this should have happened six weeks after the operation) and be referred to a dietitian. Miss L has told us she lost a lot of weight and was unable to eat in the months after her surgery.

15. We think by November 2021, 12 weeks after the operation, Miss L would have reasonably became aware she was unhappy she had not received the aftercare service she was told she would. Miss L has told us she was unwell and losing weight during this period and we think she would have known she was unhappy she had not received the dietitian referral and follow-up.

16. For this part of Miss L’s complaint to be in time, Miss L would have needed to raise this by November 2022.

17. Miss L said in September 2022 she was admitted to the Trust due to the gastric issues she was experiencing. Miss L said the Trust later identified she was suffering from a gastric ulcer, and it failed to provide her with timely treatment for this. We can see in September the Trust performed a CT scan which showed no issues to the surgical site. We can see the Trust also performed an upper GI endoscopy in November which showed a gastric ulcer away from the surgical site in an unrelated location.

18. We think the latest Miss L would have reasonably known she was unhappy with the speed at which she was being provided treatment is December 2022. This is because we think Miss L would have reasonably known within four weeks of being informed she had a gastric ulcer, in November 2022, that she was unhappy she had not been provided treatment. Miss L has also told us her condition was deteriorating whilst waiting for treatment. Based on this we think Miss L’s date of knowledge is December 2022.

19. For this part of Miss L’s complaint to be within our time limit, the latest date we would have needed to have received this by is December 2023.

20. Considering the information above, we think Miss L became aware of the need to complain at the earliest in November 2021, and the latest in December 2022. We received Miss L’s completed complaint form in May 2025. This means Miss L’s complaint is approximately one year and five months out of time, from the latest date. The earlier events are even further out of time.

21. As explained above, 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 Miss L to understand the reasons why she could not bring her complaint to us sooner. We have also considered the time the organisation has taken to respond to Miss L.

22. Miss L raised her complaint to the Trust in January 2025. This was approximately two years and one month after the latest date Miss L became aware she had a reason to complain. We can see the Trust issued its response four months later in April. We can see local resolution was completed promptly within a four-month timeframe and we have taken this time into consideration when reaching our decision. We received Miss L’s completed complaint form the following month in May.

23. We can see there is an initial gap between when Miss L became aware she had a reason to complain (at the latest date in December 2022), and when she raised her complaint to the Trust in January 2025. We asked Miss L if she was able to explain the delay in raising her complaint to the Trust.

24. Miss L explained she was struggling to cope emotionally and physically with the aftermath of her surgery due to the gastric issues she was experiencing. She also told us of the difficulties she had in being unable to eat and weight loss. Miss L said she struggles to verbalise her problems as she has memory issues, and she was stressed and alone during this time period.

25. We recognise this was a difficult time for Miss L and she was struggling emotionally and physically due to the impact of her gastric issues. We appreciate these issues would have impacted Miss L’s ability to complain and was a distressing time for her.

26. We appreciate raising a complaint during this time would have been difficult, and we do not want to undermine the impact these events have had. We can see during this time Miss L moved home and was attending appointments at a second Trust. This suggests the reasons Miss L has provided did not affect her so significantly as to suggest she could not have brought a complaint to us sooner.

27. We have considered the reasons Miss L has provided for why she was unable to bring her complaint to us sooner. We acknowledge Miss L has been through a difficult time with her health and our decision is in no way intended to detract from that.

28. There is a very large initial gap between Miss L’s latest date of knowledge in December 2022, and her contacting the Trust to raise her complaint in January 2025. We do not have sufficient reason to explain why Miss L was not able to raise her complaint to us earlier.

29. Taking this into account, we do not consider it appropriate to set our time limit to one side. We understand Miss L will be disappointed by our decision and our decision is in no way a reflection of the seriousness of these events or how Miss L was affected.

Our Decision

1. We have carefully considered Miss L’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We were sorry to hear about Miss L’s experience with the Trust, and we recognise Miss L has been through a difficult and distressing time.

2. Miss L’s complaint about the Trust falls outside of our 12-month time limit. We have considered the reasons Miss L provided for why the complaint was not made to us sooner. Having considered all the circumstances of the complaint, including what Miss L told us, we have decided we cannot put the time limit to one side. This means we will take no further action.

3. In making our decision we do not want to diminish the seriousness of the issues involved and we thank Miss L for bringing her concerns to our attention.

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