2020 complaint 9. The Ombudsman’s powers are set out in the HSCA. This is the law that governs our work. Section 9(4) of the HSCA says a person needs to make their complaint to us within a year of becoming aware of the problem. It says we cannot investigate complaints brought to us after one year, unless we see there is a good reason to do so.
10. When speaking with Ms C she told us she had reason to complain from the start of her father’s admission on 9 June 2020. As her complaint is about events throughout this admission, we consider she became aware of all aspects of this complaint by the date her father was discharged, 29 October 2020. We call this the ‘date of knowledge’.
11. For the complaint to have come to us in time, it would have needed to have been brought to our Office within 12 months of the date of knowledge, by 29 October 2021. We first received this complaint from Ms C on 11 July 2025. This means it came to us over three years and eight months outside of our 12-month time limit.
12. When any complaint comes to us outside of our time limit, we must consider the time taken by the person complaining and the time taken by the Trust to respond.
13. Information Ms C shared with us confirmed she did not raise her complaint to the Trust about her father’s 2020 admission until 10 December 2024. This was over four years after her date of knowledge and is a considerable period of delay.
14. We spoke with Ms C to understand the reasons for this delay. Ms C explained she was continually at the hospital during her father’s admission from June 2020 and after her father was discharged home in October 2020, he was no longer able to live independently. She said her life was thrown into complete chaos, that she became his full-time carer, and was unable to take a shower without him calling to her for help or leave him alone with carers from the council when they attended.
15. Ms C said her mother then became unwell and died at the Trust in May 2021. Ms C explained she suffered considerable emotional trauma from both the change in her father’s life, the change in her own life, and in dealing with her grief after the loss of her mother, which was compounded by finding her mother deceased at the Trust. Ms C said caring for her father had to take priority, that there was no time or support to complain.
16. We recognise the shock and incredible change to daily life that Ms C experienced once her father was hospitalised and after his discharge home in 2020. We acknowledge how difficult it must have been for Ms C to have undertaken the duty of becoming her father’s carer, alongside then losing her mother in such tragic circumstances in May 2021, at an already difficult time. We also recognise that Ms C was then grieving the loss of her mother, and we respect that complaining was not Ms C’s priority at that point.
17. It remains Ms C did not complain for a further three and a half years after the loss of her mother. At the time she complained nearly 12 months had passed since her father’s sad death, meaning nearly a full year when she was no longer having those caring responsibilities.
18. We know grief is not linear, nor is it time bound. We accept that for some, a period of pause is needed during times of grief before matters such as pursuing a complaint can then commence. This remains a period that was so significant, we do not see there were barriers in place throughout this number of years, to have prevented Ms C from raising her complaint much sooner.
19. Ms C told us she was emailing the Trust’s Patient Advice and Liaison Service and raising concerns whilst her father was in hospital in 2020. This indicates to us that even during that immediately difficult and exhausting period in her life, Ms C was able to and knew how to raise concerns. We cannot see why she was unable to raise her formal complaint about the 2020 admission at that time, or much nearer to the time of the events.
20. Ms C told us some 10 weeks after her father’s discharge she was in contact with The Sepsis Trust who provided information, help and support, and suggested advocacy assistance. We can see Ms C engaged with an advocate when she made her complaint in 2024, and yet we are left without good reason why she did not pursue the support of an advocate offered to her at that much earlier time, to have complained sooner.
21. Ms C also told us there were delays in the Trust processing her requests for her father’s records, in turn delaying the complaint process. Whilst we understand Ms C chose to explore the paperwork, to do her own research and in effect gather her own evidence, this is not a requirement to complain. To make a complaint about NHS care, either to the Trust or to our Office, it is not required or expected that the person conducts their own investigation or has a fully formed view or supporting evidence, before they can do so.
22. We explained earlier that when any complaint comes to us outside of our time limit, we must also consider the time taken by the Trust to respond. The regulations tell us and the NHS about the complaints process and how to investigate and respond to complaints. They say the organisation investigating a complaint should send the complaint response 'within the relevant period', which it defines as 'the period of 6 months commencing on the day on which the complaint was received'.
23. The time between the Trust receiving Ms C’s complaint on 10 December 2024 and sending its response on 24 March 2025 was three and a half months. This is within the period set out in the regulations, meaning we do not find any delay on the part of the Trust to be cause for the complaint coming to us outside of our time limit.
24. We have considered the relevant factors and the law, and we do not see exceptional reason to set our time limit aside. We have therefore decided not to consider this complaint further.
2023 complaint 25. The HSCA says we cannot investigate a complaint where a person has the option to take legal action, unless we consider it is not reasonable for them to do so. We do not base our decision on how successful legal action would be. Rather, we consider whether legal action is a reasonable option for someone to pursue.
26. We discussed this with Ms C to understand her circumstances and the outcomes she seeks. Ms C told us the sole outcome she seeks is financial compensation, of at least if not more than £20,000.
27. Financial compensation is something that can be pursued through legal action, specifically through a clinical negligence claim.
28. We are generally not able to provide the same levels of financial remedy that a court can. Whilst we can make some recommendations for financial remedy, we would not achieve the amount Ms C has come to us seeking. The courts are best placed to consider this more significant financial outcome for Ms C.
29. In her complaint to us, Ms C advised she had not pursued the legal route as she does not have the funds to engage a solicitor. Yet, Ms C has the option of seeking free legal advice, which she is yet to explore. Ms C could seek legal representation under a conditional fee arrangement, commonly known as a ‘no-win-no-fee’ basis, which would not incur any upfront costs to her. By seeking legal advice Ms C can obtain the necessary help and support for free, to better understand this process from the relevant legal adviser.
30. We explained that in line with our law, Ms C needs to explore her legal options now. Our process is not a precursor to taking legal action and instead, the HSCA says she should explore the option of legal action first.
31. There is a three-year time limit for most clinical negligence claims. Ms C is still within this three-year time limit for her 2023 complaint, and therefore still has the option to take legal action.
32. We have considered the relevant factors and the law. Ms C is still in time to pursue legal action regarding her father’s 2023 admission. We would not achieve the amount she seeks, and the legal route is better suited to do so. We do not see any barriers to prevent Ms C from exploring this option currently, and in line with our law, we think it is reasonable that she does so. We have therefore decided not to consider this complaint further.
In conclusion 33. We are very sorry for any disappointment caused by our decision. We are very grateful to Ms C for bringing her complaint to us and for speaking with us so openly about what happened. We understand the entirety of this period was very difficult for Ms C and we know how important her complaint is.
34. We must apply the HSCA fairly, and this includes our time limit and consideration of any alternative legal remit. We hope this statement clearly explains the reasons why we will not be considering Ms C’s complaints further.