NHS in England Closed After Initial Enquiries Search on PHSO website

Guy's and St Thomas' NHS Foundation Trust

P-004565 · Statement · Decision date: 5 January 2026 · View Guy's and St Thomas' NHS Foundation Trust scorecard
Complaint (AI summary)
Miss U complains that two Trusts failed to timely diagnose her cancer between 2018 and 2022, leading to a stage four diagnosis and more invasive treatment.
Outcome (AI summary)
The ombudsman declined to investigate the complaint as it fell outside the time limit, finding no strong reason to set the limit aside.

Full decision details

The Complaint

4. Miss U complains about the care and treatment provided to her by the Trusts during the period between 2018 and 2022 in which she claims they failed to diagnose her cancer upon presentation. She claims King’s College Hospital NHS Foundation Trust treated her without the appropriate referral meaning her cancer was not diagnosed or treated in a timely manner.

5. Miss U complains Guy’s and St Thomas’ NHS Foundation Trust delayed diagnosing her cancer due to a lack of action. Miss U believes that further tests and investigations should have been conducted by the Trust between April 2022 and June 2022.

6. Miss U claims that had an earlier diagnosis been made, this would have prevented her cancer from reaching stage four. As a result, she claims the treatment she required would have been less invasive with a reduced recovery time.

7. Miss U is seeking service improvements from both Trusts along with financial remedy.

Background

8. Miss U was a patient at Kings College Hospital NHS Foundation Trust between 2018 and 2022 where she first presented with concerns regarding the inner lining of her cheeks.

9. In January 2021 Miss U attended an appointment at Kings College Hospital NHS Foundation Trust in which staff in the oral medicine outpatient clinic examined her. Her medical notes note staff observed changes, but the changes did not cause them significant concern.

10. Miss U underwent a biopsy at Kings College Hospital NHS Foundation Trust in February 2022. Her medical records show staff noted intraoral changes. These changes were not of immediate concern, but staff planned to monitor them. They referred Miss U to Guy’s and St Thomas’ NHS Foundation Trust.

11. In April 2022 Miss U attended an appointment at Guy’s and St Thomas’ NHS Foundation Trust. The Trust advised during this appointment that Miss U would be added to a waitlist for an operation to remove the concerned area.

12. In April 2022, staff at Kings College Hospital NHS Foundation Trust saw Miss U. They noted no changes in her oral lesions.

13. Miss U attended a pre-operative assessment in June 2022. Miss U states she noted a visible deterioration in her condition at this appointment that she feels should have prompted a further review.

14. Miss U attended Kings College Hospital NHS Foundation Trust on 29 June 2022 as she was struggling to eat. A biopsy was taken and the Trust referred her back to Guy’s and St Thomas’ NHS Foundation Trust for review and assessment for surgery.

15. In July 2022, staff at Guy’s and St Thomas’ NHS Foundation Trust’s head and neck clinic saw Miss U. Staff explained her dysplasia (abnormal cells) had progressed into an ulcerated mass, indicative of cancer.

16. In August 2022 Miss U underwent surgery to remove the cancer.

Findings

19. 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 Miss U to understand the reasons why she feels she could not bring this complaint to us sooner. We have also considered the time each organisation has taken to respond to Miss U.

20. Miss U became aware she had a reason to complain about both Trusts in July 2022 following her cancer diagnosis. This diagnosis confirmed Miss U’s earlier suspicions that the Trusts had missed opportunities for earlier diagnosis and had delayed treatment to prevent her cancer from reaching stage four.

21. Miss U did not bring her complaint to us until June 2025, two years and 11 months later.

22. We acknowledge Miss U’s explanation for the delay in coming to us and appreciate the gravity of the procedure she had to undergo because of her diagnosis. We recognise, from July 2022, she had treatment for cancer. This included surgery in August 2022, which she told us she needed time to recover from.

23. We are sorry to hear about the physical and psychological impacts she told us her treatment had, and how this delayed her return to a normal life. We appreciate her health was a barrier to progressing her complaint at the time.

24. That said, we cannot see Miss U has explained barriers which prevented her from progressing her complaint for the entirety of this period.

25. Miss U stated she started her undergraduate degree in nursing in September 2023 after having deferred this course by a year following her diagnosis in July 2022. Upon consideration of this information, we deem it reasonable for Miss U to have been able to progress her complaint from September 2023.

26. We saw Miss U did not then complain to the organisations involved for over a year. She complained to Guy’s and St Thomas’ NHS Foundation Trust in October 2024. She complained to King’s College Hospital NHS Trust in March 2025. By this point, her complaint was outside of our time limit.

27. We recognise Miss U told us she was unable to complain sooner due to her being a student at King’s College Hospital NHS Trust. She only felt able to complain after a breakdown in communication with the organisation regarding her student placement in March 2025, after which she complained a few days later.

28. We do not consider this explains why she could not complain earlier. This is because she was able to engage with formal studies and so cannot see she was unable to raise a complaint due to illness. We do not see her being a student at one of the organisations involved prevented her from being able to make a complaint. Both Trusts would have been obligated to consider her complaint had she raised one.

29. This means we cannot see good reasons to explain the passage in time in Miss U complaining from September 2023. On this basis, we have not seen enough reason to set aside the time limit in this case. As such, we cannot take further action on her complaint.

30. We recognise Miss U has experienced ongoing health issues. She has told us how much this has profoundly affected her. We can see that she has tried to bring this complaint following exhausting local resolution with each of the Trusts. We are sorry that these have not been successful.

31. It is important we consider and act within the confines of the law. We regret any further upset this decision may cause Miss U. We hope this statement clearly sets out the reasons why we will not be pursuing her complaint further.

Our Decision

1. We have carefully considered Miss U’s complaint about Guy’s and St Thomas’ NHS Foundation Trust and King’s College NHS Foundation Trust (the Trusts). 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.

2. We recognise Miss U has experienced ongoing health issues. She has told us this has affected her profoundly and we were very sorry to hear this. We have taken Miss U’s concerns seriously and carefully considered them. Having done so, we do not consider Miss U has provided strong enough reasons, which would allow us to put our time limit to one side.

3. We acknowledge our decision will be disappointing for Miss U. We are sorry for any further distress our decision may cause, and we hope our explanation set out below shows clearly how we have considered her complaint and the reasons she has provided to us.

Other Decisions About Guy's and St Thomas' NHS Foundation Trust

P-004974 · 4 Mar 2026
Mr A complains about the care his son, C, received from the Trust in 2023. He says the Trust failed …
Closed After Initial Enquiries
P-004893 · 24 Feb 2026
Ms P complains about the care she received from the Trust in 2020 and between August 2023 and December 2023. …
Closed After Initial Enquiries
P-004753 · 30 Jan 2026
An NHS Trust discharged a patient before they were medically fit, failed to carry out an occupational health assessment, did …
Closed After Initial Enquiries
P-004749 · 30 Jan 2026
Mr A complains about the care provided to his wife, Mrs B, by Guy’s and St Thomas’ NHS Foundation Trust …
Not Upheld
P-004706 · 28 Jan 2026
Miss U complains about the care and treatment her mother received at a Trust.
Closed After Initial Enquiries
View all decisions for this organisation →