University Hospitals Birmingham NHS Foundation Trust

3. Mrs A complains about the care and treatment her late mother, Mrs L, received from the Trust between July and August 2023.

4. Mrs A says staff at the Trust placed Mrs L on a dialysis chair that was known to be faulty and the chair collapsed while Mrs L was sitting on it. Mrs A says Mrs L sustained an injury to her leg because of the faulty dialysis chair. Mrs A also says staff failed to document this incident.

5. Mrs A says the Trust did not carry out an appropriate discharge care package assessment on Mrs L. Mrs A says because of this failing, the discharge failed. She says this led to Mrs L being discharged home too early and without adequate equipment, or with an at home care plan in place.

6. Mrs A says this placed her and her family in an unacceptable and difficult situation. They tried to keep Mrs L safe and support her safely to the bathroom. However, Mrs A says her Mrs L fell out of bed forty-eight hours after being discharged home, as there was only one bed rail instead of two, and Mrs L sustained an injury to her head and was readmitted to the Trust.

7. Mrs A says she and her family are experiencing ongoing distress, guilt and heartbreak knowing they were unable to keep Mrs L safe when she was at home. Mrs A says she and her family will continue to experience nightmares for the rest of their lives.

8. Mrs A would like the Trust to acknowledge the failings and make service improvements.

9. Mrs L attended the Trust’s Emergency Department in early July 2023 with generalised weakness and was admitted on the same day. The Trust transferred Mrs L to a ward the following day. Mrs L was discharged from the Trust in early August and then readmitted forty-eight hours later, due to falling out of bed and injuring her head.

10. On the same day Mrs L’s son, Mr Y, complained to the Trust by email about Mrs L’s care and treatment. Mr Y raised a further concern to the Trust by email the following day. In midAugust Mr Y wrote a letter to the Trust to confirm all the concerns he had about Mrs L’s care and treatment.

11. Later in August, Mrs L sadly died. The Trust provided its response to the complaint in mid-November. The Trust signposted our service in the response and explained our time limit.

12. In early April 2024, Mrs A brought the complaint to us. Later in April we explained to Mrs A the complaint was not ready for us, as she still had concerns that she wanted the Trust to address. We advised Mrs A to return to us if she remained unhappy with the Trust’s further response and we also advised her about our 12-month time limit.

13. Mrs A raised her further concerns to the Trust in early June. The Trust acknowledged the further concerns soon after this and provided its final response to the complaint in February 2025. The Trust again signposted our service and our time limit in its final response. Mrs A brought the complaint back to us in early August 2025.

16. 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.

17. Mrs A says she and Mr Y became aware they had reasons to complain about the care and treatment Mrs L received from the Trust in early August 2023. In line with our legislation, Mrs A or Mr Y needed to bring the complaint to us by early August 2024, for it to have been brought to us within our time limit.

18. Mrs A first brought the complaint to us in early April 2024. The complaint was within our 12-month time limit at this point, but it was not ready for us at that time, as Mrs A had further issues she wanted to raise with the Trust.

19. Mrs A then brought the complaint back to us in early August 2025. At this point, the complaint was one year outside our 12-month time limit. Mrs A’s complaint is therefore out of time. We have considered the reasons for this, to see if there was a good reason why the complaint could not have been made to us sooner.

20. During our consideration of the timeline of the complaint, we have taken account of the time the Trust took to respond to Mr Y and Mrs A’s complaints. This is because they had no control during this period. Therefore, they were not responsible for any delays during this period.

21. We considered the timeline of the events to establish if there were any periods where Mr Y and Mrs A did not progress the complaint and considered their reasons for this. We have found there were three periods where Mr Y and Mrs A did not progress the complaint.

22. The first period is when Mrs A waited just under five months, from mid-November 2023, when the Trust sent its initial response, until early April 2024, when she first brought the complaint to us. We asked Mrs A about her reasons for not pursuing her complaint during this period.

23. Mrs A told us during this period, her family (four siblings) were considered the response from the Trust, and it took them time to consider their options. Once her siblings were all in agreement, they escalated the complaint to us, rather than go back to the Trust.

24. The second period is when Mrs A waited just under two months from early April 2024, when we told her the complaint was not ready for us, until early June 2024 when she raised further concerns to the Trust.

25. We asked Mrs A about her reasons for not pursuing the complaint during this period. Mrs A told us during this period, she did not want to raise further concerns to the Trust, as she wanted an independent enquiry. However, we can see she did follow our advice and raised further concerns to the Trust.

26. She also said that to her knowledge, our 12-month time limit was never highlighted to her. Our note of the telephone conversation Mrs A had with us in April 2024 shows the 12month time limit was discussed during the call.

27. The third period is when Mrs A waited two months from early February 2025 when the Trust sent its final response, to early April 2025 when Mrs A brought the complaint back to us.

28. We asked Mrs A about her reasons for not pursuing the complaint during this period. Mrs A said during this time, she was again reviewing the Trust’s response and liaising with her family on how to proceed further.

29. We acknowledge Mrs A and her family have been through a difficult time. While acknowledging what they have been through, we do think there appears to have been a few opportunities for Mrs A to bring the complaint to the Trust and to us sooner.

30. The first is in mid-November 2023, when Mr Y had an initial response from the Trust. We think there was an opportunity here for him to reflect on the Trust response and go back to it with any further concerns. He could have also brought the complaint to us soon after this time too, as the Trust had signposted Mr Y to our service and informed Mr Y of our time limit.

31. The second is in mid-April 2024, when we informed Mrs A her complaint was not ready for us, and she needed to raise her further concerns to the Trust. We think there was an opportunity here for Mrs A to raise her further concerns to the Trust sooner, as we had informed her of our 12-month time limit.

32. The third is in early February 2025, when Mrs A received the final response from the Trust. We again think there was an opportunity here for Mrs A to bring the complaint back to us. As the Trust had clearly signposted our service and again referenced our time limit. So, this would now be the second time the Trust had made Mrs A aware of our time limit.

33. We sympathise with Mrs A and her family for the difficult situation they have been in.

34. The evidence we have seen shows there were long delays in Mrs A raising her complaint to us. And there were further delays in raising further concerns to the Trust when we decided the complaint wasn’t ready for us. We think this then led to delays in Mrs A bringing her complaint back to us, putting her complaint outside of our 12-month time limit.

35. We recognise how upsetting the events within Mrs A’s complaint have been and continue to be for her and her family.

36. We have considered all the evidence, including Mrs A’s reasons for the delays and the time taken for local resolution to be completed. We have decided not to set the 12-month time limit aside. We have decided to take no further action on Mrs A’s complaint.

37. It is important we consider and act within the law and we regret any further upset this decision may cause to Mrs A and her family. We hope this statement clearly explains the reasons for our decision and why we will not be considering the complaint further.

1. We have carefully considered Mrs A’s complaint about the care and treatment her late mother, Mrs L, received from a Hospital in Birmingham (the Trust). We were very sorry to hear about Mrs L’s experience at the Trust and of the impact these events had on her and her family. We recognise Mrs A and her family have been through a difficult and distressing time.

2. Miss A’s complaint falls outside of our 12-month time limit. She has provided us with her reasons for bringing her complaint to us outside of our 12-month time limit, and we have carefully considered these. Having considered all the circumstances of the complaint, including what Mrs A told us, we have decided to take no further action.