Torbay and South Devon NHS Foundation Trust

3. Mr N complains the Trust has not responded to his complaint about its patient safety review following his wife’s death. Specifically, he says it has not addressed his question about the involvement of Mrs N’s GP and haematologist (a specialist in blood diseases) in the review.

4. Mr N says this has left him annoyed and with unanswered questions about whether Mrs N’s death could have been delayed.

5. Mr N wants the Trust to explain why the GP and haematologist were not contacted as part of the patient safety review.

6. On 12 October 2023, Mrs N was admitted to the emergency department of the Trust by ambulance. This was due to shortness of breath and a dry cough that had been present for over a week.

7. On 13 October 2023, Mrs N was transferred to the respiratory ward and sadly died later that day.

8. On 11 March 2024, the Trust advised Mr N they would be conducting an investigation into his wife’s death. It provided its response (the patient safety review) on 13 September 2024.

9. A patient safety review is an analysis of a patient safety incident. A review takes place when something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm for one or more person(s) receiving healthcare.

12. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore if the organisation would be willing to take further steps to put this right and resolve the complaint.

13. Mr N complains about the Trusts Patient Safety review that took place following Mrs N’s death. Mr N complains the Trust did not consult with Mrs N’s GP and haematologist as part of their review. Following the review, Mr N raised his concerns with the Trust. The Trust offered a local resolution meeting, however, Mr N declined and requested a written response. Mr N tells he did not receive this.

14. As an outcome to his complaint, Mr N told us he wanted answers to why doctors his wife had regular contact with were not part of the review undertaken by the hospital. He says their input could have answered questions he has about whether his wife’s death could have been delayed.

15. The Good complaint handling guide explains how organisations should clarify complaints and explain their complaint processes. It sets out the types of things organisations should explain about their investigation process, including who is involved and how evidence will be gathered.

16. We have reviewed the Trust’s complaint responses including the patient safety review and cannot see the Trust did not provide a response to Mr N’s concerns. As we consider the Trust’s actions were not in line with the aforementioned guidance.

17. During this process, we contacted the Trust on 26 November 2025 to see if it would be willing to answer Mr N’s questions in writing. The Trust agreed to this and confirmed to us on 23 December 2025 that it will send him a written response. The letter will explain why the regular GP and Haematologist were not included in the patient safety review.

18. We approached Mr N and explained the Trust was willing to take steps to resolve his complaint. Mr N was happy with this and confirmed a written response from the Trust would resolve his complaint.

19. Our NHS Complaints Standards (2023) say organisations should find ‘suitable and appropriate ways to put things right for people who raise a complaint’. The Trust has agreed it will complete this action by 31 January 2026.

20. We are satisfied this action will resolve Mr N’s complaint and this is in line with our Principles of Good Complaint Handling Guide. For this reason, we will not be taking any further action on Mr N’s complaint.

21. We would like to thank both parties for their cooperation and understanding during this process.

1. We have carefully considered Mr N’s complaint about Torbay and South Devon NHS Foundation Trust (the Trust). We are sorry to learn of the circumstances of Mr N’s complaint and the impact this has had on him.

2. We have discussed Mr N’s concerns, including the outcomes he is seeking, with the Trust. Following our discussion, the Trust has agreed to provide Mr N with a response to his outstanding questions. We are satisfied these actions are in keeping with our principles of good complaint handling. We explain this in more detail below.