15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so, we have found the Trust has already done enough to put right the impact of these events.
Contradictory information
16. Mr A says the doctors provided contradictory information regarding his father’s treatment. Mr A says the conversation with him and his family is not the same as the alleged conversation doctors had with his brother the following day.
17. The Trust has explained the records show the decision to stop active treatment was a clinical decision. It has also explained there are records that show the family needed time to discuss this. The Trust could not identify a record of the exact discussions Mr A referred to, but we can see there is evidence to support his view, that the decision to stop treatment was made by the clinicians.
18. GMC guidance says ‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’ The evidence we have seen suggests the Trust gave the family information they needed regarding clinical decisions about Mr I’s care, whilst being sensitive to the timing of the implication of the decision.
19. We are unable to say for certain why’s Mr A’s brother has a different view. We can tell from the records his family wanted more time to discuss matters at certain points, and we understand the death of loved one is difficult and distressing to witness and experience.
20. Having carefully considered the available evidence, we did not see indications something went seriously wrong. In terms of communication, we can see the Trust did communicate Mr I was at the end of his life, and decisions made regarding his treatment were all clinical decisions. Therefore, we will not look into this part of the complaint further.
Records of conversations in medical records
21. Mr A says the conversations the Trust’s staff had with his family members were not appropriately recorded in his father’s records. We understand this must be frustrating to Mr A as he seeks a clearer understanding of what happened at the time.
22. Mr A says as a result of the conversations not being recorded in his father’s medical notes, his family have accused him of making the decision to withdraw his father’s treatment. He told us this caused him emotional distress and reputational harm. We can see from the records there was a conversation with Mr A and the family however there are no records of the alleged conversation with Mr A’s brother.
23. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided. As we are impartial, we must make robust decisions based on facts and evidence.
24. We do not doubt Mr A’s account or recollection of the conversation with his brother. When considering this point, we paid particular attention to what Mr A told us and looked to see if there was any evidence which we could use to support his account. We have been unable to identify any records or any other supporting information which would allow us to challenge or criticise the information provided by the Trust.
25. Unfortunately, Mr A believes a conversation between his brother and the doctor took place and we are not able to prove or disprove this. Regrettably, without further evidence we are not able to reach a view on whether something likely went wrong.
26. While we can appreciate this must be distressing and difficult for Mr A, we cannot see anything went wrong in this matter. This means we would be unable to make a decision on this part of the complaint.
Refusal to provide statement
27. Mr A says the Trust have refused to provide a statement to confirm he did not consent to the withdrawal of the medical treatment, and it was a clinical decision made by the clinical team.
28. The Trust have provided a letter from the oncologist who was dealing with Mr I’s care. Their letter states the decision regarding Mr I’s end-of-life treatment was a medical decision as the medical and nursing teams both recognised Mr I was coming towards the end of his life.
29. Furthermore, the Trust response confirms the decisions made regarding Mr I’s treatment were made by the doctors treating Mr I and not by his family.
30. While it is noted the treatment was initially stopped as Mr I did improve a little, his subsequent deterioration meant the medical team had a conversation with the family about putting Mr I on end-of-life care. The Trust said this was a medical decision as both the medical and nursing teams, including the Palliative care team, recognised Mr I was coming to the end of his life.
31. Our principles of good complaint handling Being customer focused | Parliamentary and Health Service Ombudsman (PHSO) says organisations should try and resolve matters informally where possible. In providing this response the Trust has taken steps to provide the information it felt Mr A was seeking whilst remining factual to the records. We are not critical of the response but recognise it did not meet Mr A’s expectations.
32. Having considered the available evidence, we have not found the Trust failed to provide assurances that all medical decisions were made by the clinicians in charge of Mr I’s care. The Trust have confirmed in its response that all medical decisions were made by the medical teams and not by any family members. Our NHS complaints standards (2022) say when an organisation investigates a complaint it should:
‘explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’
33. There is no specific wording which must be provided, and we find the Trust acted in line with our complaint’s standards. It provided a letter from the oncologist as well as confirming in its final response that all decisions made for Mr I’s care were clinical decisions. We did not see indications of failings in the refusal to provide a statement, so we have decided not to consider this part of the complaint further.
Delay in complaint handling
34. Mr A says the Trust’s delay in responding to his correspondence from January to May 2025 meant conversations could not be accurately remembered and it jeopardised the investigation into his complaint. He said he had emailed the consultant’s department directly and continuously sent follow up emails monthly until he received a response in May 2025 that he should submit his complaint formally to PALS.
35. The Trust has apologised for the delay in Mr A’s complaint being sent to PALS. However, it has said the doctor confirmed they did not recollect the conversation in any event, and even if the complaint went through in January, it would still remain unreasonable for a clinician to recall whether or not they had a conversation in April 2024.
36. The Trust added Mr A was aware his emails were not being read, as he had been receiving out of office response emails. Mr A did proactively try to contact other individuals through emails and phone calls; however, he could have potentially searched for the number for PALS or contacted another department if he wasn’t getting a response.
37. We cannot see any evidence the delay was on purpose, but we acknowledge the Trust did take too long to acknowledge his complaint, and this was not in line with our complaint handling guidance. The Trust has apologised but we need to be sure it has taken steps to prevent this happening again.
38. As part of this, we contacted the Trust and asked what steps it had taken to prevent these events happening again. The Trust confirmed the complaint was initially directed to the consultant and in May 2025, it was informed Mr A had still not received a response despite sending multiple emails. The Trust said importantly, Mr A’s initial correspondence was not raised as a formal complaint or PALS query at the time. The Trust said it liaised with the consultant, clinical lead and secretary to understand the situation. It determined the delay was due to a consent issue, and the reluctance to send a response without the necessary consent. Mr A was then advised to contact PALS and make a formal complaint.
39. The Trust have said it has taken learning from this experience. It said it has learned the importance of overseeing all complaints in the service to ensure full visibility and timely action. The patient experience team now oversees all the complaints the Trust receives, even ones directed to clinicians. This is so this team can check the progress of such complaints.
40. The Trust told us the approach is currently working well and it has received positive feedback from senior management and clinicians. We see, with the patient experience team having greater oversight of complaints, these staff are more likely to see and deal with any delays. This makes a repeat of Mr A’s experience less likely.
41. Our NHS complaint standards say organisations must ‘take action to make sure any learning is identified and used to improve services.’ Taking all this into account, we consider the Trust acted in line with our NHS complaints standards. It has also provided the outcomes Mr A told us he wants. This means we have decided not to consider this part of his complaint further.
42. We thank Mr A for taking the time to bring his complaint to our attention. We hope our explanation brings some reassurance about the care and treatment his father received and the improvements the Trust has made to its complaint handling process.