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Epsom and St Helier University Hospitals NHS Trust

P-004779 · Statement · Decision date: 4 February 2026 · View Epsom and St Helier University Hospitals NHS Trust scorecard
Choice and Consent End of life care Administration Complaint record keeping failures
Complaint (AI summary)
Mr A complained the Trust reduced his mother's oxygen and removed life support without consent, against medical advice and her best interests.
Outcome (AI summary)
The complaint was closed as it fell outside the PHSO's time limit, and there was no good reason to extend the time limit.

Full decision details

The Complaint

3. Mr A complains about the treatment his mother, Mrs B, received from the Trust. Mr A complains on 24 May 2022 the Trust: • reduced his mother’s oxygen supply against medical advice • removed his mother’s life support without her consent and without the consent of her next of kin, without a court protection order and against his mother’s best interest.

4. Mr A told us the loss of his mother in these circumstances has caused himself and the whole family a great deal of emotional distress. This is because he believes his mother died a horrible painful death that the Trust could have avoided.

5. Mr A would like the Trust to formally review the incidents that led to his mother’s death. He would also like service improvements, so similar incidents do not happen again. He would also like the Trust to apologise to him and pay a financial remedy in recognition of the trauma he has been through.

Background

6. Mrs B sadly passed away on 24 May 2022. Mr A attended meetings with Trust staff that day as he had concerns about the way his mother was being treated.

7. On 15 June 2022 Mr A made a complaint to the Police in relation to the circumstances around his mother’s death.

8. Mr A first complained to the Trust on 22 August 2023. His complaint included the issues he has asked to consider.

9. The Trust responded on 23 April 2024. The Trust confirmed that following Mrs B’s death it had carried out a Structured Judgement Review (SJR), which is the process used to review the care received by patients who have died. The Trust told Mr A the review did not highlight any area of concern in his mother’s care, including criminal activity by the clinicians caring for her.

10. On 8 October 2024, Mr A contacted the Trust again about his concerns. On 20 December 2024 it issued him a further response addressing the same two issues he had previously complained about. Mr A remained dissatisfied and approached our Office on 24 April 2025.

Findings

13. The Health Service Commissioners Act 1993 says a person needs to complain within a year of becoming aware of the problem. We cannot investigate complaints brought to us after more than one year, unless we can see there is a good reason to do so.

14. We can see Mr A was aware of his concerns about his mother’s care and treatment on 24 May 2022. This is because he met with staff about them. To be within the time limit to complain, Mr A needed to complain to us by 24 May 2023. As he did not complain to us until April 2025, Mr A’s complaint is out of time by approximately one year and 11 months. We have therefore considered the reasons for this, and whether we should put our time limit to one side.

15. Following the death of Mrs B on 24 May 2022, Mr A first complained to the Trust on 22 August 2023. This is one year and three months after he became aware that he had reason to complain.

16. We asked Mr A why he waited until August 2023 to complain to the Trust. He told us that following the death of his mother he suffered from Post Traumatic Stress Disorder (PTSD) which he struggled to recover from and still affects him today. Mr A told us his PTSD meant he could not approach the Trust sooner than he did. He also said there was a delay because he had reported the issues to the police and Coroner and was waiting for those investigations to be completed before raising an official complaint with the Trust..

17. We acknowledge this was an incredibly difficult time for Mr A. We do understand why he did not feel ready to raise an official complaint straight away, especially given his comments about suffering from PTSD. We realise Mr A and his family would have needed to take some time to come to terms with what had happened and to formulate a complaint. We do not think, on its own, that explains the lengthy delay in complaining. We note that Mr A was able to raise his concerns with the police, and the coroner, promptly at the time. We see no reason why he could not have done the same with the Trust.

18. Mr A told us he could not complain sooner as he was waiting for the police to complete its investigation first. On 22 June 2022 the police updated Mr A in relation to its investigation. In this update the police told him that at that time it did not suspect a crime had taken place and he could complain to the hospital or consult a solicitor.

19. Following this update there would be no reason that Mr A could not then raise a complaint with the Trust as he had been told there was no ongoing police action.

20. Mr A told us that waiting for the coroner to investigate his mother’s death was another factor which contributed to the delay in him making a complaint. From the information available to us we can see that the coroner decided not to complete a forensic post-mortem once the police made the decision referred to above.

21. Once Mr A knew that the coroner was not completing a forensic post-mortem, there would be no reason that not to complain to the Trust. In its update the police specifically told Mr A this option was still open to him at the time.

22. We can see that during this time Mr A raised his concerns with the police and the coroner and was able to provide statements when needed. We do not see there was anything to stop him approaching the Trust with an official complaint much sooner than he did, especially once the police had informed him that they would be taking no further action and advising him he could do so.

23. Following the update he received from the police in June 2022, it was another one year and two months before Mr A complained to the Trust. His complaint was already out of time by then.

24. There were also delays on Mr A’s part after he complained to the Trust. He received the Trust’s initial response on 23 April 2024. He sent a follow-up complaint on 8 October 2024, over five months later. The Trust sent a further response, in December 2024. The Trust sent its final response in January 2025. Similar to the previous ones it told Mr A if he remained unhappy, he could contact our office. We did not receive his complaint until April 2025, four months later and two years and eleven months after Mr A knew of his reason to complain.

25. There was an initial delay of one year and two months in Mr A making a complaint. Then further days (of five months, then three months) in him following up and pursuing his complaint. That means a delay on over two years combined when he was not actively pursuing his complaint. We do not see we can put our time limit to one side considering just how far outside our time limit Mr A has raised his complaints.

26. We also considered how long the Trust took to respond to Mr A’s complaint. It provided two responses from the Trust. Mr A raised his first complaint with the Trust in August 2023, which the Trust responded to in April 2024. Mr A raised further concerns in October 2024 and received his response in December 2024.

27. In total Mr A was waiting for replies from the Trust for ten months. That was not in his control so have taken this into consideration and deducted this time from the overall time it has taken Mr A took to raise his complaint with us.

28. Ms E also told us that he was unaware that there was a time limit to approaching our office. We can see that the Trust issued two complaint responses and in each response told Mr A that if he was not satisfied he could approach our office. On each of these occasions the Trust included a link to our website as well as our customer helpline telephone number, in case Mr A wanted any further information.

29. Information on our time limits is readily available on our website. As this is the case, we would not consider that being unaware of our time limit would be a good reason to put our time limit to one side, especially considering the Trust directed Mr A to this information twice.

30. We have carefully considered Mr A’s reasons for bringing his complaint to us when he did. Unfortunately, even after taking those into account, we have not seen good reason to put the time limit to one side. We have therefore decided not to consider this complaint further.

31. We understand this will be a disappointing decision for Mr A. We hope we have shown we have thought about the reasons he gave and have fully considered the circumstances before we made our decision.

Our Decision

1. We have carefully considered Mr A’s complaint about Epsom and St Helier University Hospitals NHS Trust (the Trust). We have decided his complaint about his mother’s care and treatment falls outside our time limit and we have not seen good reason to put our time limit to one side.

2. We were very sorry to also hear about the circumstances of Mr A’s complaint and the impact it has had on him and his family.

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