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South Tyneside and Sunderland NHS Foundation Trust

P-004825 · Statement · Decision date: 12 February 2026 · View South Tyneside and Sunderland NHS Foundation Trust scorecard
Transfer, discharge and aftercare
Complaint (AI summary)
Mrs N complained her mother was prematurely discharged without proper oxygen weaning, home oxygen, or a care package, leading to a stroke and death.
Outcome (AI summary)
The ombudsman closed the case because Mrs N’s complaint was outside the legal time limit.

Full decision details

The Complaint

4. Mrs N complains her mother Mrs E was prematurely discharged home on 29 February 2024, without being weaned off oxygen appropriately first, and without any home oxygen or care package in place.

5. Mrs E had a stroke in the early hours of 3 March. Mrs N says this left her mother without any quality of life, needing 24-hour care and suffering for four months before she sadly died on 27 July 2024. Mrs N says her mother would be alive today if not for these failings. Mrs N is haunted and heartbroken by witnessing the way her mother died, and she is left completely let down by the Trust.

6. To resolve her complaint, Mrs N would like the Trust to acknowledge its failings, apologise for their impact and to improve its future service.

Findings

9. The Ombudsman’s powers are set out in the HSCA. This is the law that governs our work. Section 9(4) of the HSCA says a person needs to make their complaint to us within a year of becoming aware of the problem. It says we cannot investigate complaints brought to us after one year, unless we see there is a good reason to do so.

10. Sadly, Mrs E suffered a stroke at home on 3 March 2024. This is when Mrs N became aware of her reason to complain. We call this the ‘date of knowledge’. For the complaint to have come to us in time, it would have needed to have been brought to our Office within 12 months of the date of knowledge, therefore by 3 March 2025.

11. We first received this complaint when Mrs N submitted her completed complaint form to us on 22 July 2025. This means the complaint came to us four and a half months outside of our 12-month time limit.

12. When any complaint comes to us outside of our time limit, we must consider the time taken by the person complaining and the time taken by the organisation to respond. We spoke with Mrs N to understand the reasons why she could not bring her complaint to us sooner. We also considered the time the Trust took to respond to Mrs N’s complaint.

13. From the information shared with us we can see Mrs N first complained to the Trust on 18 March 2024, just two weeks after the date of knowledge. The Trust sent a written response to Mrs N one and a half months later, on 8 May 2024.

14. Very sadly, Mrs E died on 27 May 2024. Three weeks later, Mrs N replied to the Trust to raise her outstanding concerns. The Trust sent its second and final response to Mrs N two months after that, on 10 October 2024.

15. We think this is all reasonably prompt and timely. Mrs N demonstrated that she was able to act quickly after becoming aware of the need to complain by raising her complaint just two weeks later to the Trust. She also demonstrated being able to act promptly again to pursue her complaint by returning to the Trust with her outstanding concerns, just three weeks following her mother’s sad death.

16. The regulations say the organisation investigating a complaint should respond within six months. We can see on both occasions the Trust acted promptly, in accordance with this.

17. Unfortunately, Mrs N did not take any further action on her complaint until nine and a half months after receiving the Trust’s final response, when she submitted her complaint to us. This is a significant period of delay.

18. We asked Mrs N about this delay. She said whilst she felt angry when she received the Trust’s final response in October 2024, enough to want to pursue things then, she also felt exhausted by the process. She explained with the approach of Christmas and life having returned to normal, she inferred not having the opportunity to do so.

19. We asked what changed in July 2025 to have enabled her to pursue her complaint then, and not before. Mrs N explained that due to her brother-in-law sadly having cancer, her husband moved in with him to provide care, that this meant she had time and space to think on things. She explained having done so, she then reviewed the paperwork and felt she needed to act.

20. We recognise the complaints process can be lengthy and time-consuming, and it can feel exhausting. We also understand how busy life can be when returning to normal after such a difficult time. Yet we can see Mrs N was able to both raise her complaint and then pursue her complaint when circumstances were at their most difficult, so soon after her mother’s debilitating stroke and then very soon after she sadly died.

21. We recognise these were times where Mrs N’s life was extremely busy with daily hospital visiting, and then at a point when grief was most heightened. Having seen she could engage with her complaint even at those most difficult times, we do not see that there were sufficient barriers in place across the nine and a half months after receiving the Trust’s response, to have prevented her from bringing her complaint to us sooner.

22. We understand that due to the circumstances involved with her husband and brother-in-law, Mrs N felt she had the space and time to reconsider the events and to act on her ongoing concerns. It remains Mrs N told us she had those concerns when she received the Trust’s final response, in October 2024. We respect that Mrs N chose not to act on her complaint at that time, however it remains she could have chosen to have done so then, and she did not. Had she done so, her complaint would have come to us in time.

In summary 23. From the dates outlined above, we are satisfied the Trust responded to Mrs N’s complaint in a timely manner, in line with the regulations. We do not see that the complaint has come to us out of time due to any delay on the part of the Trust.

24. There remains a period of nine and a half months between Mrs N receiving the final response and bringing her complaint to our Office. We consider a period of this length to constitute a delay and had she acted sooner, the complaint would have come to us in time. We have thought carefully about the explanations Mrs N has given, and do not consider these exceptional reasons to justify putting our time limit to one side.

25. We are very sorry for any disappointment caused by our decision. We are grateful to Mrs N for bringing her complaint to us and for speaking with us so openly about what happened. We understand this period was very difficult for Mrs N and we know how important her complaint is. We must apply our time limit fairly. For the reasons explained, we do not see good reason to set aside our time limit. We hope this statement clearly explains the reasons why we will not be considering this complaint further.

Our Decision

1. We were very sorry to have learned of Mrs N’s concerns about her mother’s care. We recognise that what happened continues to cause Mrs N considerable ongoing upset and distress, and we extend our condolences to her.

2. After careful consideration, we have decided not to consider Mrs N’s complaint further as it falls outside of our time limit.

3. We sincerely thank Mrs N for sharing her experience with us. We are very sorry for any disappointment caused by our decision, which we explain in more detail below.

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