Chelsea and Westminster Hospital NHS Foundation Trust

5. Dr T complains between 23 September 2022 and 20 October 2023 the Trust did not provide her with the appropriate or timely treatment for a burn on her right cheek. Consequently, she had been left with scarring on her face for a longer period than necessary and she experienced avoidable side effects from the treatment it did provide.

6. Dr T also says she had to seek private treatment. She says this was extremely distressing for her physical health and health and required her to take unpaid leave from work.

7. She also complains that in February 2024 PALS (Patient Advice and Liaison Service - the Trust’s complaints team) did not respond to her in a way she had requested. She says her interaction with PALS affected her care and treatment at the Trust from that point resulting her appointment being cancelled in May 2024.

8. Dr T says she has been let down by the Trust, and it has removed her as a patient in its burns unit.

9. Dr T says the poor care led to her having a noticeable scar on her cheek which is causing her distress as she believes it was avoidable. She suffered an avoidable hyperpigmentation which did not heal as expected.

10. She has a constant worry about her appearance and the long effects on her skin. She also says the inaccuracies in her clinical records caused her to feel she was not listed to and the communication issues caused ger to feel isolated. The Trust’s care has caused an overall negative effect on her mental health.

11. Dr T had two appointments with the Trust between September and December 2022. At the first appointment on 23 September the doctor recommended she undergo a full-face CO2 laser treatment (using a carbon dioxide laser to resurface the entire face) rather than just treating her burn scar. Dr T told us she was unsure if this was the right treatment for her.

12. Dr T had another appointment on 10 October where she had a localised treatment on her right cheek. At this appointment the doctor informed her the next appointment would be in December.

13. On 28 December, as she had not received any clinical letters or information about upcoming appointments from the Trust, Dr T contacted PALS. She specifically stated she was not complaining but looking to find out about her treatment plan and when her appointments were due.

14. Dr T says rather than PALS giving her the required information it forwarded her email to the team involved. She says this caused the doctor to inform her that he had no availability and transfer her to a new consultant on 5 January 2023.

15. Dr T responded to the doctor on 6 January 2023, that though she was happy to see any other consultant for her treatment, she would have appreciated knowing why he could not see her as originally planned.

16. Dr T states that on 21 April 2023 rather than just treating her burn scar, the second doctor she saw treated a large area of her right cheek. She says after that treatment, she had noticeable hyperpigmentation (parts of a person’s skin becoming darker than the rest of their skin), which she says she did not experience with the previous CO2 treatment.

17. On 14 July, she had another appointment. She said before the treatment she expressed concerns about her worsening hyperpigmentation, informing the doctor she had read that further treatments be avoided if the skin had not fully settled from previous procedures. Dr T says the doctor ignored this and treated her right cheek again.

18. Dr T further states that during her appointments on 27 September and 20 October a laser practitioner (a person trained and qualified to perform cosmetic laser treatments in the skin or body) advised the doctor to use a different treatment, which they believed could be helpful in addressing her uneven scar and hyperpigmentation. Dr T says the doctor did not take the advice and continued with the planned treatment.

19. On 7 February 2024, Dr T sent an email to PALS titled ‘complaint’. In this email she requested a meeting with the complaints manager to discuss the complaint, informing it there were several issues she wanted to raise including administrative issues and clinical issues.

20. On 21 February, Dr T followed up on her last email. Once again, she requested a meeting with them, stating she had multiple issues to raise spanning around 18 months.

21. The Trust responded to her email on 4 March. In that email it informed her that complaining will not adversely affect her care and clinicians endeavour to put things right when a patient makes a complaint.

22. It advised her about the waiting times and suggested she approach her GP for advice and referral to a team that may be better suited to handle her issue. It further advised her of how she can make a formal complaint about the burns team.

23. Dr T says after she made a complaint in February 2024, her clinical appointment scheduled for 5 April was rescheduled for 31 May and then cancelled. She says following this the Trust gave her no further appointments and then it discharged her.

24. Dr T says a few days before 31 May, the Trust informed her it had cancelled the appointment. She says when she contacted the administration staff responsible for booking the appointment they explained the cancellation was due to her complaint.

25. Dr T responded to the Trust’s March email on 6 November. In this email she stated that she called PALS on 4 March after receiving the email. She stated that during the conversation she was told she could not be given an explanation as the team would like to speak to the consultants first.

26. She further stated that after that email, her appointment was cancelled days before the appointment, and she was informed it was ‘due to her complaint’. She believes her care was compromised because she complained. She further requested a clear and comprehensive address of all the points raised.

On 20 December, the Trust responded. In its res It stated the appointment in April had been booked with her previous consultant. As Dr T had asked for a new consultant the Trust says it rescheduled the appointment in line with the new consultant’s availability.

27. It stated in May 2024 it offered Dr T an appointment which she refused. Dr T told us this was because the appointment was offered with too short notice.

28. The Trust said Dr T informed it she would contact the Trust to arrange a new appointment. The Trust asked her to inform the Trust if she required a new appointment or a meeting with the medical team to discuss her concerns.

29. The Trust says Dr T did not contact the service again until November, at which point it made several offers of a further appointment that Dr T did not take up. Dr T told us by this point she had decided to seek private treatment.

30. On 6 January 2025, Dr T responded to the email, informing the Trust of her upset in being advised to go back to her GP for a referral to a dermatologist for acne scarring. She also informed it of her disappointment with her appointment being cancelled.

31. On 7 January, the Trust responded to her email, asking for her to confirm if she wanted an appointment. It also requested she clarified the issues she wants it to investigate so it can fully respond.

32. In response on 9 January Dr T stated, ‘I have already laid out my concerns, I look forward to receiving your final response’. The Trust responded the same day saying it was not clear what she wants them to investigate, and it will be grateful if these were explicitly provided.

33. The Trust said it was Dr T who had then cancelled the appointment in May, as it was offered at too short notice for her.

34. In its complaint response dated 27 March 2025, the Trust explained it was unlikely to be able to provide the treatment she sought as she had raised complaints about the service and escalated them to the Ombudsman

Care and treatment received in September to December 2022 under the initial doctor

37. Dr T complains about the treatment she received from the Trust from September to December 2022.

38. 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 good reason the complainant could not complain earlier.

39. Firstly, we considered the Trust’s actions. The Trust provided a final response within one month, this is in keeping with NHS complaint standards and what we would expect to see. We have not seen any substantial delays in its complaint handling.

40. We consider Dr T became aware of concerns about her treatment between September and December 2022. The fact she submitted a request with PALS also suggests this.

41. In the request she sent to PALS on 28 December 2022 she asked the Trust to inform her what sort of treatment the NHS commissions for burn scars, and also requested the Trust outline her treatment plan to her. At this point Dr T was not entirely happy with the treatment or treatment plan she the doctor had provided.

42. In January 2023 she again asked questions about her treatment. We have not seen any evidence Dr T escalated her concerns to PALS until 28 February 2024, around 14 months after her initial treatment.

43. Dr T did not recognise this part of her complaint as being made out of time. When we asked Dr T why she did not raise her complaint sooner, she informed us she contacted PALS in February 2024 which is within the established timeframe.

44. Our guidance says complainants must have competed the local resolution process with the organisation and then have brought their complaint to us within 12 months. Despite this, we recognise there is NHS guidance that says complaints should be made to the NHS organisation within 12 months of the date the individual knew there was an issue.

45. As Dr T did not contact us until May 2025, the events we have set out above were brought to us at least 16 months outside of our time limit. As Dr T did not approach the Trust about the care in this period until over 12 months after we believe she reasonably knew she had concerns, she has not made this complaint in line with NHS guidelines either.

46. We can see Dr T was unhappy with the response and action flowing from her request to PALS. Her response on 6 February 2023 suggests this. However, she has not provided any reasons for the substantial delay in progressing her complaint to us. Following this we cannot see any justification to set aside our time limit and consider this part of Dr T’s complaint further.

Care and treatment received in April to October 2023

47. Dr T complains about the treatment she received from the Trust from April to October 2023.

48. Again, firstly we considered the Trust’s actions. The Trust provided a final response within one month, this is in keeping with NHS complaint standards and what we would expect to see. We have not seen any substantial delays in its complaint handling.

49. Dr T’s first appointment in 2023 was in April. After that appointment she experienced hyperpigmentation. She informed the doctor about her concerns at the appointment in July 2023. It is our view by July 2023, Dr T knew she had a reason to complain about the treatments in April and July 2023.

50. The final appointments in 2023 took place in September and October 2023. She informed us the doctor ignored advice from the laser practitioner at these appointments. Similarly, it is our view she knew she had a reason to complain about these appointments both in September and October 2023.

51. Dr T did not complain to us until May 2025. This part of her complaint was brought to us at least seven months outside of our time limit.

52. Dr T first complained to the Trust three months after this, in February 2024. The Trust responded promptly in March 2024. Dr T did not return to the Trust with her further concerns until November 2024, around eight months after receiving the Trust’s response.

53. Dr T has not provided any reason that shows why she was prevented from progressing her complaint with the Trust, or from coming to us sooner. We cannot see good reasons to set aside our time limit and consider this part of her complaint further.

Complaint handling

54. Dr T also complains that the Trust discharged her from its services due to her complaint.

55. NHS complaint standards state staff should ensure to welcome complaints and staff who are specifically the subject of a complaint should be made aware of the issues as soon as possible. It further states that staff actively listen and demonstrate a clear understanding of what the main issues of the complaint are and what outcomes they seek.

56. The Trust responded to Dr T’s request for a meeting with the complaints department on 4 March 2024. It advised her that she can make a formal complaint to it listing the specific concerns she wanted it to investigate.

57. On receiving the email, Dr T had a call with the Trust on the same day. We do not have a detailed record of that call, but the Trust’s subsequent emails asking that she clearly sets out her concerns, leads us to conclude the Trust did not receive a formal complaint in the call.

58. Dr T did not follow up with the Trust for eight months. In November 2024 she contacted the Trust requesting a clear and comprehensive response to the issues raised. However, evidence we have seen to dated does not show she provided the Trust with any further details of the issues as it requested.

59. We have seen no evidence of where Dr T clearly explained her concerns regarding her care. Instead, her contact appears to focus on being unable to speak to the complaints team.

60. In May 2024, the Trust offered Dr T an appointment with a consultant plastic surgeon. Dr T rejected the appointment informing it that she would contact the Trust to make another appointment, which she never did. She also denied further appointment requests to discuss her concerns.

61. We have not seen any evidence that demonstrates Dr T did anything to progress her complaint for eight months.

62. The Trust requested Dr T clarify her concerns on various occasions, it also tried to set up a meeting with the consultant who might be able to help. It is our view the Trust has taken reasonable steps to gather information about Dr T’s complaint in order to explore her concerns.

63. For this reason, we are satisfied and the Trust acted in line with the NHS complaint standards. We hope this offers Dr T some reassurance.

Cancelled her appointment and discharged her from its services

64. Dr T also complains that following her complaint the Trust cancelled her appointment and discharged her from its services.

65. Our NHS complaint standards say complainants should be offered the option for formal complaints to be kept confidential. They also explain complaint information should only be shared with those essential to the process.

66. Having reviewed the information provided to us we can see in January 2024 Dr T was offered a new consultant and she accepted this offer. At this stage it appears her follow up appointment was already planned for April.

67. Dr T agreed to the new consultant and a new appointment was scheduled for May. Given part of the rationale for the handover of care was timeliness of her treatment, we recognise how frustrating this was for Dr T.

68. We cannot say why Dr T was told her May appointment was cancelled due to her complaint, but the Trust’s records explain her April appointment was moved to May to accommodate a change of consultant. This was an action that came as a direct result of her raising questions about her care in December 2023, not because of a formal complaint.

69. Despite this we can see how administrative staff may have interpreted it as a complaint and led Dr T to think it was cancelled for this reason.

70. As this was not information relating to a formal complaint we cannot go as far as to say the Trust has failed to act in line with guidance, but we recognise there was an opportunity for it to be much clearer in its communication in Dr T’s records. We can also see that has led to her experiencing avoidable frustration at that time.

71. We have not seen any evidence Dr T contacted the Trust between May and November. Upon receiving further contact from Dr T in November, it offered an appointment on several occasions. When Dr T made a complaint, the Trust has explained what happened and why.

72. The letter from the Trust does not expressly state it will not provide Dr T with care. For this reason, we do not consider there is evidence the Trust actively discharged Dr T, as there were several offers of appointment. However, we appreciate the intonation she has taken from it and understand why she was concerned. We hope our explanation helps Dr T understand the sequence of events and reassure her the Trust’s action have been independently reviewed and were appropriate.

1. We have carefully considered Dr T’s complaint about Chelsea and Westminster Hospital NHS Foundation Trust (the Trust). We recognise she had a difficult experience seeking care and treatment at the Trust.

2. Dr T’s complaint about the care she received from the Trust between September 2022 and October 2023 falls outside of our time limit. We have decided not to consider it further.

3. We did not see any signs anything went seriously wrong with the Trust’s complaint handling or in its rationale for cancelling Dr T’s appointment.

4. We will explain our reasons for our decision in this decision statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Dr T for sharing her experience with us.