15. 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 the complainants delay in coming to PHSO was reasonable.
16. In line with the Law, we have considered when Miss P knew she had a reason to complain about each complaint part. We call this Miss P’s date of knowledge. We have also considered how long the complaint process with Trust A took. We have discussed with Miss P any reasons for time delays in bringing the complaint to us.
Miss P’s date of knowledge
Trust A gave Miss P a CT scan on 8 November 2018 and failed to record the reasons for this scan in her medical records
17. On 6 September 2021 Miss P had an appointment at Trust A. Miss P was told it could see a brain bleed in her post-operational CT scan from 8 November 2018. On 27 October 2021 Miss P had an appointment at Trust B, and she discussed the brain bleed with the doctors.
18. Miss P complained about the brain bleed to Trust A in her first complaint. On 4 October 2022, Trust A confirmed the CT scan showed no brain bleed and this was an error. Miss P then became concerned no reason was documented in her records for the CT scan.
19. Miss P had reason to complain to Trust A by 4 October 2022 at the latest. To be within our time limit she needed to bring her complaint to us by 4 October 2023. She brought her complaint to us on 9 June 2025, one year and eight months outside our time limit.
Trust A switched Miss P’s DBS machine on too soon after her surgery
20. Miss P told us she spent time researching DBS surgery when she prepared her second complaint between 4 October 2022 to 20 January 2023. Miss P found out it is recommended patients have a few weeks healing time after surgery before their DBS machine is turned on.
21. We can see Miss P was concerned about her post-operative symptoms in May 2019 and she complained to Trust A about them on 16 March 2022. She received Trust A's response on 4 October 2022. We consider she knew at this point she was unhappy with her care and treatment and could have brought her complaint to us at this point. She did not need to do further research before bringing her complaint to us. To be within our time limit, Miss P needed to bring her complaint to us by October 2023. Miss P brought her complaint to us on 9 June 2025, one year and eight months outside our time limit.
Trust A did not report Miss P’s symptom of whole body shaking which began in May 2019
22. Miss P told us when she was preparing her second complaint between 4 October 2022 and 20 January 2023, she gathered all her appointment letters and medical records. Miss P looked at appointment letters from 18 June 2019, 3 July 2019, 4 August 2019 and 27 September 2019. Miss P realised Trust A had not reported her symptoms of body shaking in any of these letters.
23. We can see the latest date Miss P had reason to complain was 20 January 2023. To be within our time limit, Miss P needed to bring her complaint to us by 20 January 2024. She brought her complaint to us on 9 June 2025, one year and five months outside our time limit.
Trust A communicated poorly with Trust B on three occasions, 27 September 2019, 6 September 2021 and 27 October 2021.
24. Miss P told us during her appointment on 14 August 2019 at Trust A, she first raised her concerns about Trust A’s communication with Trust B. Miss P believed Trust A resolved the communication issues after this.
25. Miss P was made aware of Trust A’s poor communication again in March 2021. Trust B said it was unaware of any communication from Trust A. Miss P believed Trust B may not have seen Trust A’s communication because a new nurse had taken over Miss P’s care. Trust B said it would raise this with Trust A. For these reasons, Miss P believed the communication issues would be resolved.
26. On 6 September 2021, Miss P brought up Trust A’s communication in an appointment. Trust A told her it did not need to communicate with Trust B. We consider at this stage three occasions of poor communication should have prompted Miss P to formally complain.
27. We consider Miss P knew she had reason to complain about Trust A's communication by 6 September 2021 at the latest. To be within our time limit, Miss P needed to bring her complaint to us by 6 September 2022. She brought her complaint to us on 5 June 2025, two years and nine months outside of our time limit.
Trust A have not returned Miss P to baseline after her DBS surgery
28. Miss P told us on 27 June 2022, she had an appointment at Trust A. At this appointment, Trust A told Miss P her DBS machine had been turned down to 0 and she had not returned to her baseline level.
29. We consider Miss P knew she had reason to complain about not returning to her baseline level on 27 June 2022. To be within our time limit, Miss P needed to bring her complaint to us by 27 June 2023. She brought her complaint to us on 9 June 2025, two years outside of our time limit.
Trust A poorly communicated about the closing and reopening of Miss P’s complaint on 4 August 2022.
30. Trust A confirmed it had received Miss P’s first complaint on 7 June 2022. Miss P was advised the complaint would be processed and she would be sent a letter with the next steps within 25 working days. This gave a deadline of 2 August 2022.
31. On 3 August 2022, Miss P emailed Trust A’s complaint co-ordinator to ask for a response. Trust A said it had spoken to Miss P and her family on 27 June 2022, who said they did not want to continue with the complaint. Miss P says neither she nor her family told Trust A she wanted to withdraw her complaint. Trust A reponed Miss P's complaint.
32. We consider Miss P knew she had reason to complain to Trust A about it closing her complaint on 4 August 2022. To be within our time limit, Miss P needed to bring her complaint to us by 4 August 2023. She brought it to us on 9 June 2025, one year and ten months outside our time limit.
Complaint to the Trust
33. Miss P complained to Trust A on 20 January 2023 about all the issues she brought to us. There are delays from Miss P becoming aware of the need to complain and her complaining to Trust A which range from three months to over two years.
34. Trust A responded to Miss P’s complaint on 3 April 2023, three months after she made her complaint. As the time Trust A took to respond was outside of her control, we will put this time aside.
Complaint to PHSO
35. Trust A sent its final complaint response on 3 April 2023. Trust A’s complaint response signposted Miss P to PHSO. Miss P brought her complaint to us on 9 June 2025, two years and two months after she received the Trust’s response. We asked Miss P for her reasons for this delay.
36. Miss P told us she relies on assistive technology to communicate. Miss P can only use her computer to communicate for short periods of time as she gets headaches. Miss P has relied on advocates to help her with her complaints to Trust A, Trust B, and PHSO. This has impacted the time it has taken Miss P to complete the complaint process. We have taken this into consideration in our decision
37. Miss P told us she delayed bringing her complaint to us because she was waiting for Trust B to respond to her complaint before she brought her complaint about Trust A to us. She told us she was waiting to see if any issues came up in Trust B’s response that she may want to bring to PHSO.
38. Miss P first complained to Trust B on 16 March 2022. Miss P sent a second complaint to Trust B on 3 February 2023. Miss P was initially told she would receive a complaint response from Trust B by 10 March 2023. Miss P’s advocates chased Trust B for a response monthly.
39. Trust B sent Miss P a final response on 7 November 2024. Miss P told us when she received Trust B’s response she realised PHSO could not achieve anything further and did not want to bring Trust B’s complaint to us.
40. We considered what would have happened if Miss P had promptly brought the complaint about Trust A to us. We considered whether we would have decided Miss P should wait for Trust B’s response. Miss P’s complaint about Trust A is about the clinical care provided to her by Trust A. The one complaint part involving Trust B focuses on the actions of Trust A, not those of Trust B. We can see the complaints about the two Trusts do not overlap and could have been considered separately.
41. For this reason, we do not consider Miss P needed to wait for Trust B’s response to address her complaint about Trust A with us. We therefore have not seen sufficient reason to put aside the period between 3 April 2023 when she got the response from Trust A and 7 November 2024 when she received Trust B's response. This is an unreasonable delay of one year and seven months.
42. We can see once Miss B received Trust B's response on 7 November 2024, she contacted us on 18 December 2024 to progress her complaint. Miss P was asked to complete a complaint form. Miss P sent her completed complaint form to us on 23 June 2025, six months later.
43. We asked Miss P the reasons for her complaint delay between 24 December 2024 and 23 June 2025. Miss P told us she was making enquiries at private hospitals to ask if they would be willing to provide a second opinion on her medical care. Miss P told us she needed to find a Clinic to agree to give her a second opinion so she could put this as an outcome for her PHSO complaint. Miss P told us she did not realise this is not an outcome for a PHSO complaint and we would not expect her to do this.
44. Miss P told us her advocate and GP had approved this. Miss P has provided us with all correspondence. We have not seen any evidence she was advised to stop the complaint process to pursue a second medical opinion. Trust A's final response signposted Miss P to us. We consider she would have known to pursue her complaint with PHSO instead of contacting private clinics.
45. Miss P contacted her advocacy organisation on 30 May 2025 about bringing her complaint to PHSO. Miss P was notified her advocate had left the organisation. She was assigned a new advocate on 13 June 2025. This delayed her complaint by two weeks. We do not consider this two-week delay is enough to put aside the six-month time delay in returning to us.
46. For these reasons we have not seen sufficient reason to put aside the delays outside our one-year time limit which vary from one year five months to two years and nine months.
Conclusion
47. We have put aside the time Trust A took to respond to Miss A's complaint as this was outside of her control. For proportionality reasons, we have not explored the reasons for the delays in Miss P's initial complaints to the Trust.
48. We have seen a substantial one year seven-month delay in Miss P bringing her complaint to us after she received Trust A's final complaint response. We have not seen sufficient reason to put this delay aside. For this reason, the complaint is out of time and we cannot investigate further.
49. We were very sorry to hear of Miss P’s experience, and the difficulties she faced during and since the events she complains about. We recognise she has been through a distressing experience and do not doubt the impact this has had, and continues to have, on her. We hope our report reassures Miss P that we have carefully considered the reasons for the delay in bringing the complaint to us.