North Middlesex University Hospital NHS Trust

3. Mr A complains about the following aspects of the care and treatment North Middlesex University Hospital NHS Trust provided to his mother, Ms A in January 2020. He says:

• hospital staff did not communicate with the family about the plan to perform his mother’s surgery • a clinician punctured the artery in his mother’s neck when attempting to insert a central venous catheter • staff did not express the seriousness and urgency of the situation when contacting the family • there were delays in his mother’s care and arranging appropriate investigations following her stroke • clinicians did not appropriately monitor his mother when she was in the critical care unit (CCU).

4. Mr A says as result of the Trust’s poor care, his mother had a stroke. She sadly died in April 2020 of an internal bleed. Mr A says he believes these events were the starting point for her death. He says this has caused significant distress to the family.

5. By bringing the complaint to us, Mr A says he would like an explanation, service improvements and a financial remedy.

6. On 6 January 2020, Ms A attended A&E at the Trust because of pain, swelling and redness around her stoma site. She had a CT scan, and the surgical team assessed her and agreed to carry out an exploratory operation to treat the cause of her symptoms.

7. On 7 January 2020, clinicians performed the surgery and found a perforation of Ms A’s bowel. Following surgery, Ms A was transferred to the recovery area and her blood pressure was low.

8. The treating clinicians later decided to Ms A give vasoactive drugs to treat her low blood pressure via a central venous catheter (thin flexible tube into a vein) in her neck. The clinician performing the procedure accidently punctured Ms A’s carotid artery and then noticed she was not responding as she had been. Ms A had a CT scan and was transferred to the critical care unit (CCU).

9. The stroke team reviewed Ms A while she was in CCU. They noted Ms A’s symptoms stemmed from an occlusion (blocking/closing) of one of the vessels supplying her brain.

10. Ms A was later moved to a neurological rehabilitation facility. She very sadly died on 13 April 2020. Mr A tells us his mother’s primary cause of death was an internal bleed and the secondary cause was pneumonia.

12. 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 a good reason to do so. We have discussed this with Mr A to understand the reasons why he could not do so. We have also considered the time the organisation has taken to respond to Mr A.

13. Mr A knew he had a reason to complain at the time of the events on 7/8 January 2020. For the complaint to be in time, it should have been brought to us by January 2021. Mr A brought the complaint to us on 11 February 2024. The complaint is therefore out of time by approximately three years and one month.

14. Mr A submitted a complaint to the Trust on 21 January 2020 and it responded on 11 March 2020. This six-week period the Trust took to respond was outside Mr A’s control, and we can set this aside. We also stopped accepting health complaints between 26 March and 30 June 2020 to not place additional pressure on the NHS during a national emergency. We can also therefore put aside this three-month period. Having put these two periods aside, there remains delays of approximately two years and eight months.

15. Mr A did not contact the Trust again or progress his complaint after receiving its response letter in March 2020. He says he could not think clearly at the time of events and his mother was understandably his main priority. After making the complaint and receiving a response, Mr A’s mother very sadly died in April 2020. Mr A explains he was full of anger and rage about what happened, and he feels like he can talk about it more now. He says he attended one session with a counsellor during this time but did not seek any other additional help or support.

16. Mr A says he also typically views these things as a waste of time as large organisations close ranks when questions are asked. He says he experienced this when he was asking questions while his mother was still in hospital. He says something did not sit right with him and it hasn't done ever since and it has taken him quite some time to come to terms with the fact he lost his mother, and he still struggles with it. Mr A says he cannot shake the feeling that something went wrong, and he feels if his mother hadn't gone to North Middlesex Hospital, she would still be alive today.

17. We are very sorry to hear about Mr A’s concerns and do not doubt it was an incredibly distressing and upsetting time for him as he dealt with what happened to his mother and her very sad death. The Trust directed Mr A to our service in March 2020 and it took him almost four years to bring the complaint to us. The complaint is quite significantly outside of our time limit, and we would therefore need to see a good reason for the delays.

18. Whilst we understand Mr A did not want to speak to the Trust again about what happened, we consider he could reasonably have brought his complaint to us sooner than he did. We cannot see anything has changed in Mr A’s circumstances which means he is able to bring the complaint to us now.

19. We do not consider it is reasonable to exercise our discretion and set the time limit aside in this case and we have not identified any exceptional circumstances which would lead us to investigate. We will therefore take no further action.

1. We have carefully considered Mr A’s complaint about North Middlesex University Hospital NHS Trust (the Trust). We are very sorry to hear to Mr A’s concerns and for the very sad loss of his mother. We appreciate it has been a very difficult and distressing time for him and the rest of his family.

2. The complaint falls outside of our time limit, and we have decided it is not reasonable to put our time limit aside and consider it further.