A practice in the South Holland area

3. Mr A complains the Practice failed to carry out appropriate tests to identify the cause of his wife’s symptoms in March 2019.

4. Mr A also complains United Lincolnshire Hospitals NHS Trust (the Trust) inappropriately placed a tube down his wife’s throat in May 2019 and unnecessary carried out chest physiotherapy when she was end of life in March 2022.

5. Mr A is seeking acknowledgement of failings and service improvements.

8. The Health Service Commissioner’s Act 1993, section 9 (4) (the Act) says that the complainant must refer the complaint to us within one year from the day the person became aware they had reason to complain. The Act gives us the ability to put the time limit to one side, if we can see a basis to do so. Paragraph 2.239 of our policy on handling complaints (the service model guidance, which is a framework that caseworkers should operate within) says we should consider the complainant’s reason for any delays and the time taken to complete local complaints handling to decide whether to put the time limit aside.

Tests

9. Mr A complains that the Practice did not carry out tests to identify the cause of his wife’s symptoms. He explains that she was seen in Practice in August 2018, where she was inappropriately referred for physiotherapy. On 15 March 2019, she attended a different hospital where a biopsy was completed, which confirmed she had a tumour on her tongue. He therefore explains this is his date of awareness. The Practice response supports this chronology.

10. In line with the HSCA 1993 we expect complaints to be brought to us within one year of becoming aware of the matter complained about.

11. That means to be in our time limit for this element of his complaint he needed to come to us by 15 March 2020. He did not bring a complaint to us until 18 March 2024, so the complaint is about four years outside of our time limit. That said, we next consider the reasons for this delay and whether they are sufficient to put our time limit to one side.

12. We considered the time taken during the complaint handling, in line with our service model guidance. We have seen that Mr A had raised a complaint with the Practice about three years and seven months after we have deemed he had knowledge of the issue he complained about. From the evidence available to us, we can see Mr engaged in ongoing local resolution with the Practice from 31 October 2022 to when the Practice provided their final response on 15 September 2023 and directed him to PHSO. We appreciate the complaint handling took just short of a year, and we have taken account of that when considering the time limit. Ultimately, we have seen a three year and seven-month gap between Mr A date of awareness and him raising a complaint with the Practice and a five-month gap between Mr A receiving the final response and coming to PHSO in March 2024. We discussed the reason for the above delays with Mr A. He told us this was because he was caring for his sick wife.

13. We fully appreciate the demands of a caring role upon him. We sympathise that he was clearly going through a distressing period whilst his wife was not well and had focused on caring for her. However, we also note that the complaint was about his wife’s care which was clearly a significant factor in their lives, and the inaction has led to a significant amount of delay. Whilst we do not wish to disregard the impact of being a carer we also are not persuaded that it was reasonable for this amount of time to pass.

14. Furthermore, we note his wife sadly passed away in March 2022. Mr A did not raise a complaint for a further six months after this. We do fully appreciate he will have been grieving and have taken that into account but there remains a significant amount of delay.

15. Overall, the complaint is out of time. We have explored the reason provided for the delay but those are not strong enough to allow us to put the time limit aside as there was an initial lengthy gap where Mr A could have done more to pursue his complaint. We have seen no basis to set aside our time limit for this part of his complaint.

Feeding tube

16. Mr A complains the Trust inappropriately placed a tube down his wife’s throat. He says that the Trust attempted to place a cannula, which resulted in a tracheotomy, this is a small surgical opening made through the front of the neck and windpipe and a plastic tube is placed through the hole allowing air flow in and out of the windpipe. Mr A was not able to confirm a definitive period of when this occurred but has stated it may have happed in March 2021.

17. The Trust confirmed that the tube was inserted during the admission in May 2019. As the tube was placed to open the trachea to aid her breathing we are conscious they would have been aware of the matter at the time and the tracheostomy was done at that point and therefore we are satisfied that this would be the date of awareness.

18. In line with the HSCA 1993 we expect complaints to be brought to us within one year of becoming aware of the matter complained about.

19. That means to be in our time limit for this element of his complaint he needed to come to us by May 2020. He did not bring a complaint to us until 18 March 2024, so the complaint is about three years and ten months outside of our time limit. That said, we next consider the reasons for this delay and whether they are sufficient to put our time limit to one side.

20. We considered the time taken during the complaint handling, in line with our service model guidance. We have seen that Mr A initially raised a complaint to the Trust on 8 November 2022. He had received his first response on 4 April 2023, where he was signposted to PHSO. Mr A the engaged in a meeting with the Trust in July 2023, and then received the final response on 12 February 2024. As such we appreciate complaint handling took place over about fifteen months and have taken account of this.

21. However, there was a three year and six-month gap between Mr A date of awareness and him raising a complaint with the Trust. We discussed the reason for the above delays with Mr A. He told us this was because he was caring for his sick wife. We have already explained above that whilst we sympathise with him and understand it would have been a challenging time caring for his wife, we have seen no basis to set aside our time limit for this part of his complaint.

Chest physiotherapy

22. Mr A complains the Trust unnecessary carried out chest physiotherapy when his wife was end of life on 14 March 2022. He explains his wife did not have the strength to endure this.

23. The Trust had explained that the physiotherapy team were treating his wife as she was not declared end of life at the point. Whilst the Trust response does not confirm the exact date the chest physiotherapy took place, we can see from the evidence that the Trust had considered Mrs A end of life stage on 13 March 2022. Therefore, we are satisfied that this event took place in early March 2022 at the latest, as she was actively receiving treatment until she was considered end of life. We understand he was aware of this issue at the time and have therefore taken early March 2022 as date of awareness.

24. In line with the HSCA 1993 we expect complaints to be brought to us within one year of becoming aware of the matter complained about.

25. That means to be in our time limit for this element of his complaint he needed to come to us by March 2023. He did not approve us until 18 March 2024, so the complaint is about one year outside of our time limit. That said, we next consider the reasons for this delay and whether they are sufficient to put our time limit to one side.

26. Mr A did not complain to the Trust until ten months after we have deemed he had knowledge of the issue complained about. From the evidence available to us, we can see Mr A initially raised a complaint to the Trust on 8 January 2023. He had received his first response on 4 April 2023, where he was signposted to PHSO. Mr A then engaged in a meeting with the Trust in July 2023, and then received the final response on 12 February 2024. It therefore appears the complaint handling took place over about 13 months and we have taken account of this.

27. We have identified an initial ten-month gap from the date of awareness until he had raised a complaint with the Trust, and a further month after the final response. We asked Mr A for the reasons of delay; he explained it was because he was caring for his wife. Whilst we understand this and from the evidence we have seen, we do note that his wife sadly passed away in March 2022. Mr A did not raise a complaint for a further ten months after this, and whilst we do not doubt how upsetting and difficult it would have been for Mr A following his wife’s death, we do not believe it was unreasonable to seek guidance via and advocate during this period, which he did do at a later period. It is, therefore, difficult to say the entire ten-month delay is justified.

28. Overall, the complaint is out of time. We have explored the reason provided for the delay but those are not strong enough to allow us to put the time limit aside. We do not aim to take away from the distress Mr A has experienced. Ultimately, we believe there was an opportunity to pursue the complaint a lot sooner than he did. Overall, we have seen no basis to set aside our time limit for this part of his complaint. We would like to thank Mr A for sharing details of the upsetting events with us and acknowledge this would have been a challenging time after his wife’s death.

1. We have carefully considered Mr A’s complaint about the Practice not carrying out appropriate tests for his wife. We also considered his complaint about United Lincolnshire Hospitals NHS Trust (the Trust) regarding the inappropriate treatment provided to his wife. We are very sorry to hear about the distress he has experienced and for the loss of his wife. We will explain our decision in more detail below.

2. This complaint falls outside of our one-year time limit for bringing complaints to us. We have not seen a good reason to put our time limit to one side, so we have decided not to consider it further. In making this decision, we do not wish to diminish the distress Mr A has felt because of his experience