An independent provider in the Halton area

4. Ms K complains about HCRG, and that on 30 November 2020, a nurse did not carry out a test to check if she was pregnant before administering a contraceptive implant.

5. She also complains about aspects of the care and treatment provided to her by the Trust on 2 April 2021 when she presented at the Trust’s Urgent Treatment Centre (UTC).

6. Specifically, she complains the Trust:

• did not carry out a sufficient assessment or examination and did not ask her many questions to determine she was pregnant • incorrectly discharged her home with advice to buy ibuprofen for her stomach pain.

7. She says as a result of her complaint issues, her babies died in the sixth month of her pregnancy. She says this led to her experiencing severe anxiety and depression, after giving birth. She also says this led to her experiencing physical health problems, including neurological disorders, urinary incontinence and menstrual disorders.

8. Ms K seeks a financial remedy.

9. On 30 November 2020, Ms K attended a clinic run by HCRG to have a contraceptive implant fitted (a small plastic rod that is put under the skin to prevent pregnancy). HCRG said the implant went ahead without any complication and the nurse advised Ms K to use alternative contraception for seven days.

10. On 2 April 2021, Ms K attended the Trust’s UTC due to having pains in her legs and abdomen and large varicose veins. In its complaint response, the Trust said the medical team carried out a clinical assessment and examination.

11. The Trust said it did not identify any abnormalities or clinical concerns when it saw Ms K, and there was no evidence she was pregnant. It discharged her with advice to take ibuprofen for the pain.

12. Ms K tells us she later discovered she had been pregnant on the day the nurse administered the implant, and around four months pregnant when she attended the UTC.

13. On 10 April, Ms K attended another hospital due to experiencing abdominal pains. It was confirmed she had a twin pregnancy, and she gave birth on 16 April. Sadly, Ms K’s twins died the same month.

14. Shortly after, Ms K contacted a law firm to pursue a clinical negligence claim. In September 2022, the law firm said it could not pursue her claim.

15. Ms K initially contacted the Trust to complain in September 2022, who signposted her to another organisation in error. She told us she raised her complaint in January 2023, but the citizen’s advice bureau provided an incorrect address for her to send her complaint to. She sought advocacy help and raised her complaint again in September 2023. She had a final response from HCRG in October 2023, and from the Trust in January 2024.

16. Ms K contacted us in February 2024, at that time we decided it was reasonable for her to try and pursue legal action again. She came back to us in April 2024, providing evidence that she could not pursue a clinical negligence claim any further.

19. 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 Ms K to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Ms K.

20. Ms K told us she became aware of her cause to complain shortly after her babies died, in April 2021. By law, she would have needed to bring her complaint to us by April 2022.

21. Ms K did not complain to HCRG or the Trust at that time. She told us this was because she approached a law firm in April 2021 to pursue a clinical negligence claim against HCRG and the Trust. She explained the law firm took time to consider her claim, and in September 2022, it told her it could not pursue her claim any further. Ms K says she then sought some further advice and decided to raise her complaint.

22. We recognise this was a difficult time for Ms K and that she considered legal action was the best route to take. There was nothing preventing Ms K from also pursuing her complaint with HCRG and the Trust at the same time, independently from legal action.

23. Ms K initially tried to complain to the Trust in September 2022. Due to confusion within the Trust about who was responsible for her care, it referred Ms K to a different organisation to raise her complaint. Ms K says she raised her complaint in January 2023, but this was sent to an incorrect address.

24. We have not seen that Ms K received any contact from either HCRG or the Trust about her complaint and she did not pursue her concerns again until September 2023. HCRG and the Trust responded to Ms K’s complaint in October 2023. The Trust issued its final response in January 2024.

25. We have considered Ms K’s contact with our office. We can see Ms K initially contacted us in September 2022, shortly before she tried to raise her complaint. By this time her complaint was outside our time limit. As Ms K had not yet complained to HCRG or the Trust, her complaint was not ready for us. We provided advocacy details to her at this time to help her in raising her complaint. In line with our process, we would not be able to consider our time limit further until she had completed the complaints process.

26. Ms K contacted us again in March 2023 to tell us she had not received a response to her complaint. At this time her complaint was still not ready for us, and we provided contact details so she could follow her complaint up. We cannot see that any further progress was made until she approached HCRG and the Trust in September 2023.

27. Ms K explained some further reasons for the delay in raising her complaint. She told us she had poor mental and physical health prior to and after giving birth. Following the death of her babies, she explained she experienced trauma, had depression and anxiety which affected her functioning, and she received no support. She said she also had some family bereavements around the same time and other personal issues. This included her husband losing his job and financial issues.

28. We are sorry to hear of the distress and challenges that Ms K had around this time. As Ms K was able to pursue legal action soon after the events occurred, we do not see any barriers which meant she could also not raise a complaint.

29. We also appreciate that Ms K’s first language is not English and when she did raise her complaint, she sought some help and advice to do so through an advocacy organisation. We consider she could have done this sooner to progress her complaint when she became aware of her cause to complain.

30. We have carefully considered Ms K’s reasons for not complaining to us sooner. We can see she experienced a number of challenges during an already difficult time. Ultimately it was Ms K’s decision to pursue legal action which she was entitled to do. We have seen nothing which might have prevented her from being able to pursue a complaint sooner. There are no strong reasons for us to be able to set aside our time limit.

31. It is clear it has been a difficult period for Ms K, and we understand how much this complaint means to her. Overall, we do not think Ms K’s reasons justify the extent of the delay. If she had pursued her complaint without delay, it is likely she could have sent it to us sooner.

32. For these reasons we will not be considering this complaint further. It is important we consider and act within the law and we regret any further upset this decision may cause. We thank Ms K for bringing her complaint to us and we hope this statement clearly explains the reasons why we will not be considering it further.

1. We have carefully considered Ms K’s complaint about HCRG and the Trust. The complaint falls outside of our time limit, and we have decided there is no good reason for us to put our time limit aside to consider it further.

2. We acknowledge how important Ms K’s complaint is and recognise this has been a difficult time. We are sorry to hear of the sad death of her babies and recognise the heartbreak this has caused.

3. We understand our decision may be disappointing to Ms K and we are sorry to add any further distress to an already challenging time. We explain the reasons for our decision below.