North West Ambulance Service NHS Trust

NWAS 3. Mrs L complains about aspects of care and treatment NWAS provided to her mother, Mrs P, between 2 and 6 January 2023. Specifically, she complains NWAS: • left her mother on a trolley for over 30 hours with appropriate care and treatment, including fluids and medication • manoeuvred her mother to the toilet with a fractured pelvis.

4. Mrs L says NWAS’s poor treatment contributed to her mother’s deterioration and death which was avoidable. She explains this has caused a great amount of distress and pain.

5. Mrs L would like NWAS to apologise and acknowledge where it got things wrong.

The Trust

6. Mrs L complains about aspects of care and treatment the Trust provided to her mother, Mrs P, between 2 and 6 January 2023. Specifically she complains the Trust: • left her mother on a trolley for over 30 hours with appropriate care and treatment, including fluids and medication • did not appropriately monitor her mother’s falls risk allowing her to fall in hospital.

7. Mrs L says the Trust’s poor treatment contributed to her mother’s deterioration and death which was avoidable. She explains this has caused a great amount of distress and pain.

8. Mrs L would like the Trust to apologise and acknowledge where it got things wrong.

Events from 2 to 6 January 2023

11. 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.

12. Mrs L explains the events in her complaint took place between 2 and 6 January 2023. This is because she has concerns surrounding her mother’s death, and this is when she died. This is her date of knowledge, a term we use for when someone knew they had a reason to complain. We recognise Mrs L was unhappy at the time, as she made a complaint to the organisations in January 2023. The local complaint resolution process completed, and Mrs L brought her complaint to us in May 2024.

13. We have discussed this with Mrs L to understand the reasons why she did not come to us sooner. We have also considered the time the organisations took to respond.

14. Mrs L says she was progressing things through her MP, the complaints team and the NHS process. She says it wasn’t until she received her mother’s medical records in October 2023 that she had evidence to show the NHS’s findings were incorrect.

15. We understand Mrs L’s reasons for wanting to see the medical records in full and doing her own research. We do not expect someone to gather the evidence, do their own investigation or have a fully formed view as to what went wrong at each stage before they complain to us. We are mindful Mrs L’s efforts were beneficial to her to help her understand what happened. It remains this was not a requirement of our process or a reason not to come to us sooner.

16. Whilst Mrs L may have gone on to identify more information from reading the medical records, she knew she had a reason to complain after her mother had died. Her original complaint was made before she had these records and it included detail about her mother’s care and treatment and her falling on the ward. It therefore remains that her date of knowledge was at the point her mother sadly died, and not at this later time.

17. We must also explore the gap between Mrs L getting the records in October 2023, to coming to us in May 2024.

18. We acknowledge Mrs L had to manage selling her mother’s house, a family funeral, alongside problems with her own, and her husband’s health. She explained she wasn’t aware the time limit started when her mother died.

19. We empathise with the position Mrs L was in and we respect her choice to have not prioritised her complaint at that very difficult time. It remains we do not think these things prevented her from contacting us sooner than May 2024. Mrs L had already started and was engaged in the process, from a much earlier time. The Trust’s final response in July 2023 recommended Mrs L approach us as soon as possible due to our time limit, and yet a further 9 months passed before she did.

20. The Ombudsman’s powers are set out in the HSCA. Section 9(4) of this legislation says a person needs to make their complaint to us within a year of becoming aware they have a need to complain. We cannot investigate complaints brought to us after one year, unless we consider there is good reason to do so.

21. We have seen a gap of 9 months after both final responses were received, when we consider Mrs L could have made contact with us, to pursue the matter. We appreciate the circumstances described and have considered these carefully. These would not be exceptional reasons to justify putting the time limit to one side.

22. We are incredibly mindful of how important Mrs L’s complaint is to her and empathise with what a difficult time she was going through. Our decision is in no way intended to detract from her experience or what she has been through.

23. We thank Mrs L for taking the time to bring her complaint to us and speaking with us about what happened.

1. We have considered Mrs L’s complaint about NWAS and the Trust about the concerns she has around her mother, Mrs P’s death. We would like to extend our sincerest condolences to Mrs L. We were sorry to learn of the reasons for her complaint and recognise the events she has complained to us about have caused her distress.

2. After very careful consideration, we have decided the complaint falls outside of our time limit. We will go on to explain the reasons for this in detail below. We thank Mrs L for taking the time to share her experience with us, we don’t underestimate how difficult this must have been.