A practice in the Somerset area

4. Mrs T complains the Practice failed to request the necessary CA125 blood test in June 2014, despite her sister, Miss T, presenting with concerns and symptoms of an ovarian problem. She complains between June 2014 and July 2017, the Practice missed multiple opportunities to diagnose Miss T’s cancer, misdiagnosing her with irritable bowel syndrome.

5. Mrs T also complains the Trust misdiagnosed Miss T with renal stones in 2016, failing to identify her cancer on an ultrasound in June 2016. She complains the Trust failed to take a pelvic scan or CA125 blood test when Miss T attended A&E on 29 January 2017, despite symptoms of weight loss, bloating and suspicions of an ovarian issue causing significant pain.

6. Miss T was diagnosed with advanced stage 3c ovarian cancer in July 2017. Mrs T says her sister endured six years of chemotherapy, surgery and debilitating health before she sadly died from her cancer, on 24 January 2023. Mrs T says her sister died prematurely and avoidably at 59 years of age, as a direct result of the Practice and the Trust failing to identify her cancer at an earlier stage. Mrs T has suffered immense stress throughout and is left deeply angry that these services let her sister down.

7. To resolve her complaint Mrs T would like the Practice and the Trust to acknowledge their failings and to apologise to her for their impact. She seeks improvements, for lessons to be learned and action taken by each organisation to prevent this happening to others in future. Mrs T also seeks financial redress in recognition of the impact of these failings.

10. Mrs T complains about events that took place from July 2014 to July 2017, when her sister was diagnosed with a sadly incurable cancer. When we spoke with Mrs T, she told us her sister had spoken with her about these events at the time they occurred. She recalled in detail the location and way the conversation took place in 2014, when Miss T told her of her problematic symptoms, and that she had gone to the Practice with them.

11. Mrs T also recalled in detail the location and conversation when, in January 2017, Miss T told her she had ongoing symptoms alongside a terrible pain. Mrs T told us that with her own background in nursing, her first reaction was to think this may be a large ovarian cyst or even ovarian cancer. She said whilst this was in the back of her mind and she didn’t share these concerns with Miss T, she advised her sister to go straight to A&E.

12. Mrs T told us how Miss T had felt dismissed at the Trust and was frustrated with the way her care was going. She said how Miss T told her she was asked to pick whether to be referred to gynaecology or bowel specialists, and how it was apparent even at the time, that healthcare practitioners did not know what they were doing with regards to her care.

13. Mrs T said she was there when her sister met with the surgical team in July 2017, when they said they thought Miss T had cancer. Mrs T told us she remembers thinking that this had been one of her concerns for some time, considering the symptoms and concerns her sister had explained in the years before.

14. 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 of the problem. It says we cannot investigate complaints brought to us after one year, unless we see there is a good reason to do so.

15. In line with the HSCA, we need to consider our time limit by first identifying when Mrs T became aware of the problem. Mrs T’s complaint, in its briefest form, is that from 2014 the Practice and the Trust missed opportunities to diagnose her sister’s cancer sooner than it did, in July 2017. Mrs T and her sister were told of the cancer diagnosis in July 2017, and they both knew all the issues in the complaint to us Miss T was diagnosed in July 2017.

16. This is what we call the ‘date of knowledge’. For her complaint to have been in time, Mrs T needed to bring it to us within 12 months of her date of knowledge, meaning by July 2018. Mrs T first contacted our Office with her complaint in January 2024. This makes her complaint five and a half years out of time, by law under the HSCA. This is a significant delay, and it is important we consider the reasons for it.

17. Mrs T first raised her complaint with the Practice and the Trust in February 2023, five and a half years after her date of knowledge. When we spoke with Mrs T, she told us that whilst she had concerns at the time of these events, Miss T never voiced any concerns with her care. Mrs T said if her sister done so she would have supported her in pursuing those concerns, but because she did not, Mrs T said she had to put it to the back of her mind.

18. We recognise the shock and incredible upset that Mrs T and her sister will have felt when Miss T received such a distressing diagnosis. We acknowledge how difficult it must have been for Mrs T to have had concerns and to have not felt she could discuss these with Miss T, in case this caused additional upset at an already very difficult time.

19. We respect that it was Mrs T’s choice to have not spoken with her sister about her concerns, or to have raised a complaint whilst her sister was alive. It remains that Mrs T could have chosen to have taken either of these actions, and she did not. We understand Miss T continued to receive treatment and was able to live a further six years following her diagnosis. We do not think there were barriers in place throughout this considerable number of years, to have prevented Mrs T from choosing to discuss or raise her concerns with Miss T, or with the organisations involved.

20. It is also important that we consider this complaint is about Miss T’s care. By Mrs T’s own admission, her sister did not voice having any concerns about her own care. We cannot know whether this was because Miss T did have worries but chose not to raise them, or whether Miss T did not have any such concerns. In any event, Miss T knew of her interactions with the Practice and the Trust since 2014 and knew of her diagnosis in 2017. She had the option and ability to have raised a complaint had she wished, and yet chose not to do so.

21. Mrs T also told us it was not until her sister died in January 2023 that in beginning to sort her estate, she came across the medical paperwork that had been in Miss T’s possession. Mrs T says reading into this gave her cause for concern and prompted her to make her complaint in February 2023.

22. We understand that having seen this paperwork, Mrs T felt her prior concerns were validated, and this moved her to act. It remains Mrs T told us she had those same concerns some five and a half years earlier. We also note that Miss T had this paperwork in her possession and still chose not to raise a complaint. Where this may have been new information to Mrs T, it was not new to Miss T to have been good reason for the time taken before the complaint was made.

23. Mrs T also explained that it was only in the summer of 2024, after receiving responses from the Practice and the Trust, that she felt she could conclude that poor care may have caused a significant impact to her sister’s prognosis. She says with this evidence there is clear requirement for further investigation by an independent expert.

24. We know that once Mrs T raised her complaint, she experienced delays in receiving responses to her concerns. We recognise the frustration this caused, as final responses were shared by both organisations in June 2024. It remains Mrs T’s complaint had already fallen significantly outside our 12-month time limit at the point she first complained in February 2023.

25. In addition, whilst we understand Mrs T chose to explore the paperwork, to do her own research and in effect gather her own evidence, this is not a requirement to complain. To make a complaint about NHS care, either to the organisation or to our Office, it is not required or expected that the person conducts their own investigation or has a fully formed view or supporting evidence, before they can do so.

26. It remains the complaint Mrs T now brings to us, is a complaint that she became aware she could have raised at any time from Miss T’s diagnosis in July 2017. We appreciate the difficult circumstances involved the immediate period following Miss T’s distressing diagnosis. We very much empathise with the position Mrs T found herself in, and we respect the steps she took and the choices she made. We do not consider these exceptional reasons to justify putting our time limit to one side.

27. We are very sorry for any disappointment caused by our decision. We are very grateful to Mrs T for bringing her complaint to us and for speaking with us so openly about what happened. We understand the entirety of this period was very difficult for Mrs T and we know how important her complaint is. We must apply our time limit fairly. For the reasons explained, we do not see good reason to set aside our time limit. We hope this statement clearly explains the reasons why we will not be considering this complaint further.

1. We were very sorry to have learned of Mrs T’s concerns about her sister’s care. We recognise that what happened continues to cause Mrs T considerable ongoing upset and distress, and we extend our condolences to her for her loss.

2. After careful consideration, we have decided not to consider Mrs T’s complaint further as it falls outside of our time limit.

3. We sincerely thank Mrs T for sharing her experience with us. We are very sorry for any disappointment caused by our decision, which we explain in more detail below.