A practice in the Enfield area

The Practice

4. Mrs H complains about aspects of care and treatment the Practice provided to her husband, Mr H from March 2022 to August 2022. Mrs H says the Practice:

• Failed to investigate Mr H’s symptoms, including his weight loss • Did not request a blood test or refer for other appropriate investigations • Failed to follow up after Mr H’s initial appointment • Exceeded the two week wait for Mr H’s cancer referral

5. Mrs H says the Practice’s failures meant Mr H did not get the treatment he needed. She told us Mr H was impacted negatively by the events, and she feels more could have been done to ensure he received the appropriate care.

Royal Free Trust

6. Mrs H complains about aspects of care and treatment Royal Free Trust provided to her husband, Mr H from September 2022 to October 2022. Mrs H says Royal Free Trust:

• Provided insufficient information about Mr H’s care • Did not follow up appropriately when Mr H fell on 30 September 2022 • Did not dress Mr H’s wound • Gave inappropriate advice about Mr H’s drain and where this should be placed.

7. Mrs H says Royal Free Trust’s failures meant Mr H did not get the treatment he needed. She told us Mr H was impacted negatively by the events, and she feels more could have been done to ensure he received the appropriate care.

North Mid Trust

8. Mrs H says North Mid Trust failed to disclose Mr H had a bedsore during his inpatient stay in October 2023. Mrs H is also concerned about the overall standard of end-of-life care that was provided to her husband.

9. Mrs H is concerned the failure to disclose Mr H’s bedsore indicates a lack of care and attention to Mr H during the final period of his life. As a result of the Trust’s actions, Mrs H has felt let down and is left wondering whether more could have been done for her husband. She remains upset about the care provided to him, especially during his final days.

10. To resolve her concerns about the Practice, Royal Free Trust and North Mid Trust, Mrs H is seeking accountability for the organisations’ actions and service improvements to ensure they have learnt from this.

11. This very brief background is only intended to place the key events related to this complaint in context, not to provide a detailed chronological account of everything that happened.

The Practice

12. Mr H attended the Practice between 16 March and 17 August 2022 with symptoms including stomach pain, frequent bowel movements, bloating, appetite loss, and weight loss. The GP ordered stool and blood tests, abdominal and pelvic scans, and cancer marker tests. They identified a groin hernia, referred him to a surgeon, and made two urgent referrals to specialists for suspected digestive system cancer.

Royal Free Trust

13. Mr H was admitted to the Royal Free Trust in September 2022, having been referred from North Mid Trust. Mr H arrived at the Emergency Department (ED), was triaged and seen by a specialist surgical team in the evening and was given a suitable ward bed in the early hours of the morning the following day.

14. On 30 September, Mr H fell while returning from the toilet. A nurse found him on the floor with a head injury. Staff checked his vital signs, gave pain relief, and alerted the medical team. Royal Free Trust said it carried out further investigations including ordering scans of Mr H’s head and spine. The Trust said the scans showed no serious injuries, just swelling around his eye.

15. Royal Free Trust said it logged the fall as an incident and apologised for any delay in cleaning him up. It said staff responded quickly and appropriately to the situation.

North Mid Trust

16. Mr H was admitted in September 2023 with dark urine, jaundice, weakness, and poor intake. Clinicians noted his history of bladder cancer and a gallbladder tumour diagnosed in November 2022, which had spread to the liver hilum (the liver hilum is part of the liver where blood vessels, bile ducts, and nerves enter or leave). Mr H began palliative chemotherapy in January 2023.

17. On admission, North Mid Trust ran ECGs (an electrocardiogram, which is a simple test that checks how your heart is working by measuring its electrical activity) and blood tests. Signs of poor oxygen supply to his heart led to close monitoring, with later tests confirming cardiac stress.

18. On 27 September, nurses noted moisture damage on Mr H’s sacrum and repositioned him regularly. By 2 October, he had developed a grade 2 sore.

19. By 30 September, the Trust advised that liver function had not improved, and bilirubin levels were rising (bilirubin levels show how well the liver is working, if they are high, it can mean the liver is not working well). It presumed the specialist liver drain Mr H had was ineffective and explained his liver was failing, with a prognosis of days or weeks to live. Mr H understood but was anxious about telling his family. The Trust offered support and flagged the need for advanced palliative planning.

20. On 1 October, hospice care was discussed. Records show Mr H agreed to speak with his wife, declined further treatment, and asked for his feeding tube and cannula to be removed. With Mrs H present, he confirmed he wanted no further intervention and hoped to spend his final days at home or in a hospice. The Trust continued 4-hourly observations and symptom management.

21. On 4 October, staff at North Mid Trust discovered Mr H did not actually have a specialist liver drain. The Trust apologised and said inserting one now would not help. Mr H again declined treatment and was discharged to a hospice on 5 October. He sadly died about a week later.

Concerns about the Practice and Royal Free Trust

27. The Ombudsman’s powers are set out in the Health Service Commissioner’s Act (HSCA) 1993. 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. We cannot investigate complaints brought to us after one year, unless we see there is a good reason to do so.

28. Mrs H’s complaint about the Practice relates to events that occurred between March and August 2022. We consider that, at the latest, Mrs H became aware of her reasons to complain in August 2022, based on her own admission that Mr H was so concerned about his health he refused to leave the Practice until he was seen.

29. Mrs H’s complaint about Royal Free Trust relates to Mr H’s admissions between September 2022 and October 2022. In the interests of proportionality we accept October 2022 as Mrs H’s latest date of knowledge for her concerns about the care and treatment the Trust provided to Mr H.

30. For her complaint to be within time, Mrs H needed to bring it to us within 12 months of her date of knowledge for each organisation. That meant by August 2023 for the Practice and by October 2023 for the Royal Free Trust. Our records show we received Mrs H’s complaint in October 2024. This means her complaint about the Practice falls one year and two months outside our time limit, and her complaint about the Royal Free Trust falls one year outside our time limit.

31. This makes Mrs H’s complaint significantly out of time. We asked Mrs H about the delay to understand the reasons why she could not bring her complaint to us sooner. We also considered the time the organisations took to respond.

32. Evidence shows Mrs H raised her complaints about the organisations to North Central London Integrated Care Board (the ICB) in April 2024. The Practice and Royal Free Trust both provided responses in June 2024 and the ICB sent its final response in September 2024.

33. NHS Complaint Regulations 2009 say the organisation investigating a complaint should respond within six months. We do not consider the time taken by the organisations unreasonable, considering the Regulations.

34. By the time Mrs H made her complaint to the ICB about the organisations, it was already eight months out of time for the GP Surgery and six months out of time for Royal Free Trust.

35. When asked about the delay in raising her complaints, Mrs H gave us several reasons. She explained that her entire focus was on caring for Mr H and managing the demands of his worsening health. She described this period as a nightmare and said her priority was her husband’s wellbeing. Mrs H also told us that it was only after Mr H died, and the manner of his death, that she felt driven to seek accountability for what had happened to him.

36. Mrs H shared a further explanation for not contacting the Practice sooner. She said that following Mr H’s initial appointments, they were quickly drawn into a series of hospital visits and eventually a prolonged admission to the Royal Free Trust. She explained that this period, which included follow up care, left little opportunity to raise concerns with the Practice at the time.

37. In relation to the Royal Free Trust, Mrs H told us that she did not appreciate the importance of the time limits for raising a complaint while she was focused on caring for Mr H.

38. We are very sorry to hear of the circumstances Mrs H has described. We recognise the period when Mr H's health was worsening and required multiple hospital visits and inpatient stays, would have been very distressing. This must have been a very difficult time for them.

39. We have carefully considered Mrs H's reasons and are grateful for the time and work she has put into providing us with a clear and detailed complaint, and we thank her for this.

40. Having carefully considered the reasons Mrs H shared, we do not think these are sufficient to set our time limit aside.

41. NHS England’s online complaint resources detail steps people can take if they are unhappy with the care and treatment received at NHS organisations. The information available explains the complaints process and states that complaints should be made within 12 months of the incident or of it coming to the person’s attention. These resources also provide information for those who need help making a complaint, including how to obtain an advocate who can offer free support with the process.

42. NHS England’s online information also includes details about the Parliamentary and Health Service Ombudsman and signposts people to our website. Our website clearly explains our role and the time limit for bringing complaints to us.

43. Given the information available, we think it would have been reasonable for Mrs H to take independent steps to consider what options were open to her sooner than April 2024. For this reason, we have decided not to consider the complaint further.

44. We understand how much this matter means to Mrs H and thank her again for sharing the details of her complaint. It is important that we act within the law, and we hope this statement clearly explains the reasons for our decision.

Concerns about North Mid Trust

Disclosure of bedsore

45. Mrs H says North Mid Trust failed to disclose her husband Mr H had a bedsore during his inpatient stay in October 2023. She says the Trust discharged Mr H to a hospice, where staff then disclosed that he had a grade 3 pressure ulcer. Mrs H is concerned this indicates a lack of care and transparency during her husband’s final days.

46. NMC guidance sets out the professional standards for nurses and says they should make sure patients are informed about their care and information about them is shared properly, this includes sharing information in a way they can understand.

47. Mr H’s medical records show that on 2 October 2023, nursing staff recorded that he had a grade 2 pressure ulcer on his sacrum, which is the lower back area near the tailbone. The notes say staff discussed this with Mr H who was advised to avoid lying on his back to reduce pressure on the sore. They also show that Mr H chose not to follow this advice. This shows Mr H was told about the sore and how to manage it, and he made his own decision about his positioning.

48. Based on the evidence we have seen, we are satisfied the Trust did tell Mr H about the pressure sore. Staff informed Mr H about the sore, advised on how to manage it, and involved him in decisions about his care. The Trust acted in line with the NMC Code. We have not seen any signs of failings in this part of the complaint.

49. We hope this provides Mrs H with some reassurance that Mr H’s pressure sore was disclosed to him.

Overall end-of-life care

50. Mrs H says she is concerned about the overall standard of end-of-life care provided to her husband during his hospital stay in October 2023. End-of-life care refers to the support given to people who are thought to be in the last days or weeks of life. It focuses on comfort, dignity, and emotional support for both the person and their family. Mrs H feels the Trust did not do enough to support her husband in his final days and is left wondering whether more could have been done.

51. NMC guidance says nurses should identify and assess the needs of people and families for care at the end of life, including requirements for palliative care and decision making related to their treatment and care preferences.

52. On 30 September 2023, Mr H told staff he wanted to stop active treatment. He said he felt he had no quality of life in hospital and asked staff to speak with his wife about his decision. On 1 October, staff held a formal conversation with Mr H and Mrs H about his wishes. Mr H confirmed he did not want further treatment or investigations, including scans, blood tests or feeding tubes. He said he would prefer to spend his final days in a hospice or at home, although he understood this might be difficult for his wife.

53. Staff referred Mr H to the palliative care team and began planning for discharge. Palliative care is a type of support for people with serious or long-term illness. It focuses on managing symptoms, improving comfort, and supporting needs. It can be provided at any stage of illness, not just at the end of life. Mr H’s records show he remained comfortable and symptom-free, with no pain, nausea, breathlessness or chest pain. Staff monitored his condition and supported him while arrangements were made. On 5 October, the Trust discharged Mr H to a hospice in line with his wishes.

54. Our clinical adviser confirmed that Mr H did not receive formal end-of-life care during his hospital stay. Instead, the Trust provided palliative care and symptom monitoring while preparing for his transfer. End-of-life care began once Mr H arrived at the hospice.

55. Mr H’s records show whilst he was an inpatient, staff regularly checked his symptoms and comfort. He remained pain-free and staff did not observe or record any symptoms that typically cause distress at the end of life, such as pain, nausea, breathlessness, chest pain or agitation. Mr H did not report experiencing any discomfort. This shows the Trust actively managed his comfort and supported his wellbeing.

56. Records also show Mr H said he was not afraid of dying but was worried about the impact on his wife. Staff acknowledged this and offered support to both Mr and Mrs H. The Trust responded quickly once Mr H expressed his wishes. Staff involved the palliative care team the next day and arranged discharge within five days. This shows the Trust acted promptly and appropriately.

57. While Mr H did not receive end-of-life care at the hospital, the Trust helped make it possible by planning his transfer and supporting him throughout. We consider his care was in line with the NMC Code, which we have referred to in paragraph 51 above.

58. Based on the evidence we have seen, we are satisfied the Trust provided appropriate care to Mr H in the period leading up to his discharge. He made informed decisions, received support from the palliative care team, and was transferred to a hospice in line with his wishes. This means, based on the evidence we have seen we have not seen any indications of failings for this part of the complaint.

59. We recognise that Mrs H continues to be profoundly affected by what happened. We are very grateful to her for sharing this experience with us and hope this statement fully explains the reasons why we will not take further action on her complaint.

1. We have carefully considered Mrs H’s complaint about the Practice, Royal Free Trust and North Mid Trust. It is clear from what Mrs H has shared with us these events have continued to cause her great upset and distress. We know how difficult this time has been for her and how much she has been affected by the sad death of her husband, Mr H. We extend our sincere condolences for her considerable loss.

2. In relation to her concerns about Royal Free Trust and the Practice, this part of Mrs H’s 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.

3. Having reviewed all the information provided by Mrs H about North Mid Trust, we have decided not to consider the complaint further. This is because we have seen no indication that anything went wrong.