A practice in the North Somerset area

4. Mr X complains about the care and treatment provided to his late mother, Mrs Y in early 2023. Mr X complains:

• the GP practice did not follow correct procedure in response to an inconclusive/contaminated urine sample • the Dr’s signed off a report as no further action that listed Mrs Y’s symptoms as a cough, wheeze, infection and possible heart failure • the Dr’s failed to carry out blood tests, X-rays and an ECG during a home visit.

5. Mr X says this accelerated the decline leading to Mrs Y’s death.

6. By bringing the complaint to us, Mr X would like policy changes.

7. On 17 January 2023, Mrs Y was informed she needed a urine test done. On 23 January 2023, an out of hours Dr sent a report to the GP practice stating Mrs Y had a cough, wheeze, infection and possible heart failure. On 26 January 2023, Mrs Y passed away.

8. On 6 March 2023, Mr X first complained to the organisation and this correspondence continued throughout April and May. On 4 May 2023 and again on 18 May 2023 the organisation directed Mr X to PHSO if he was dissatisfied with its response.

9. In September 2024, Mr X was directed to PHSO by his MP and advised to fill out a complaint form. On 13 May 2025, Mr X’s complaint was opened with PHSO.

12. The law says a person needs to make their complaint to us within one 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 Mr X to understand the reasons why he could not complain to us sooner. We have also considered the time the GP Practice has taken to respond to Mr X.

13. Mr X has told us he became aware of the problem on 23 January 2023, when an out of hours doctor informed Mr X that his mother Mrs Y had a cough, wheeze, infection and possible heart failure. We are satisfied Mr X became aware that Mrs Y had an infection on this date.

14. We believe Mr X became aware of the failure of the GP Practice to carry out blood tests, X-rays and an ECG during a home visit on the 25 January 2023.

15. We believe that Mr X became aware that the Out of Hours report was signed of as ‘no further action’ on 11 April 2023 when he received the report.

16. To support our view that Mr X was aware of all the matters he complains about by April 2023, we can see that:

• Mr X requested the Out of Hours report on 24 February 2023 and received this on 11 April 2023.

• Mr X emailed the GP Practice about his mother being left without treatment for two days after his Out of Hours call, prior to receiving the report in February 2023.

• Mr X formally complained to the GP Practice on 5 March 2023, and he continued to correspond through April and May.

17. Mr X is complaining about the care and treatment the GP Practice provided to his mother in January 2023. We consider he was fully aware of all this issues he has complained about by April 2023.

18. To meet our time limit for looking at a complaint, Mr X needed to bring the complaint to us by April 2024. Mr X complained to us in May 2025, one year and one month outside our time limit. We have considered the reasons why he did not bring the complaint to us sooner.

19. Mr X first complained to the GP Practice on 5 March 2023. The correspondence with the GP Practice continued through March, April and part of May. On 4 May 2023 the GP Practice responded and directed Mr X to PHSO. The GP Practice directed Mr X to PHSO again on 18 May 2023. Local resolution with the GP Practice took approximately two and a half months to complete before he was directed to us.

20. Mr X contacted the General Medical Council (GMC) on 20 March 2023 and 18 August 2023 with questions. On both occasions the GMC directed Mr X to ‘how to make a complaint’ with them. Mr X submitted a complaint with the GMC 10 months later and it thanked him for getting in touch on 7 May 2024. In July 2024, the GMC responded to Mr X’s complaint. Although the GMC is not part of the NHS local resolution process, we can see the GMC took approximately three months to consider and respond to Mr X’s complaint. We have seen no reason Mr X could not have complained to us during this time.

21. Mr X first contacted us by telephone about this complaint on 15 August 2024. Our caseworker informed him he needed to put his complaint in writing (as the law says) and sent him a complaint form to complete. Our caseworker explained our time limit to Mr X during that call. He contacted us again on 13 December 2024, four months later, and asked us to post a copy of the complaint form. We posted the form to Mr X the same day. He submitted the completed form via his MP on 18 March 2025, three months later.

22. We asked Mr X why he did not bring the complaint to us sooner and he stated that he was gathering all the evidence he needed to bring the complaint. He also stated he had approached the GMC.

23. We have seen evidence that Mr X was able to pursue the complaint from May 2023. We can see that Mr X was able to complain to the organisation and the organisation responded within three months. We can also see that Mr X was able to complain to the GMC and to his MP. We consider Mr X could have complained to us in that time and that he had been clearly signposted to do so by the GP Practice.

24. We informed Mr X of our time limit in August 2024. He waited a further 7 months to bring his complaint to PHSO. We appreciate he spent this time gathering information and reviewing the records. We do not consider Mr X needed to do this before approaching us and the various points he was sign posted to us made clear he could put his complaint in writing to us much sooner than he did.

25. We have not seen good reasons why he did not bring the complaint to us sooner, after the GP Practice signposted him to us in May 2023. Our legislation on the time limit is clear, and we have not seen good reason to put the time limit to one side.

26. We understand how much this complaint means to Mr X and thank him for bringing this complaint to our attention. It is important we act with the law and our policy, and we regret any further upset our decision may cause. We hope that this statement clearly explains the reasons why we will not be considering this complaint further.

1. We have carefully considered Mr X’s complaint about the GP Practice. We were truly sorry to hear of the care and treatment provided to Mr X’s mother, Mrs Y.

2. We appreciate this was a very distressing time for both Mr X and Mrs Y. We also appreciate the effect this had on Mrs Y’s health. We are grateful for the time and effort Mr X spent bringing the complaint to our attention.

3. After considering the relevant information, we have decided the complaint falls outside the time limit and there is no good reason for us to put our time limit aside to consider it further. We explain in this statement the reason for our decision.