A practice in the Haringey area

5. Mrs U complains about the care and treatment her husband, Mr U, received in June 2024 from a Practice in Haringey, North London (the Practice).

6. Specifically, she complains the Practice:

• failed to take into account her husband’s presentation and symptoms • did not assess or investigate her husband’s symptoms appropriately • did not review her husband’s medical history before the appointment • did not send her husband to A&E based on his presentation, history and symptoms and • did not provide the correct treatment and misdiagnosed him.

7. Mrs U says as a result of these failings, her husband became suddenly unwell and sadly died. Mrs U says this was a sudden and unexpected death, and it has had a significant mental, emotional and physical impact on her and her family. She says she is grieving, devastated and searching for answers.

8. As an outcome to her complaint, Mrs U seeks an apology, acknowledgment of failings and service improvements.

9. What follows is a summary of events. We have not included all the details as those involved are already aware of this information. However, we have included this information to put this complaint in context.

10. In June 2024, Mr U attended the Practice for an appointment with his GP for a cough and sore throat. The GP assessed him and found his blood pressure was slightly elevated but not at a level that needed an immediate hospital referral. His oxygen levels were normal and there were no visible signs of cardiac distress. The GP arranged for him to have blood tests and a chest X-ray at the hospital. They advised him to attend the hospital the same day.

11. The same evening, Mr U became unwell, and an ambulance was called to take him to hospital. Sadly, Mr U died at the hospital.

14. 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.

15. Mrs U told us she became aware of the matters she is complaining about in June 2024, after her husband’s morning appointment at the Practice, and his sudden death the same evening. Mrs U complained to us in August 2025. This means her complaint was brought to us approximately 14 months later, around two months outside of our time limit. Mrs U’s complaint is out of time.

16. We have considered whether it is reasonable to exercise discretion to accept Mrs U’s complaint out of time. We have considered Mrs U’s reasons for not bringing the complaint to us sooner.

17. Mrs U complained to the Practice shortly after her husband’s death in June 2024 and attended a meeting with her daughter at the Practice a few days later.

18. Mrs U’s daughter made a formal complaint to the Practice in January 2025, around seven months after the initial meeting with the Practice. We asked Mrs U why she did not make the formal complaint sooner, and why her daughter made the complaint on her behalf. Mrs U says she was heavily affected by her bereavement and relied on her daughter for support at this stage. We consider it reasonable to set aside the time between June 2024 and January 2025, as Mrs U was engaging with the NHS complaints process within the expected timescales.

19. At the end of February 2025, Mrs U contacted the North Central London ICB (NCL ICB) to make a complaint about the Practice. We asked her why she contacted the NCL ICB as her complaint was already with the Practice and she had not yet received a final response. Mrs U explained she did so after speaking to other people and receiving informal, word-of-mouth advice about how to progress her concerns. She believed this was the correct next step.

20. NCL ICB provided Mrs U with information about how to complete a complaint form and details of advocacy services available to support her. We can see Mrs U was actively pursuing her complaint at this time and was aware of her dissatisfaction with the Practice. As Mrs U’s daughter was also waiting for the final response from the Practice, we consider it reasonable to set aside the time between January and February 2025.

21. In March 2025, the Practice issued its response to Mrs U’s daughter and signposted her to our service. We asked Mrs U why she did not complain to us at this time, or why her daughter did not complain to us at this time, as she had been dealing with the complaint on Mrs U’s behalf.

22. Mrs U said she decided to take over the complaint herself in March 2025, as her daughter was struggling with her mental health. Mrs U said she had contacted NCL ICB to get support on how to progress her complaint. We find from this point, Mrs U had enough information to approach us, and she did not need to continue with the ICB before doing so. From this point, local resolution had concluded. Mrs U did not need to wait for any further response from NCL ICB before contacting us.

23. Mrs U said she believed she needed to complete NCL ICB’s complaints process before approaching us, and delays from different organisations affected how quickly she could act. We have considered this carefully.

24. Informal advice and delays in NCL ICB responses did not prevent Mrs U from contacting us once she had clear written signposting. The Ombudsman can be approached as soon as local resolution has ended. The complaint responses from the Practice to Mrs U in March and April 2025 had our details in them. We therefore do not consider it reasonable to set aside the time from March 2025 onwards.

25. In April 2025, the Practice sent a written response to Mrs U’s NCL ICB complaint. This response once again signposted Mrs U to our service. We asked Mrs U why she did not complain to us at this time. Mrs U says she did not see our details and must have overlooked them in the letter. While we recognise this was a difficult period for Mrs U, she was engaging with NCL ICB and managing her complaint to them at the same time.

26. We are satisfied the Practice and NCL ICB provided our information to Mrs U, and she reasonably could have approached us at this time. We have not seen sufficient reason to put the time between March and April 2025 to one side.

27. Mrs U received NCL ICB’s response in June 2025, which once again signposted her to our service. Mrs U said she saw the link to access our service in the NCL ICB response. We asked Mrs U why she did not complain to us at this time. Mrs U has explained she was unaware there was a time limit to bring her complaint, as she was focused on continuing the complaints process with NCL ICB.

28. We have taken this into account. By this stage we can see that Mrs U had been clearly informed how to contact us on more than one occasion, and there was no barrier preventing her from doing so. We do not consider it reasonable to set the period of April to June 2025 aside.

29. Mrs U first contacted us in July 2025, and we received her complaint in August 2025. She has explained the delay was affected by bereavement, her daughter’s mental health difficulties and her own limited confidence with paperwork and digital processes. We are very sorry for the distress Mrs U has experienced, and we have carefully considered whether these circumstances prevented her from contacting us sooner.

30. While we recognise the impact of the delays, we are not satisfied these circumstances prevented her from contacting us between March and August 2025. During this period, she was able to correspond with NCL ICB and later complete and submit her complaint form to us.

Conclusion

31. Mrs U brought her complaint to us in August 2025, two months outside of our time limit. We have put aside the time where Mrs U was actively grieving and was relying on her daughter to deal with the complaint on her behalf.

32. While we recognise the difficulties experienced by Mrs U, we note that during this period Mrs U was able to correspond with NCL ICB and later complete and submit a complaint form to us. This shows that although things were clearly very challenging, she was not prevented from bringing her complaint to us earlier.

33. For these reasons, we have decided the time between March and August 2025 cannot reasonably be set aside. Mrs U had our details during this period and could reasonably have contacted us. We have therefore decided not to take any further action on this complaint.

34. We were very sorry to hear of the distress Mrs U has experienced. It has been a very difficult period, and we understand how much this complaint means to her. It is important we consider and act within the law and we regret any further upset this decision may cause. We hope this statement clearly explains the reasons we will not be considering the complaint further

1. We have carefully considered Mrs U’s complaint about the care and treatment of her husband, Mr U, at a Practice in Haringey, North London (the Practice). We are sorry to hear how Mrs U has been affected by the sudden and unexpected death of her husband. It is clear she has had a difficult and upsetting experience.

2. After considering the information provided by Mrs U, we have decided the concerns she has raised fall outside our time limit. We have not seen sufficient reason to put this to one side.

3. We will explain the reasons for our decisions in this statement.

4. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mrs U for sharing her experience with us. It is important to acknowledge that although we are unable to look at the concerns she has raised, this does not detract from the experience she had, or the impact this had on her.