Manchester University NHS Foundation Trust

4. Ms T complains about the care and treatment her daughter, Ms A, received from the Trust from 2015 to July 2023. She says:

• The Trust failed to safely discharge Ms A in late June 2023, despite severe back pain, lack of appetite, and vomiting, as well as symptoms consistent with Deep Vein Thrombosis (DVT) including immobility and a swollen leg • The Trust failed to diagnose Ms A with DVT in tests carried out between June and July 2023, despite symptoms of immobility and a swollen leg • The Trust wrongly administered Ms A an injection of Midazolam in July 2023, which caused her death within thirty minutes • The Trust was dismissive of Ms A’s symptoms of back pain and vomiting, which she consistently reported since April 2023, and did not conduct relevant tests to investigate these symptoms, causing delays in her cancer diagnosis and preventing the opportunity for better outcomes • The Trust inappropriately delayed performing a hysterectomy from the time Ms A was referred for this in February 2020, until it was performed in January 2022 • Trust staff failed to adhere to Ms A’s wishes, only providing a partial hysterectomy rather than a full hysterectomy as she had requested, in January 2022 • Trust staff wrongly fitted Ms A with a stent (ureteric catheter tip) and failed to remove this until October 2022, leading to infection • The Trust gave Ms A unnecessary scans from 2015 to 2022, increasing her risk of cancer • The Trust was dismissive of Ms A’s genealogical issues since 2015, causing delays in her receiving a hysterectomy • Trust staff failed to accurately complete medical records leading to poor communication and miscommunication internally, and with the patient, as Ms A was not given her cancer diagnosis with the support of family or friends in June 2023 • Trust staff failed to attend meetings with Ms T to discuss Ms A’s care from June to July 2023 • Trust staff did not appropriately communicate with Ms A and her family, leading to confusion and distress. Specifically, Ms A and her family were not consulted regarding Ms A’s Do Not Attempt Resuscitation order (DNAR) in July 2023.

5. Ms T says the Trust’s actions ultimately led to Ms A’s pain and suffering and premature death. Since Ms A’s death, Ms T has experienced significant emotional distress, including stress, anxiety, trouble sleeping, and social withdrawal. She says that she has had to move from her family home and now rarely goes out.

6. As an outcome of this complaint, Ms T would like a formal and sincere apology from the Trust.

8. The ‘Health Service Commissioners Act 1993’ (the Act) 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 good reason to do so. We have discussed this with Ms T to understand the reasons why she could not bring her complaint to us sooner. We have also considered the time taken for this complaint to be considered and responded to by the Trust.

9. Ms T has told us she knew she had a reason to complain about the events relating to Ms A’s partial hysterectomy January 2022, when Ms A had the procedure done. With the Act in mind, this means Ms T needed to bring her complaint about this point to us by January 2023, unless it was not reasonable for her to do so. Ms T did not bring her complaint to us until December 2024, which means she approached us one year and 11 months outside of our time limit. This is a significant period.

10. As such, we looked at what happened between January 2022, when Ms T became aware of her reason to complain, and when she approached us in December 2024.

11. Although Ms T explained she initially raised the issue following Ms A’s partial hysterectomy in January 2022, Ms A wished for her to drop the complaint at this time as she had now had this surgery and did not wish to proceed. Ms T told us her daughter was looking towards the future.

12. This means the complaint was already 1 year and 11 months out of time before the complaint was raised again with the Trust. Ms T has not given us any indication of a barrier preventing a complaint between January 2022 and July 2023. Later delays, for example, whilst Ms T was awaiting a response from the Trust, occurred after our one year limit had already expired. The delay before contacting the Trust is explained by Ms A not wishing to pursue it at this time, which was her right to decide and which we must take into account when considering our time limit.

13. Similarly, we can see Ms T knew she had reason to complain about Ms A’s ureteric catheter tip (stent) in October 2022, when she says the Trust’s delay to remove it caused Ms A an infection. When Ms T complained about this to us, it was approximately 1 year and 2 months outside of our time limit. Ms T did not complain to the Trust until July 2023.

14. When we asked Ms T about the delays in bringing her complaints regarding Ms A’s partial hysterectomy and stent to us, she said the impact of the Trust’s mistakes did not really become apparent until July 2023, when Ms A sadly died.

15. We can see Ms T was aware of cause for complaint on all the matters raised with us, and the serious impact she says they caused, by July 2023 when Ms A died, as this is when Ms T tells us the poor treatment and misdiagnosis of her daughter became apparent. This means she needed to bring the complaint to us by July 2024, and it is approximately five months outside of our time limit.

16. Ms T initially contacted the Trust to make a formal complaint in July 2023. However, the Trust explained it could not begin exploring those matters until September 2023 as Ms A’s family continued to raise further points for investigation until this time. The Trust initially responded in December 2023, and Ms T responded expressing her dissatisfaction with this response in April 2024. The Trust held a meeting with Ms T in June 2024 ahead of its final response in August 2024. Following this response, Ms T did not approach us until December 2024, four months later.

17. We understand it took a considerable amount of time to complete the Trust’s complaint process, and we have taken this into account when considering Ms T’s complaint.

18. As outlined, there were periods of time where Ms T could have progressed her complaint, but did not do so, and we have not seen strong reason to set our limit to one side. This was a four-month period between the Trust’s first response and Ms T raising further concerns with it, and a further four months between the Trust’s final response to her complaint and approaching us in December 2024. We can see the Trust’s response in August 2024 confirmed that it felt all efforts to resolve the complaint had been exhausted and so it gave Ms T details of how to contact us if she was still dissatisfied. This means when Ms T first contacted us in December 2024, her complaint was at least five months outside of our time limit.

19. Ms T has not provided us with any strong reasons as to why she delayed progressing her complaint during the periods set out above. She has explained that she was grieving following the loss of her daughter, and we recognise that loss can be a profoundly difficult experience. What we must consider is whether it prevents someone from making a complaint.

20. We have not seen, from what Ms T has shared with us, that her grief acted as a barrier to her making and progressing a complaint. We know that some people find complaining upsetting and stressful and, in those cases, it is open to them to access free NHS advocacy services which can help with the process. Ms T has not shared with us any information which shows she was unable to make and progress a complaint with the help of advocacy support or with the support of a friend or family member.

21. Because of this, we have decided not to consider this complaint further. We understand Ms T disagrees with the law that sets our time limit, and we appreciate how frustrating these constraints can feel, especially given the circumstances and her very sad loss. Our decision is not intended to diminish what she has told us or the impact of these events on her. We hope we have clearly explained how we reached our decision and why we are not able to set our time limit to one side in this case.

1. We have carefully considered Ms T’s complaint about Manchester University NHS Foundation Trust (the Trust).

2. We are sorry to hear about the circumstances surrounding Ms T's complaint. We recognise the upset and distress she has faced because of the loss of her daughter, Ms A, and how profoundly this has affected her.

3. Having considered the evidence available, we can see Ms T’s complaint falls outside of our one-year time limit and we are unable to set the time limit aside. We recognise our decision will likely be disappointing for Ms T, and we explain the reasons for our decision below.