Source · PHSO decision

Norfolk and Norwich University Hospitals NHS Foundation Trust

Ref: P-005212 Statement Decision date: 12 April 2026 Jurisdiction: NHS in England Closed After Initial Enquiries

Mrs L complained the Trust mismanaged her husband's insulin, provided undignified care, misdiagnosed him, and wrongly placed him on end-of-life care, leading to his avoidable death.

End of life care

Outcome

AI summary
Closed. The complaint falls outside the ombudsman's time limit, and no good reason was found to set it aside for investigation.

The complaint

3. Mrs L complains about aspects of the care and treatment healthcare professionals from the Trust gave to her husband in March and April 2023. She says they did not give manage his insulin properly and gave him undignified care. She says doctors misdiagnosed him and wrongly placed him on an end-of-life care pathway.

4. Mrs L believes her husband’s death was avoidable. She wants the Trust to accept responsibility for what happened and make changes to procedures so other patients, and their families, are not affected by similar issues.

Findings

6. 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. We have asked for clarification from Mrs L to try and understand the reasons why she did not complain sooner when she was dissatisfied with the complaint responses. We have also considered the time the Trust took to respond to the complaint.

7. Mrs L’s complaint to us is out of time. The events she complained about happened more than two years before she contacted us.

8. Mrs L complained to the Trust in May 2023, just a few days after her husband’s death. The Trust took until 24 September 2024 to reply to her complaint. During that period, we can see Mrs L contacted the Trust for explanations of the delay. She also contacted us to say she had not had a response to her complaint. Mrs L complained again to the Trust on 25 September and the Trust sent its final response to her on 28 October. The Trust gave our contact details if Mrs L was unhappy with the responses.

9. We do not consider Mrs L was responsible for delays in the Trust’s complaint handling. But she could have contacted us more quickly following the end of that process. Mrs L complained to us on 7 October 2025. This was almost a year after the Trust’s final response to her complaint.

10. We asked Mrs L to explain the reasons for the delay in making her complaint to us. She explained how she has been caring for her mother who has dementia. Although, she told us she has been caring for her mother since May 2023, which was around the time she first complained to the Trust. We were sorry to hear about her mother’s health problems, and we appreciate how upsetting it must be for her to complain about her husband’s care. We cannot see how these difficult circumstances would have prevented her from contacting us.

11. Mrs L has been unable to provide a satisfactory explanation about why she could not contact us sooner following the Trust’s final response.

12. Clearly, the events of March and April 2023 continue to be a source of distress for Mrs L. We appreciate our decision not to investigate further is likely to add to her distress. We hope we have clearly explained why we are unable to waive the time limit in this case.

Our decision

1. We have carefully considered Mrs L’s complaint about the Trust. Mrs L’s complaint relates to her husband’s care and treatment in hospital. She believes failings by clinicians led to her husband’s death, which she says could have been avoided. We can see how devastating these events have been for Mrs L. We offer our sincere condolences to her for her loss.

2. The 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. We recognise this will be disappointing for Mrs L.

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Decision details

Reference
P-005212
Decision type
Statement
Jurisdiction
NHS in England
Decision date
12 April 2026
Outcome
Closed After Initial Enquiries
Responsible body
Norfolk and Norwich University Hospitals

Complaint summary

AI
Summary
Mrs L complained the Trust mismanaged her husband's insulin, provided undignified care, misdiagnosed him, and wrongly placed him on end-of-life care, leading to his avoidable death.

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Data from PHSO under Open Government Licence.