Source · PHSO decision

Royal Cornwall Hospitals NHS Trust

Ref: P-005216 Statement Decision date: 13 April 2026 Jurisdiction: NHS in England Closed After Initial Enquiries

Ms A complained the Trust's inappropriate monitoring of her brother's ICD led to his preventable death.

Treatment

Outcome

AI summary
Closed. The complaint was outside the ombudsman's time limit and could not be investigated further.

The complaint

3. Ms A complains about the Trust’s management of her brother’s implantable cardioverter defibrillator (ICD). Her brother (Mr B) died in May 2022 and she says his death may have been prevented if the Trust had appropriately monitored his ICD. She would like the Trust to improve its service and make a financial payment.

Findings

5. Our Service Model Guidance says a complainant must refer their complaint to us within one year from the day they first became aware that they had a reason to complain. This is referred to as the ‘date of knowledge’. We cannot consider complaints brought to us more than one year after the date of knowledge unless we can see there was an exceptional circumstance which prevented the person from doing so.

6. Ms A says she became aware of the need to complain straight away and we have accepted May 2022 as the date of knowledge. To meet our time limit Ms A needed to formally bring her complaint to us by May 2023.

7. Ms A made her initial complaint to the Trust on 7 June 2022 and the Trust issued its response on 30 June 2022. In its response the Trust advised Ms A to contact them again if she had any further questions of if she felt the Trust had not resolved her complaint. The Trust also provided our contact details and said she could contact us if she was still unhappy after any further attempts by the Trust to resolve her complaint.

8. Ms A did not take any further action on her complaint until she brought it to us in October 2025. When asked about the delay she said she suffered a deterioration in her mental health after her brother died and did not feel she could pursue her complaint with the Trust or bring it to us at that time. She said her mental health had improved by October 2025 and she felt able to pursue her complaint again.

9. We were sorry to hear about the impact the experience had on her. We understand the impact of grief, which is experienced differently by everyone, and we are sorry to hear about how difficult Ms A found it to pursue her complaint after receiving the response from the Trust. We understand how difficult it can be to take the next step.

10. Having considered all the information, we think it would have been possible for Ms A to bring her complaint to us within our time limit. We have not seen anything in the explanation Ms A gave to make us think there are compelling reasons for us to set aside the time limit. We think that having already complained to the Trust and received its response, it would have been reasonable for her to bring her complaint to us sooner, in line with our time limit.

11. We have seen no evidence which would allow us to set our time limit aside and investigate Ms A’s complaint at this time. For this reason, we have decided not to consider the complaint further.

12. We acknowledge how distressing this incident was for Ms A and the profound impact the death of her brother has had. We hope this statement helps Ms A to understand our decision. We would like to offer our condolences on her loss.

Our decision

1. We have carefully considered Ms A’s complaint about the Trust and decided it is outside our time limit.

2. We thank Ms A for taking the time to tell us about what happened. We acknowledge the impact this incident had and we hope this statement explains the reasons for our decision.

Other decisions about Royal Cornwall Hospitals NHS Trust

View all decisions for this organisation →

Decision details

Reference
P-005216
Decision type
Statement
Jurisdiction
NHS in England
Decision date
13 April 2026
Outcome
Closed After Initial Enquiries
Responsible body
Royal Cornwall Hospitals NHS Trust

Complaint summary

AI
Summary
Ms A complained the Trust's inappropriate monitoring of her brother's ICD led to his preventable death.

Source links

PHSO portal
Search on PHSO website →

Data from PHSO under Open Government Licence.