University Hospitals Birmingham NHS Foundation Trust

4. Mrs P complains about the Trust’s care and treatment of Mr P between April 2022 and October 2023.

5. Firstly, she complains the Trust did not complete an endoscopy in April 2022 and did not identify Mr P’s cancer from his 8 June 2023 CT scan.

6. Mrs P believes Mr P would have had a very different outcome had the Trust completed an endoscopy in April 2022 or identified his cancer on 8 June 2023. She says his avoidable death has totally devastated her, and that she blames herself for not pushing for more tests. She explains the Trust’s actions have also had a significant impact on her children, who have lost a wonderful dad.

7. Mrs P also complains the Trust: • left Mr P in a corridor for 4 hours on 8 August 2023, putting him at risk of infection • did not complete an inpatient bladder scan on 10 August 2023.

8. Mrs P says this was really upsetting to both her and Mr P.

9. Finally, Mrs P complains about the Trust’s communication. She says the Trust: • did not inform Mr P or his family he had sepsis in October 2023 • provided conflicting and confusing information to her and Mr P about his diagnosis and treatment, between 29 June 2023 and 25 October 2023.

10. Mrs P says this was confusing and distressing.

11. Mrs P is seeking service improvements and financial remedy.

Premature

14. We have looked at everything Mrs P sent us and we consider her complaint regarding sepsis is not yet ready for us. This is because it appears she has not yet completed the Trust’s complaints process.

15. It is important that the Trust has the chance to look at a person’s complaint, give them a response, and put right any mistakes. Often this is the quickest way to resolve complaints. Therefore, Mrs P’s complaint that the Trust did not inform her or Mr P that he had sepsis is not yet ready for us and we cannot take any further action at this time.

Out of time

16. 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.

17. We have discussed this with Mrs P to understand the reasons why she could not complain to us within our one-year time frame. We have also considered the time it took for the Trust to provide its complaint response.

18. Mrs P explained to us that she became unhappy with the Trust’s care and treatment of Mr P after his cancer diagnosis on 28 June 2023.

19. To enable us to consider a complaint, we need to know when an event occurred. Mrs P identified the following dates for each component:

• did not complete endoscopy – April 2022 • did not identify Mr P’s cancer from CT scan – 8 June 2023 • left Mr P in a corridor – 8 August 2023 • did not complete inpatient bladder scan – 10 August 2023 • provided conflicting and confusing information – 29 June 2023 to 25 October 2023

20. Next, we must determine when the complainant knew they had reason to complain. These dates are outlined below in the order given above, then explained in the following paragraphs: • did not complete endoscopy – 28 June 2023 • did not identify Mr P’s cancer from CT scan – 28 June 2023 • left Mr P in a corridor – 8 August 2023 • did not complete inpatient bladder scan – 10 August 2023 • provided conflicting and confusing information – 25 October 2023

21. Mrs P told us she did not realise the Trust should have completed an endoscopy until after it diagnosed Mr P with cancer in his duodenum (the first part of the small intestine), in addition to lung cancer, on 28 June 2023. She explained this was because her and Mr P believed the Trust’s previous diagnoses of irritable bowel disease and diverticulitis. This gives a date of knowledge for the endoscopy component as 28 June 2023.

22. Mrs P also explained she became aware the Trust should have diagnosed Mr P’s cancer from his 8 June CT scan, after his diagnosis on 28 June, from a PET scan. This gives a date of knowledge for the CT scan component of 28 June 2023.

23. Mrs P told us that when the Trust left Mr P in a corridor on 8 August 2023, it caused her and Mr P to become really upset. She also said that the Trust’s failure to carry out an inpatient bladder scan on 10 August 2023 caused them to become distressed. Therefore, we can say that Mrs P knew she was unhappy with the care at the time of these events.

24. Regarding the Trust providing conflicting and confusing information, it is difficult to give a precise date of knowledge for this as Mrs P has informed us the events took place over a period of time. However, her latest possible date of knowledge would have been 25 October 2023.

25. This means for Mrs P’s complaints about the Trust to be in time she should have brought them to us by:

• 28 June 2024 • 28 June 2024 • 8 August 2024 • 10 August 2024 • 25 October 2024

26. Mrs P brought her complaints about the Trust to us on 11 October 2025. This means his complaints are out of time by: • one year, three months and three weeks • one year, three months and three weeks • one year and two months • one year and two months • 11 months and two weeks

27. The evidence we have available to us shows Mrs P did not complain to the Trust until 30 June 2025.

28. The Trust provided a final response on 17 September 2025, and Mrs P brought her complaint to us on 11 October 2025. We appreciate the Trust took two months and two weeks to provide Mrs P with a final response and have taken this into consideration.

29. Considering a two month and two-week response time from the Trust, we next weighed up whether it would be reasonable to expect Mrs P to have brought her complaint to us sooner.

30. We discussed this with Mrs P to understand the reasons for her delay in bringing her complaint to us.

31. We understand the period after Mr P’s death on 25 October 2023 was a very difficult time for Mrs P as she was grieving the loss of her husband.

32. We asked Mrs P why it took until 30 June 2025 for her to complain to the Trust. Mrs P explained she initially did not complain as she felt it would not bring Mr P back. She has also told us she was suffering from depression and received counselling for this. Finally, she told us she did not know there was a time limit.

33. Mrs P explained she decided to complain because the Trust’s treatment of Mr P had continued to play on her mind over time.

34. She also told us that a healthcare professional providing palliative care to Mr P had advised her to complain before his death, as did another healthcare professional. Over time she realised that they would not have told her this if something had not gone wrong, and she needed to find out what that was.

35. We asked Mrs P what changed on 30 June 2025 to enable her to complain to the Trust. Mrs P told us that nothing had really changed, she just said the longer it has gone on, the more it has played on her mind.

36. We appreciate Mrs P’s dissatisfaction and strength of feeling increased at this point. However, we must consider a person’s date of knowledge to be the date at which they knew they were unhappy with an organisation’s actions, not when they decide circumstances have become such that they want to complain.

37. Mrs P knew she was unhappy with the Trust’s actions at the time. Therefore, we would expect her to have pursued her complaint with the Trust in a timelier manner. While we understand Mrs P says she was not aware of the 12-month time limit, this was clearly displayed on the Trust’s website. As such, we cannot say this information was unavailable to Mrs P.

38. Overall, the evidence shows Mrs P was aware she had reason to complain in June, August and October 2023.

39. We have seen no evidence, nor has Mrs P provided any reasons that would have prevented her from pursuing her complaint about the Trust earlier than she did.

40. This means we have not seen strong enough reasons to set aside our time limit in this case. Therefore, we are taking no further action on Mrs P’s complaint about the Trust.

41. We recognise Mr P’s treatment and death was distressing for Mrs P and are sorry for her loss. In making this decision, we do not intend to undermine her experience.

1. We have carefully considered Mrs P’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We are sorry for Mrs P’s loss and appreciate how distressing the death of Mr P must have been for her.

2. We have decided Mrs P’s complaint that the Trust did not inform her or Mr P he had sepsis is not ready for us. This is because it appears she has not yet complained to the Trust about this matter.

3. We have decided Mrs P’s other complaints about the Trust fall outside of our time limit and there is no good reason for us to put our time limit aside to consider it further.