A practice in the Rotherham area

4. Mrs O represents her husband, Mr O, regarding his complaint about the care and treatment of the Practice. He specifically complains that:

• the Practice did not inform him of an abnormal electrocardiogram (ECG) finding in 2015 • following his abnormal ECG in 2015, the Practice did not carry out any further relevant investigations, for example repeat ECGs or referral to cardiology until they advised him to go to the emergency department in 2022.

5. Mr O says the lack of action by the Practice delayed in him being diagnosed and treated for left ventricular hypertrophy.

6. He says his health has rapidly declined since 2015. He has developed a shortness of breath, tiredness, reduced mobility, lack of sleep and is unable to independently manage activities of daily living. His wife has become his carer.

7. Mr O believes that if investigations and treatment were carried out sooner, his health may not have declined so quickly and become so severe, it would have been better managed and have a better quality of life. He says the delay in diagnosis and treatment has had significant financial impact on him and his wife.

8. Mr O would like service improvements to minimise the risk of this happening to anyone else and a financial remedy.

10. The HSC Act 1993 (Section 9(4)), says we cannot accept a complaint if it is made more than a year after the day on which the person aggrieved first had notice of the matters in the complaint, unless we consider it reasonable to do so.

11. We have carefully considered Mr O’s date of knowledge regarding the abnormal ECG finding and relevant investigations and referrals. To assist us in doing so, we obtained information from Mr O, during an introductory call with him, his wife and niece (who is also assisting them with their complaint), documents he has sent to us, including his complaint form and the Trust’s complaint responses.

12. Mr O was suffering with shortness of breath and chest pains in 2014. He had an ECG in January 2015. They said the Practice did not inform him the ECG was abnormal. The Practice said he had hypertension and gave medication for this. They said he continued to attend the Practice over the years with the same symptoms, and the Practice just increased his medication dosage. They said the Practice did not carry out any further ECGs or refer him to cardiology.

13. In 2022, they said Mr O attended the Practice with pain in the leg/chest. The Practice took Basic Metabolic Panel blood test and advised him to go to the emergency department (ED).

14. Mr O attended the ED in November 2022 with chest pains. The ED carried out an ECG and made a referral to cardiology. They said the ED diagnosed Mr O with left ventricular hypertrophy (LVH) and left bundle branch block.

15. We asked during the call when Mr and Mrs O became aware something had gone wrong.

16. They said the doctors at the hospital in November 2022 explained the ECG report (taken in ED) showed an old finding of LVH and the doctor asked Mr O how long he had this. Mr O said he did not know he had this, as the Practice never told him. It was at this point they knew something was wrong and it prompted them to have concerns about the Practice.

17. They explained it was in late 2023 that they began putting the pieces together regarding the actions of the Practice and wanted to pursue a complaint. They said they initially requested Mr O’s medical records in 2024 and took several weeks to read them before they put in a complaint to their local Integrated Care Board (ICB) in June 2024. They said it took time to receive the records and to read them.

18. They said the Practice never told Mr O he had an abnormal ECG in 2015, just that the ECG showed he had hypertension. They said they only found this out when they received his medical records in 2024.

19. Once they got the final response from the ICB (2025), their niece helped them in getting the complaint ready before they brought it to us, which took some time.

20. We consider Mr O had cause to raise concerns/complaint about the abnormal ECG finding, lack of relevant investigations and referrals by the Practice following his attendance at the hospital in November 2022. This is because, they knew the LVH/LBBB was an old finding when it was first highlighted in the ED in November 2022, they said they were never told of this by the Practice before and this prompted concerns.

21. We are of the view Mr O’s date of knowledge is November 2022 at the latest.

22. Mr O did not complain to the ICB until June 2024 – one year and seven months after becoming aware he had reason to complain. We received his complaint form in late August 2025 – two years and nine months after his date of knowledge. His complaint is one year and nine months outside of the statutory time limit.

23. For us to move the time limit to one side we must be satisfied the explanation given for the delay is reasonable.

24. During our introductory call, we asked why they delayed in raising the complaint with the Practice and us. We asked if there were reasons why it took from November 2022 to June 2024 to raise a complaint.

25. They explained at the time (November 2022) they were more concerned about Mr O’s health and getting this treated which the hospital did very quickly and fitted him with a pacemaker.

26. They said it was late 2023 that they began putting the pieces together regarding the actions of the Practice and wanted to pursue a complaint.

27. There are several free independent NHS advocacy services that Mr O could have discussed and assisted him in raising a complaint with the Practice sooner than he did and bringing the matter to us, as well as explaining about the legal time limits.

28. The ICB’s website provides details of advocacy services to help someone make a complaint. If the person is not happy with how the ICB/Practice has dealt with their complaint, it explains how they can bring their complaint to us. It also explained that we cannot normally look at complaints more than 12 months after the person became aware of the problem.

29. Our website explains there is a 12-month time limit for making a complaint to us.

30. We are sorry to learn of Mr O’s experience he had with the Practice and the impact this is having on him.

31. Although we recognise Mr O’s reasons for delay, the onus is on the complainant to make enquiries (with the organisation – in this case the Practice) when they are unhappy with the care and treatment they receive or think they should be receiving. Raising this as a complaint brings it to the attention of the organisation and allows it the opportunity to address the issue and if appropriate offer a suitable resolution.

32. We are not persuaded there was any significant barrier during the majority of the time between the date of knowledge and the point he came to us. Although we acknowledge the experiences he was going through may cause some delay, we are not satisfied the total length of time taken in bringing the complaint to us is reasonable for us to move the statutory time limit to one side. We cannot investigate his complaint any further.

33. We are sorry to learn of Mr O’s complaint about the Practice. Our decision is not made without recognition of the impact this is having on him, and we are sorry if our decision causes any further upset. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We are sorry to learn of Mr and Mrs O’s experiences with the Practice. We acknowledge this was and continues to be an upsetting time for them.

2. We have carefully considered Mr O’s complaint about the Practice. Having done so, we cannot investigate this complaint further. This is because Mr O’s complaint falls outside the statutory time limit for us to investigate and we have not seen strong enough reasons to set this to one side.

3. Our decision is not made without recognition of the distressing circumstances around the events. We have explained the reasons for our decision below.