Manchester University NHS Foundation Trust

The NCA 4. Mr F complains the NCA perforated his wife, Mrs F’s oesophagus during a procedure in October 2023. He says this led his wife to experience ongoing complications in the following months and caused her death in October 2024. He says she should still be alive, and her death has had a severe impact on him and his family. He wants an acknowledgement of failings and a financial remedy.

MFT 5. Mr F complains MFT prematurely discharged Mrs F in October 2023 after emergency surgery to correct a perforation in her oesophagus. Mr F says this led his wife to experience ongoing complications in the following months and caused her death in October 2024. He says she should not have been discharged so quickly. He says she had not been sewn up after surgery and nobody asked if he was happy for her to be discharged in this condition. Mr F wants an acknowledgement of failings and a financial remedy.

6. In October 2023 Mrs F attended the NCA’s endoscopy unit for a procedure on her oesophagus. During this procedure the NCA perforated Mrs F’s oesophagus. It transferred her to MFT on the same day for emergency surgery to correct the perforation. MFT discharged her three days later.

7. Mr F complained about both organisations in November 2024. The NCA provided a response for both organisations to Mr F in March 2025. He brought his complaint to the Ombudsman in April.

9. Our powers to investigate complaints are set out in the Health Service Commissioners Act 1993. Section 9(4) of the Act says that we should not consider a complaint made to us more than one year after the events complained of, unless we think it is reasonable to do so. In practice, this means that we only consider complaints that are brought to us outside of this time limit where we consider that there is a strong reason to do so.

10. Mr F told us he did not know about the perforation until he received the final response from the NCA in March 2025. However, based on our conversations with Mr F, it is clear he knew about the perforation in October 2023.

11. He told us he was at his wife’s bedside following the procedure when the NCA explained to him it had perforated her oesophagus and it planned to transfer her to MFT for emergency surgery. He also told us he was unhappy about MFT discharging his wife at the time when it happened in October 2023.

12. This means that for his complaint to have been within the time limit set out above, he should have complained to us by October 2024. Mr F brought his complaint to the Ombudsman in mid-April 2025. This means it is outside our time limit by six months. We have therefore considered his reasons for this delay.

13. In Mr F’s case, this means considering if there were periods of delay beyond his control, or if there were any other barriers that would reasonably have impacted his ability to progress his complaint sooner. In doing so, we wish to be clear we have accounted for the time the Trust took to provide its responses. We have not penalised Mr F for such periods of delay that are outside of his control.

14. Mr F explained he did not complain earlier because the NCA did not tell him about the perforation. He says it mentioned it might have perforated her oesophagus, but it never mentioned it again, and did not carry out any interventions or treatment. He also told us he knew he was unhappy when MFT discharged her, but he did not think to complain. He said it took the NCA eight months to provide him with a response. He did not provide us with any other reasons why he did not raise his concerns earlier.

15. Mr F raised his complaint with the NCA in November 2024 shortly after his wife sadly died. This is over 12 months after the NCA carried out Mrs F’s procedure and MFT discharged her. At this point it was already one month outside of our time limit.

16. The NCA provided a response in March 2025. This means the NCA took around four months to provide a response to his complaint, which is not a significant amount of time. Therefore, local resolution does not appear to have prevented Mr F from bringing his complaint to us within our time limit.

17. It appears from what Mr F has told us, that he did not feel a need to complain about these events until after his wife’s sad death. We have considered whether this would allow us to put our time limit to one side to consider the events Mr F has complained about.

18. In Mr F’s case it is clear from what he has told us he was aware the NCA perforated his wife’s oesophagus in October 2023. Furthermore, NCA transferred her to MFT at the same time for emergency surgery to treat the perforation, which he was also aware of. He also told us he was unhappy when MFT discharged her in October.

19. We can see Mr F raised his concerns quickly following his wife’s death in October 2024, when the impact was most pronounced, as he complained to the NCA in November. However, he was aware of these matters one year before he complained. Therefore, based on what he has told us, it would have been reasonable for him to raise a complaint to the NCA about his concerns earlier than November 2024.

20. Considering all the above, we must recognise that Mr F’s delay in raising his concerns with the NCA has led to us receiving his complaint six months later than the law allows. We therefore cannot see that it would be reasonable for us to set our time limit aside on this occasion.

21. Mr F told us he and his wife had been married for over 40 years. We cannot imagine how difficult it must have been for him when she sadly died. We are sorry to hear about how his wife’s death continues to affect him and his family.

22. It is important we consider and act within the law and we regret any further upset this decision may cause. We hope this statement clearly explains the reasons why we will not be considering this complaint further.

1. We have carefully considered Mr F’s complaint about Northern Care Alliance NHS Foundation Trust (the NCA) and Manchester University NHS Foundation Trust (MFT). Understandably, Mr F feels both organisations got something wrong, as he told us his wife sadly went on to experience complications and died a year later. We are sorry to hear about the severe impact her death has had on him and his family.

2. We have carefully considered the law that tells us how we should carry out our work. Based on the evidence we have seen, Mr F’s complaint is outside of our 12-month time limit. We discussed the reasons for the delay with him. We do not think it would be reasonable to set our time limit aside in the circumstances. Therefore, we have decided not to consider the complaint further.

3. We do not underestimate the impact Mr F has told us about and we are grateful to him for the time and effort he has taken in raising his concerns with us. We hope the below explanation clearly explains the reasons for our decision.