Kingston and Richmond NHS Foundation Trust

5. Mr A complains:

• the Trust delayed his open inguinal hernia repair and open repair of his left hydrocele (the procedures) for six years • the anaesthetist refused (during his admission in February 2023) to follow his and the previous anaesthetist’s request for spinal anaesthetic as agreed and consented in the pre-assessment consultation • the Trust failed to place a plastic tube to drain the hydrocele fluid • the urology surgeon who was due to carry out the procedures in February 2023, failed to explain why they were unable to carry out the procedure • the Trust’s General and Urology Surgeons who carried out the procedures in February 2023 were unqualified to do so, unprepared for the operation and did not know what to do • its PALS staff were rude and falsely accused him of being racist.

6. Mr A explains the Trust’s delay in carrying out the operation meant he was unable to work because of the prolonged pain, which led to a loss of income, and ultimately his home.

7. He says the lack of drainage tube caused the hydrocele to triple in volume after the procedures, causing pain as well as difficulties in maintaining personal hygiene.

8. Following the procedures, Mr A says he continues to have ongoing pain, discomfort and reduced mobility, which he believes may be due to nerve damage caused by the clinicians. He feels he may require further operations to rectify the problem.

9. Mr A would like an acknowledgement of what went wrong, an apology for the impact caused and service improvements to minimise the risk of this happening to anyone else. He would like a financial remedy to pay for him to have the procedures re-done privately.

Length of time for procedures, anaesthetic, surgeon’s explanation, preparation and experience, and the PALS attitude

11. 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.

12. We have carefully considered Mr A’s date of knowledge regarding his individual complaints. To assist us in doing so, we have obtained information from Mr A during telephone calls with us, documents he has sent us, including his complaint form and the Trust’s complaint file.

13. We consider Mr A would have been aware of the problems relating to the anaesthetic, surgeon’s explanation, preparation and experience by mid-February 2023 – the date of the procedures and discharge. Mr A confirmed within his complaint form that his date of knowledge was mid-February 2023.

14. Regarding the delay in carrying out the procedures, we are of the view Mr A had reason/cause to complain by late 2021 – at the latest (when the Trust had cancelled the procedures and no other dates given at the time).

15. In relation to the complaint about PALS, Mr A refers to the attitude (being rude) of the PALS staff during a meeting he had with them in early September 2023, this is his date of knowledge.

16. Mr A did not complain to the Trust about the majority of the above concerns (clinical matters) until early September 2023 – between seven months and two years after becoming aware he had reason to complain.

17. He did not complain to the Trust about the PALS’s staff until mid-June 2025 – one year and nine months later.

18. Mr A’s complaint was ready for us by early September 2025.

19. We consider Mr A’s complaint is between one year and three years outside of the statutory time limit.

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

21. There are four periods of time when we consider Mr A could have raised his complaint to the Trust and then us sooner than he did. These are between:

• late 2021 and mid-February 2023 (date of knowledge of his clinical complaints) to early September 2023 (when raised with the Trust) – between seven months and two years • early September 2023 (date of knowledge of PALS meeting) to mid-June 2025 (when raised complaint about rudeness of PALS in the meeting) – one year and nine months • mid-April 2024 (date when he was sent the Trust’s final response) and mid-June 2025 (date when he replied to the Trust’s complaint response) – 14 months • early July 2025 (date of final response) to early September (date when complaint was ready for us) – two months.

22. During our introductory call, we asked for Mr A’s explanation for the delay in raising his complaint with the Trust and us.

23. He said he did complain to the Trust three times, via phone, but never sent anything in writing until later. He says he needed help from a friend to write a complaint in English. He says the delay was also because of him losing his house. He says he lost his house nine months before his operation in February 2023.

24. In his complaint form, Mr A explains that following his discharge in mid-February, he was in pain and had financial problems. He says he contacted an advocacy service in June to help him put in his complaint. After many promises, he says they did nothing to help him.

25. In early September, Mr A said he put in a complaint to the Trust’s PALS on his own. However, he says it took the Trust eight months to reply. Mr A said he contacted an advocacy service again for help, but after a few months they stopped helping him.

26. In December 2024, he says he contacted another advocacy service. He said he was disappointed and upset on how this advocacy service treated him. He believed they were racist, incompetent and unprofessional and ‘they just put a lousy complaint to .. [the Trust]’. He said this advocacy service were slow and unprofessional and then he said they sent him a ‘letter saying he can do it himself.’

27. We have carefully listened to Mr A’s explanation for the delay in complaining to the Trust and then us. We are sorry to learn of the experiences he had.

28. We cannot see evidence within Mr A’s supporting information or the Trust’s complaint file to show he made a complaint (via phone/email or letter) to the Trust until September 2023.

29. We recognise the difficulties Mr A faced, with losing his home, pain following surgery, in writing a complaint and with the advocacy services. We consider Mr A could have sought assistance from the Trust’s PALS sooner than September 2023 and following the Trust’s response in April 2024. PALS would have also explained about the legal time limits.

30. Mr A had the use of several advocacy services since the middle of 2023 until 2025. We are sorry to learn of the experiences he said he had with these services. In the main, we consider they would have explained about the legal time limits and could have assisted him in completing a complaint form and bringing his complaint to us sooner.

31. The Trust’s website explains how someone can bring their complaint to us if they are not happy with how the Trust has dealt with their complaint.

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

33. We have taken into account the length of time his complaint was in local resolution (LR) – seven months. Although this is slightly over the six months stipulated within Regulations 2009, we consider the majority of the delay in raising a complaint and bringing it to us was because of Mr A. Even taking the time in LR into account, Mr A’s complaint is considerably out of time.

34. Although we recognise Mr A’s reasons for delay, the onus is on the complainant to make enquiries (with the organisation – in this case the Trust) 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.

35. We recognise the difficulties Mr A faced. 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 distress and 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.

Drainage of hydrocele fluid and the PALS comments

36. Mr A complains the Trust failed to place a plastic tube into him to drain the hydrocele fluid and that PALS staff falsely accused him of being racist.

37. The plastic tube relates to the procedures in mid-February 2023.

38. Mr A’s complaint about PALS, refers to a meeting between them in early September 2023. This is when Mr A first made a complaint (verbal) to PALS about the treatment he received at the Trust. Throughout the meeting, PALS record that Mr A referred to clinical staff including the PALS staff, by their nationalities/ethnicity. PALS recorded that it advised Mr A in the meeting that to progress his complaint, it was necessary for him to ‘stick to the facts of the case and not to refer to people’s nationality or ethnicity.’ In response, the Trust record that ‘he asked … not to be lectured and that he was an educated person and not a racist.’ He said he did not know the names of the people, he identified them by their nationalities.

39. Although Mr A had opportunity to do so, there is no evidence he raised any of these complaints with the Trust.

40. In health cases, section 4(4) and (5) of the HSC Act 1993 prevents us from conducting an investigation unless we are satisfied the complaints process has been used and exhausted, or it was not reasonable to expect the complainant to have done so.

41. In line with the HSC Act, we cannot investigate this aspect of Mr A’s complaint. This is because there is no evidence he raised this with the Trust and gave it opportunity to respond. We cannot investigate this complaint any further.

42. Even if Mr A raised this with the Trust now and brought his complaint to us, it is more than likely we could not investigate. This is because the complaint is significantly outside of the statutory time limit time for us to investigate, in line with the HSC Act 1993.

43. We acknowledge the ongoing difficulties for Mr A. 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 A’s experiences with the Trust and the impact this is having on him. We acknowledge this was and continues to be an upsetting time for him.

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

3. In relation to Mr A’s complaints about drainage of the hydrocele fluid and the patient advice liaison service (PALS), he has not complained to the Trust about these. These complaints are not ready for us so we cannot investigate.

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