Lewisham and Greenwich NHS Trust

4. Mr N complains of various care and treatment concerns during his mother’s admission in December 2024, most notably that the Trust failed to identify or treat the condition(s) that directly caused her death.

5. Mr N considers his mother’s death was avoidable, if not for these failings. Mr N explains he and the family suffered with considerable, avoidable grief throughout 2025.

6. As outcomes, Mr N seeks the final coronial determination and financial remedy.

9. Our policy says there will be occasions when we decide there are reasons why we should not consider a complaint to us. This includes when another organisation is considering the same issues, such as the coroner’s court, and where it seems appropriate for us to wait for the outcome of their work first.

10. Mr N told us he attended a pre-inquest review hearing in April, in advance of an upcoming two-day inquest in around two to five months from now. As the inquest will consider the circumstances and cause of Mr N’s mother’s death, we would choose to wait until the coroner has complete their deliberations, considering this is a key aspect of the complaint to us. In line with our policy, we would not conduct an investigation concurrent to the coronial process.

11. Mr N also told us the first outcome he seeks is the final coronial determination. This is not something we can achieve but will be achieved via the upcoming inquest. As we cannot achieve this outcome for him, this is another reason why we would not consider his complaint further at this time.

12. Whilst this is reason alone for us to not to consider Mr N’s complaint currently, we also considered an aspect of our law that also applies.

13. The law says we cannot investigate a complaint where a person has the option to take legal action, unless we consider it is not reasonable for them to do so. We do not base our decision on how successful legal action would be. Rather, we consider whether legal action is a reasonable option for someone to pursue.

14. We discussed this with Mr N to understand his circumstances and the outcomes he seeks. Mr N explained it was mostly dependent upon the coroner’s conclusions, in terms of what steps he would take then.

15. Mr N acknowledged the coroner’s report may provide sufficient remedy, perhaps even if just in part. He stated that should the coroner identify failures, he would consider seeking a financial remedy. This is something that can be pursued through legal action, specifically through a clinical negligence claim.

16. We asked Mr N what amount he would consider reasonable. He stated he looked to seek ‘sub £100,000’. Mr N said he had spoken with his brother, and they agreed their lowest ‘walkaway’ figure, if possible to achieve through the Ombudsman process to avoid litigation, would be £20,000.

17. We are generally not able to provide the same levels of financial remedy that a court can. Mr N has come to us seeking a considerable amount, with the lowest figure he considers reasonable being far outside the amounts we typically achieve. Whilst we can make some recommendations for financial remedy, the courts are best placed to consider a more significant financial outcome for Mr N.

18. Our process is not a precursor or alternative option to legal action. Whilst we recognise Mr N may prefer to pursue his complaint via our process, as he does have the option to pursue his complaint via legal action, our law says he should do this, or at the very least explore it, first.

19. Mr N spoke of having experience with and involvement in the legal arena. He did not voice any concern about the costs that may be involved, and spoke about conditional fee arrangements, indicating he is aware he could explore legal action without incurring any upfront costs.

20. We have considered the relevant factors and the law. Mr N is still in time to pursue legal action. The legal route is better suited to achieve the amount he seeks, which is not an amount we could achieve. We do not see any barriers to prevent him from pursuing or at the least exploring this option currently, and in line with our law, we think it is reasonable that he does so. We have therefore decided not to consider the complaint further for this reason.

21. We recognise how important this complaint is to Mr N and we thank him for bringing it to us for our consideration.

1. We were very sorry to learn of Mr N’s concern, that failings in his mother’s care may have led to her premature and avoidable death in December 2024.

2. We would not currently consider Mr N’s complaint because there is an upcoming inquest planned. That aside, we would not consider Mr N’s complaint further because we consider he could take legal action on the matters he has raised.

3. We understand how important this matter is to Mr N and his family. We recognise both what happened and the processes that followed have taken considerable energy and been the cause of additional distress. We explain the reasons for our decision below.