Central and North West London NHS Foundation Trust

3. Mr O complains on 24 November 2023 the Hillingdon Hospitals NHS Foundation Trust (the HH Trust) inappropriately discharged his father, Mr E, causing him to suffer an avoidable death.

4. Mr O complains between 24 November 2023 and 20 January 2024 the Central and North West London NHS Foundation Trust (the CNWL Trust) provided below standard support to Mr E and did not take his family’s concerns about his health seriously. Mr O says this contributed to Mr E suffering an avoidable death.

5. Mr O says the impact of this is ongoing. He and his brother have flashbacks of the period leading to Mr E’s sudden passing, and his brother cries daily.

6. Mr O is seeking an explanation of the Trust’s actions.

9. 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.

10. We have discussed this with Mr O to understand the reasons why he 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.

Timeline

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

• inappropriately discharged Mr E – 24 November 2023 • provided below standard support to Mr E and did not listen to his family’s concerns – 24 November 2023 to 20 January 2024

12. 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: • inappropriately discharge Mr E – 24 November 2023 • provided below standard support to Mr E and did not listen to his family’s concerns – 17 January 2024

13. We can see from Mr O’s complaint about the HH Trust’s discharge of Mr E, that he was aware at the time that he was unhappy with the discharge process. This is because he states, ‘despite protestations on both my father’s discharge and the care pathway following this, no changes were made to ensure my father received the correct care’.

14. For this reason, we can say his date of knowledge is the same day Mr E was discharge.

15. Mr O states in his complaint that he raised concerns with CNWL Trust district nurses during their visits but was not listened to. This shows us that he was aware that he was unhappy with the CNWL Trust’s treatment of Mr E at the time.

16. Mr O initially contacted PHSO on 17 January 2024, prior to contacting either Trust.

17. Therefore, whilst Mr O’s complaint covers a period of eight weeks, we can say his latest possible date of knowledge was 17 January 2024. This is because Mr O contacted us on that date to inform us he wished to complain.

18. This means for Mr O’s complaints about the Trust to be in time he should have brought them to us by:

• 24 November 2024 • 17 January 2025

19. Mr O brought his complaints about the Trust to us on 10 September 2025. This means his complaints are out of time by: • nine months, two weeks • eight months

20. The evidence we have available to us shows Mr O first complained to the CNWL Trust promptly on 24 January 2024, after being directed to do so by PHSO. He included his complaint about the HH Trust in his email to the CNWL Trust.

21. The CNWL Trust provided an initial response to Mr O on 28 February 2024. This CNWL Trust’s response included a response from the HH Trust. From this point on the CNWL Trust managed the complaint on behalf of both Trusts.

22. The response invited Mr O to contact the CNWL Trust should he wish to be part of a review of Mr E’s treatment or find out the outcome of its internal learning review.

23. Mr O contacted the CNWL Trust on 2 March 2024 to inform it that having reviewed the complaint response there were many issues that the response did not capture. He asked to be directly involved in a formal review of Mr E’s treatment.

24. On 28 March the CNWL Trust informed Mr O it would be in touch once it had identified a lead for the review.

25. The CNWL Trust then called Mr O on 23 April, after which Mr O contacted it to say he was unhappy with the content of the email. On 26 April the CNWL Trust emailed Mr O and apologised for a lack of clarity about the processes being undertaken. It explained the review process was not a part of the complaints process and was an internal action.

26. In its email it provided details to Mr O explaining clearly what steps he needed to take if he was not happy with its initial response.

27. Mr O next contacted the CNWL Trust on 17 October 2024, six months after the Trust explained to him how to make a further complaint.

28. The CNWL Trust discussed Mr O’s complaint with him on 27 November and Mr O told it he would provide a summary of events. The CNWL Trust followed up via email on 16 December and Mr O provided the information on 2 January 2025.

29. On 7 March 2025, two months after Mr O fully submitted his further information, the CNWL Trust provided its response. It invited Mr O to contact it if he wished to discuss his complaint further. It followed up with Mr O on 31 March to confirm he had received the response.

30. Mr O told the CNWL Trust he would respond in the next couple of weeks as there were omissions that needed addressing. Mr O responded on 12 June, three months and one week after the CNWL Trust provided its response, and two months after he had said he would contact it.

31. On 26 June 2025, the CNWL Trust offered Mr O two options. Either a local resolution meeting, or if he did not wish to engage in this, it told him he could bring his complaint directly to us. It provided our contact details in this letter.

32. Mr O informed the CNWL Trust on 19 July that he would like to bring his complaint directly to PHSO. The CNWL Trust provided our contact details to Mr O for a second time on 23 July 2025.

33. On 28 August Mr O contacted us via phone, and we advised him that he needed to complete a complaint form online. Mr O said he would do so.

34. Mr O submitted his complaint in writing to us on 10 September 2025, two months and two weeks after the CNWL Trust provided its final response.

Consideration

35. We identified the CNWL Trust took one-month to respond to Mr O’s first complaint, and two months to respond to his second complaint. We also identified the CNWL Trust took two weeks to respond to Mr O’s third complaint. Given these response times, we next weighed up whether it would be reasonable to expect Mr O to have brought his complaint to us sooner.

36. We discussed this with Mr O to understand the reasons for his delay in bringing his complaint to us.

37. We understand between 2 March 2024 and 26 April 2024 Mr O believed he was actively pursuing his complaint with the CNWL Trust.

38. The CNWL Trust acknowledged via email to him that it had been unclear in its communication over the complaints process. Therefore, it is our view it is reasonable to put this period to one side.

39. We asked Mr O why it took from 26 April until 17 October for him to complain further to the CNWL Trust.

40. Mr O explained that during this time his brother had fallen ill with a heart condition, meaning he was going back and forwards to hospital to support his brother.

41. Mr O also told us he was also dealing with the threat of losing their home, as Mr E had been the leaseholder of the council property. He said they had submitted a request to add his brother to the lease prior to Mr E’s death, but the council did not action it. Therefore, he had to deal with a complaint to the council regarding that.

42. Overall, Mr O explained he was distracted away from his complaint by having to manage his own emotions, his brother’s health and a court case with the council. We are sorry to hear that Mr O’s brother suffered a difficult illness, and of the issues Mr O faced with his housing.

43. We asked Mr O what changed on 17 October to enable him to complain to the CNWL Trust. Mr O told us that it was probably in between him working and managing to get the housing issue to one side.

44. We appreciate Mr O had multiple concerns to manage during this time. We have considered whether we can say Mr O would have been unable to make his further complaint in writing to the Trust.

45. We can see from the complaint records Mr O knew on 2 March 2024 that having reviewed the Trust’s complaint response there were many issues he felt the response did not capture. We also understand from Mr O that he was able to send emails regarding his housing situation during this time.

46. Mr O told us he had evidence that managing his housing situation and supporting his brother was so time-consuming that he could not pursue his complaint with the CNWL Trust.

47. We asked Mr O to provide this to us by Tuesday 5 May 2026. Mr O did not do so but told us he would do his best to get it to us by the end of that week.

48. We therefore gave Mr O a second opportunity to provide the evidence. We told him if he did not provide it by 8 May, then we would have to make a decision based on the information available to us. Mr O did not do so, nor has he contacted us to ask for additional time.

49. The evidence we have available to us shows Mr O was aware he had outstanding concerns and that he had no barriers to written communication.

50. Therefore, we cannot say Mr O was unable to submit his further concerns to the CNWL Trust earlier than the seven months and two weeks it took him to do so.

51. We next asked Mr O why it took him from 27 November 2024 to 2 January 2025 to provide the timeline he told the CNWL Trust he would provide.

52. Mr O told us it was probably to do with the council or his brother’s health, as well as being threatened with eviction. He said he would have been focusing on that. He told us he remembered agreeing with his brother that they should not ignore the issues with Mr E’s care as they had a moral obligation to make sure it did not happen to someone else.

53. We are sorry to hear Mr O’s brother continued to experience difficulties with his health and that the housing issue remained unresolved. We appreciate Mr O’s desire to ensure other patients’ safety.

54. As detailed above, we gave Mr O the opportunity to provide evidence that the ongoing issues with housing took up so much of his time that he could not reasonably be expected to pursue his complaint. Mr O did not do so.

55. Based on the evidence available to us, we do not consider Mr O’s reasons for delay are sufficient to demonstrate he was unable to provide the CNWL Trust with the information he had promised.

56. This is because we cannot say Mr O’s brother being ill would have prevented Mr O from communicating with the CNWL Trust. Nor can we say ongoing issues with housing would have stopped Mr O being able to complete the actions he had committed to.

57. We next consider Mr O’s reasons for not bringing his third complaint to the CNWL Trust until 12 June 2025. This was three months one week after the CNWL Trust provided its response, and two months after Mr O told the CNWL Trust he would contact it.

58. The complaint file shows on 30 April Mr O explained to the CNWL Trust on 30 April that his brother was in hospital but would be discharged in a couple of weeks. He said they would provide a response then.

59. We asked Mr O why he did not provide his response until five weeks after he told the CNWL Trust he would do so.

60. Mr O said he would need to look back into his emails, but his brother had prostate issues as well as heart issues. Also, he was still dealing with a complaint to the council about their housing situation.

61. We asked Mr O what changed on 12 June to enable him to complain.

62. Mr O told us he would have to check his emails, but he could provide evidence from the local authority, courts, shelter and his brother’s medical records.

63. As explained above, we gave Mr O two opportunities to provide these records. Mr O did not provide any further information and so we have been unable to include the described emails in our consideration.

64. We next asked Mr O why he did not bring his complaint to us until 10 September 2025, two months and two weeks after the CNWL Trust provided its final response.

65. Mr O told us that life gets in the way of things, and as with the other delays, it would have been due to time constraints of working a full-time job, caring for his brother and managing the threat of eviction.

66. We asked Mr O what changed on 10 September to enable him to bring his complaint to us. Mr O told us that without a diary of his activities he could not tell us exactly, but it was obviously that a window of opportunity opened for him to finally bring his complaint in writing.

67. Mr O also told us that during the complaint process he was in telephone contact with the Trust’s adult community services. We have put aside the initial time from 2 March 2024 to 26 April 2024, that Mr O was engaged with the adult community services team, rather than the complaints department. This was due to the Trust’s communication being unclear.

68. On 26 April 2024, the Trust gave Mr O clear instructions on how to pursue his complaint with the complaints department. Therefore, we cannot say that any telephone communication with the Trust’s adult community services after this point constituted Mr O following the complaints process.

69. Additionally, if Mr O had time to discuss his complaint verbally with the Trust’s adult community services, we cannot say he did not have the ability to put his concerns into writing.

70. Overall, we have seen no evidence, nor has Mr O provided any reasons that we view would have prevented him from pursuing his complaint about the Trust earlier than he did.

71. 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 Mr O’s complaint about the Trust.

72. We recognise Mr E’s treatment and death was distressing for Mr O and are sorry for his loss. In making this decision, we do not intend to undermine his experience.

1. We have carefully considered Mr O’s complaint about The Hillingdon Hospitals NHS Foundation Trust (the HH Trust) and Central and North West London NHS Foundation Trust (the CNWL Trust). We are sorry for Mr O’s loss and appreciate how distressing the death of Mr E must have been for him.

2. We have decided Mr O’s complaint falls outside of our time limit and there is no good reason for us to put our time limit aside to consider it further.