Leeds Teaching Hospitals NHS Trust

4. Miss N complains about the care and treatment she received from the Trust between September 2021 and May 2024. She complains the Trust dismissed her concerns made by telephone call to the maternity ward prior to giving birth in September 2021. She complains the Trust recorded incorrect information on the Perinatal Mortality Review Tool (PMRT) following Miss N having given birth. Further, she complains she was laughed at during a meeting with the Trust in May 2024.

5. Miss N says these events have impacted her mental health and caused her to lack trust in the Trust. Miss N believes that the death of her daughter was avoidable had the Trust have taken her concerns seriously.

6. Miss N is seeking financial remedy from the Trust and service improvements.

Issue 1 – Concerns

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. We have discussed this with Miss N to understand the reasons why Miss N could not do so. We have also considered the time the organisation has taken to respond to Miss N.

10. Miss N claims the Trust dismissed her concerns made by telephone call to the maternity ward prior to giving birth in September 2021. Miss N claims to have called the maternity ward at the Trust on two separate occasions in a two-week period prior to giving birth. On both occasions, Miss N claims she was dismissed and not provided with adequate care and consideration.

11. Miss N claims that had her concerns been listened to and care and treatment have been provided, her daughter may not have been still born.

12. Given these claims, it is reasonable to consider that Miss N suspected the failings claimed in September 2021 following the still birth of her daughter.

13. As such, we consider September 2021 to be a reasonable date of knowledge for Miss N to have suspected the claimed failings in care for this aspect of her complaint. This has been communicated to Miss N via email when requesting further details to better inform our consideration of this decision.

14. This means we would expect the complaint to have been brought to us by September 2022 to be considered in time. The complaint was brought to us in October 2025 and is therefore three years and one month out of time.

15. We have spoken with Miss N to clarify the timeline of events and her reasons for not bringing the complaint to us within our one-year time limit. These reasons have been considered when determining if we are able to set aside our time limit in this instance.

16. Miss N has detailed the traumatic impact the death of her daughter has had on her. Miss N states that in the aftermath of these events she was unable to think about raising a complaint as she was in a fragile mental state. She tells us she was unable to return to work due to the ongoing impact of her bereavement, and that her support system was limited. Miss N says she did not have the capacity to process daily life or navigate a complaint. We are very sorry to hear of Miss N’s trauma and the impact she experienced. We do not underestimate what a difficult time this must have been for her.

17. Miss N has also told us she was unable to bring her complaint to us sooner as she became pregnant again and gave birth to her daughter in March 2025. Miss N states she deliberately paused the complaint process during her pregnancy to avoid stress and prioritise the safety of her pregnancy. Her complaint was brought to PHSO in October 2025. We recognise the additional stress pursuing a complaint of this nature would have caused during Miss N’s pregnancy.

18. We acknowledge Miss N’s explanation for the delay in coming to the PHSO and appreciate the gravity of the impact her experiences have had. We have considered if there is sufficient evidence to allow us to put the time limit to one side, given four years and one month elapsed between September 2021, when Miss N was aware of her concerns, and October 2025 when the complaint was submitted to our office.

19. This is a significant time frame and so we have carefully considered what Miss N told us. We recognise the trauma Miss N experienced because of her daughter’s death in September 2021 and we can acknowledge that this would account for Miss N delaying pursuing a complaint with the Trust in the immediate aftermath of her daughter’s death and for some time after these events.

20. Miss N tells us she was unaware of the option of obtaining support through an advocate. We recognise that complainants may not always be aware of all sources of support available to them. Despite this, individuals remain responsible for taking reasonable steps to pursue concerns they wish to raise. We have not seen evidence that a lack of awareness of advocacy services prevented Miss N from exploring how to make a complaint.

21. While we recognise the profound impact this had on Miss N, we have not been provided with evidence which demonstrates these circumstances prevented her from raising a complaint throughout the entire period of delay between September 2021 and May 2024, when Miss N made her complaint to the Trust.

22. We have also considered the time local resolution took. We can see Miss N was able to raise her complaint with the Trust in May 2024 and attend a meeting with the Trust to resolve the complaint. We consider that this evidences Miss N’s ability to pursue her concerns and meaningfully engage with the local resolution process.

23. The Trust issued a final response to Miss N in August 2024 which signposted her to PHSO should she have remained dissatisfied with their response. There was a further period of delay between August 2024 and October 2025 when Miss N submitted her complaint to our office. Miss N’s reasons for this delay are outlined in paragraph 17 of this statement.

24. The complaint was not brought to our office until seven months after Miss N gave birth. Whilst we recognise that caring for a newborn baby presents significant demands, we deem that Miss N has not been able to provide any further barriers to prevent her from raising a complaint that we would consider reasonable for the period after March 2025.

25. In conclusion, we have not identified any mitigating or exceptional circumstances which would allow us to set the time limit aside for Miss N's complaint, and for this reason we are unable to consider her concerns. We recognise this will be disappointing for Miss N, given the ongoing concerns she has and the impact this has had on her wellbeing.

Issue 2 – Perinatal Mortality Review Tool (PMRT)

26. Miss N claims the Trust recorded incorrect information on the PMRT following having given birth. The PMRT report was produced by clinicians in September 2021.

27. In March 2024 Miss N wished to try and conceive again. This prompted her to request all medical documents regarding her and her daughter’s care. When Miss N received the PMRT documents she identified the information was incorrect and as such became aware of her reason to complain. Based on this, we consider March 2024 to be a reasonable date of knowledge for Miss N to have suspected the claimed failings in care.

28. This means we would expect the complaint to have been brought to us by March 2025 to be considered in time. The complaint was made to the Trust in May 2024, and a final response was issued in August 2024. It was brought to us in October 2025 and is therefore seven months out of time. There is a period of one year and seven months between Miss N becoming aware of these issues and bringing them to our office.

29. As outlined in paragraph 24, we have carefully considered Miss N’s reasons for this period of delay, and we do not consider there is sufficient evidence for us to exercise our discretion. Therefore, we cannot put the time limit aside for this issue.

Issue 3 – Complaint Handling

30. Miss N claims during a meeting she attended with the Trust in May 2024 aimed at resolving the complaint, a clinician laughed at her. Miss N emailed the Trust on 31 May 2024 to raise a complaint regarding this matter.

31. Therefore, we consider May 2024 as the date of knowledge of failings relating to the Trust’s complaints handling. Miss N received a final response from the Trust in August 2024.

32. This means we would expect the complaint to have been brought to us by May 2025 to be considered in time. The complaint was brought to us in October 2025 and is therefore five months out of time. There is a period of one year and five months between Miss N becoming aware of these issues and bringing them to our office.

33. As outlined in paragraph 24, we do not consider there is sufficient evidence for us to exercise our discretion for the period of delay between May and October 2025. Therefore, we cannot put the time limit aside for this issue.

34. We recognise these events were particularly traumatic for Miss N and understand how this effects Miss N profoundly. We can see that Miss N has attempted to find resolution with the Trust before bringing the complaint to us, and we are sorry this has not been successful for her. We are unable to put aside the time limit on this case as the time elapsed is too long for us to be able to exercise our discretion without reasonable cause for the entirety of the period. As such, we will be closing this case as out of time.

Conclusion

35. We have decided this complaint falls outside of our time limit and we propose to take no further action. We assure Miss N in reaching this decision we have carefully considered the concerns she raised. We recognise Miss N has experienced a traumatic event and she has told PHSO how much this has profoundly affected her, and we are very sorry to hear of this impact.

36. We have taken Miss N’s concerns seriously and carefully considered them. Having done so, we do not consider Miss N has provided sufficient reasons for us to carry out an investigation of a complaint made to us so far outside our time limit. We fully acknowledge our decision will be disappointing for Miss N given how long she has been seeking answers to the concerns raised.

37. Upon careful review of all the information provided and in line with relevant legislation, we do not feel able to set the time limit to one side for this complaint. For this reason, we will not be considering this complaint further.

1. We have carefully considered Miss N’s complaint about Leeds Teaching Hospitals NHS Trust (the Trust). The complaint falls outside of our time limit, and we do not consider there is sufficient evidence for us to exercise our discretion and consider the complaint further.

2. We recognise the profound affect these events have had on Miss N and we are very sorry to hear this. We have taken Miss N’s concerns seriously and carefully considered them. Having done so, we do not consider there is sufficient evidence to show Miss N’s circumstances prevented her from bringing her complaint to us sooner than she did.

3. We acknowledge our decision will be disappointing for Miss N. We are sorry for any further distress our decision may cause, and we hope our explanation set out below shows clearly how we have considered her complaint and the reasons she has provided to us.