Royal Free London NHS Foundation Trust

4. Mrs B, supported by Ms C, complains about the care and treatment provided to her husband by the Trust from 13 July to 8 August 2023. She says:

• Trust staff were dismissive and had a poor attitude, mocking Mr B and his family, and ignoring their concerns • the Trust handled Mr B’s gall bladder infection poorly, following his diagnosis on 2 August, ignoring Mr B’s pain and not performing a CT scan within the time it was instructed to, despite Mr B’s ongoing pain • Trust staff ignored Mr B’s wishes and inserted two catheters, including a two-way catheter on 6 August and a three-way catheter on 7 August • Trust staff failed to conduct a scan and check the placement of Mr B’s catheter on 6 August, leaving it unable to drain • Nursing staff incorrectly inserted Mr B’s catheter on 8 August, despite the requirement for a doctor to perform this procedure • Trust staff wrongly terminated Mr B’s blood transfusions on 5 and 6 August, before they were completed, without any reasoning • Trust staff communicated Mr B’s death poorly to his family, failing to clarify whether Mr B had died or showing any empathy to his wife and daughter when sharing the news • Trust staff failed to provide relevant information about Mr B’s condition, care and treatment during this period of care • the Trust’s internal communication was poor, leading to confusion surrounding Mr B’s care and treatment, and poor oversight from senior staff • the Trust failed to keep accurate or complete records for Mr B’s care and treatment, leaving the family with unanswered questions or clarity, particularly surrounding what happened in the hours around Mr B’s death • Trust staff failed to obtain an ultrasound machine when completing Mr B’s blood tests.

5. Mrs B says the Trust’s actions denied her husband the dignity he deserved. She says he spent his final weeks living in a hostile environment where he experienced unnecessary pain and poor care. Witnessing this, alongside the poor communication from Trust staff regarding his care and treatment, caused Mrs B and Ms C a great deal of suffering also. Mrs B says she ultimately had a heart attack the day after her husband died because of the events.

6. As an outcome of this complaint, Mrs B would like a financial remedy in the region of £600 to £1200 to show the Trust has been held accountable for its actions.

7. On 13 July 2023, Mr B was admitted to a hospital within the Trust because of a soft tissue injury to his leg. Mr B was recovering well and a few days later he was moved to another ward.

8. Mr B was due to be discharged on 2 August 2023 but the day before, he began experiencing sudden acute abdominal pain. Mr B was diagnosed with a gall bladder infection and remained in hospital, where he was given antibiotics and monitored via blood tests. However, Mr B’s kidney function began to worsen.

9. Mr B also suffered from myelodysplastic syndrome (MDS), a rare type of blood cancer, for which he needed to receive blood transfusions. Mr B received a blood transfusion on 5 August, but it is unclear whether this was completed. He received a second unit of blood the following day, but Mrs B says this was stopped partway through when a nurse disconnected the line without explanation.

10. During this two-day period, Mr B’s infection began improving and he had a two-way catheter inserted to monitor his urine output. On 7 August, Mr B was told he needed a three-way catheter, which Mrs B says he refused. But Mrs B explained this was inserted later that evening as the Trust said it had by then received Mr B’s consent.

11. On 8 August, Mrs B says she received a telephone call from the Trust telling her Mr B was very unwell and she needed to come immediately, but it may be too late. Ms C, Mr B’s daughter, arrived at the Trust shortly afterwards, but Mr B had sadly already died. Ms C described how she was told by a doctor that her father had a three-way catheter inserted during the night and this caused him to haemorrhage (bleeding caused by a blood vessel breaking) and his blood pressure to drop. Ms C says the doctor told her that her father had suffered kidney failure and his death would be recorded as cholecystitis (inflammation of the gallbladder). However, Mrs B says she was told her husband had suffered multi-organ failure.

12. The case was referred to the coroner in August, and a postmortem was performed in September. Mrs B received the autopsy report on 12 October.

14. The ‘Health Service Commissioners Act 1993’ (the Act) says a person needs to bring 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 good reason to do so. We have discussed this with Mrs B and Ms C to understand the reasons why Mrs B could not bring her complaint to us sooner. We have also considered the time taken for this complaint to be investigated and responded to by the Trust.

15. Mrs B told us she knew in August 2023 she had reason to complain about the events discussed above. With the Act in mind, this means Mrs B needed to bring her complaint to us by August 2024, unless it was not reasonable for her to do so. Mrs B did not bring her complaint to us until November 2025, which means she approached us approximately 1 year and 3 months outside of our time limit.

16. As such, we looked at what happened between August 2023, when Mrs B became aware of her reason to complain, and when she approached us in November 2025.

17. We reviewed the information Mrs B and Ms C submitted to us, including the Trust’s complaint response and correspondence Mrs B and Ms C had with the Trust, various legal firms, and the relevant Integrated Care Board (the ICB). We can see Mr B’s death was referred to the coroner in August 2023, a postmortem was completed in September 2023, and Mrs B received the autopsy report in October 2023. We can understand it was reasonable for Mrs B to wait for the autopsy report during this period and want to reassure her we have taken into account the time this took.

18. Because of this, we considered what happened from October 2023, when Mrs B received the report, until she made a formal complaint to the Trust in May 2024.

19. From speaking with Mrs B and Ms C, we appreciate this was a very difficult time for them. Mrs B told us she experienced significant health problems from August 2023, following her husband’s death, and needed surgery and rehabilitation because of this. We also understand Mrs B and Ms C were grieving the loss of Mr B, and his funeral took place in October 2023.

20. Around a month after Mr B’s funeral, on 28 November 2023, Mrs B contacted the ICB to raise concerns about the care and treatment Mr B received at the Trust. The ICB responded one week later, on 5 December 2023, advising Mrs B to make a complaint directly to the Trust and providing the contact details she needed to do so. Mrs B and Ms C did not submit a formal complaint to the Trust until 16 May 2024, more than 5 months later.

21. To understand whether anything during this period may have prevented them from making or progressing a complaint, we asked Mrs B and Ms C about this gap. They explained they were in the process of moving country and dealing with practical tasks that go along with this, such as registering for a new GP and managing utilities. We can also see that in May 2024 Mrs B and Ms C sought support from advocacy services, although they have told us they did not receive a response to these enquiries.

22. We recognise the challenges Mrs B and Ms C faced during this time. Having thought carefully about what they told us, the information they have provided does not show they were unable to raise a complaint with the Trust sooner than they did. This is because although they were managing practical challenges associated with moving, nothing they described indicates these issues prevented them from contacting the Trust during this five-month period. We also note that it was open to them to seek advocacy services from December 2023, if they needed support in managing both the complaint and their other responsibilities at that time.

23. Once Mrs B submitted her complaint to the Trust, it is clear both she and Ms C tried to progress things. We can see they stayed in contact with the Trust, asking for updates and chasing a formal response to their concerns.

24. Between December 2024 and September 2025, Mrs B and Ms C were progressing their complaint and exploring their legal options. After the Trust sent its formal complaint response on 4 November 2024, they then requested a meeting, as suggested within the Trust’s complaint response. Whilst waiting for this meeting, we can see Mrs B and Ms C tried to move things forward by seeking help from MPs.

25. They attended a meeting with the Trust on 27 February. At this point, the Trust advised them to seek legal advice for financial redress or approach our Office as the next stage of the complaint’s procedure. This means their complaint was ready for us to consider at that time.

26. We can see Mrs B and Ms C requested copies of the meeting recording and transcript, and they approached MPs for support.

27. In July 2025 the Trust confirmed it would be unable to offer financial redress, and between July and 21 August 2025 Mrs B and Ms C sought legal advice. A solicitor declined to take on their case on 21 August 2025. They approached two more solicitors in September 2025, but they had also both declined the case by 29 September 2025. Mrs B and Ms C did not bring their complaint to us until 12 November 2025.

28. This means there was a further gap of approximately six weeks where they could have brought their complaint to us. In our discussions with Mrs B and Ms C we have not seen any reasons for this period of delay.

29. With the above in mind, we are not able to set aside our time limit. We recognise that, alongside their grief for the loss of Mr B, this must have been a challenging period for them, and we do not wish to undermine this. What we must consider is whether these circumstances prevented them from making or progressing a complaint.

30. We understand our decision will be disappointing for Mrs B and Ms C and we wish to acknowledge the concerns they have described and the significant impact this event has had on them. Our intention is not to minimise their experience. We hope this explanation provides clarity on how we reached our decision and why we are unable to set our time limit aside in this case.

1. We have carefully considered Mrs B’s complaint about Royal Free London NHS Foundation Trust (the Trust).

2. We are sorry to hear about the circumstances surrounding Mrs B’s complaint. We recognise the upset and suffering she has faced because of the loss of her husband, Mr B, and how profoundly this has affected her and her daughter, Ms C.

3. Having considered the available evidence, we can see Mrs B’s complaint falls outside our one-year time limit and we are unable to set that time limit aside. We recognise our decision will likely be disappointing for Mrs B and Ms C, and we explain the reasons for our decision below.