Chelsea and Westminster Hospital NHS Foundation Trust

4. Mrs R complains about aspects of care and treatment her husband, Mr R received from the Trust between 21 March and 1 June 2023. Specifically, she says the Trust failed to adequately monitor her husband’s oxygen levels and then says there was a delay(s) in implementing Non-Invasive Ventilation (NIV) therapy. She also says the ‘weaning’ management plan was insufficient and the Trust failed to treat her husbands ‘bloating’ in a timely manner.

5. As a result, Mrs R says her husband died due to the actions of the Trust. She also says the events that led to his death caused her and the family a great deal of distress and upset.

6. She is seeking an acknowledgement of failings, an apology and service improvements.

7. On 21 March 2023, Mr R attended A&E with chronic type two respiratory failure and end stage COPD, with a background of multiple recurrent episodes or aspiration pneumonia. The Trust admitted Mr R as an inpatient.

8. On 18 April 2023, the Trust identified Mr R as being at risk of refeeding syndrome. At the time the Trust administered pabrinex (a high potency, concentrated intravenous form of vitamin C and B) until 3 May 2023. The Trust then switched to thiamine, administered either orally or via the nasogastric (NG) tube (a thin, flexible plastic tube inserted through the nose, down the throat, and into the stomach).

9. On 25 April 2023, the Trust said it discussed with Mrs R about the importance of the NIV machine in keeping her husband alive.

10. On 27 April 2023, it appears Mrs R had a discussion with the respiratory consultant about transferring Mr R to another hospital. The Trust explained that he was too unstable for transfer at the time and he was receiving appropriate treatment at the Trust.

11. On 30 May 2023, the Trust started to administer a feeding tube. The Trust did not prescribe the full amount as Mr R vomited and the feed was stopped. The NG tube was removed on 31 May and not replaced.

12. Tragically, Mr R’s Condition deteriorated, and he sadly died on 1 June 2023.

15. The Ombudsman’s powers are set out in the Health Service Commissioner’s Act 1993. Section 9 (4) of this legislation (the law) says a person needs to make their complaint to us within a year of becoming aware of the problem. It says we cannot investigate complaints brought to us after one year, unless we see there is a good reason to do so.

16. The issues Mrs R complains about occurred between 21 March 2023 and Mr R’ tragic death on 1 June 2023. In her complaint form Mrs R has told our office she became aware of the issues on 13 April 2023 and tried to initiate a complaint in June 2023. However, she says the Trust were not willing to provide her with the clinical records, so they had to go through probate.

17. Mrs R has said once she received the records in December 2023, she went through them, before submitted a complaint with the Trust on 22 April 2024.

18. She has then explained there was a significant delay in the Trust issuing its response and did not receive a response until 10 January 2025. She then explains she took the case to the General Medical Council (GMC), before bringing the complaint to us on 31 May 2025.

19. We discussed this with Mrs R and her daughter to understand the reasons for the delays. They said initially the Trust would not allow access to Mr R’s clinical records which meant they couldn’t see what doctors were involved and couldn’t provide proof of wrongdoing.

20. When asked about the four and half month delay in bringing the complaint to our office after the Trusts response on 10 January 2025, they again explained their decision to take the case to the GMC.

21. Mr R and her daughter also explained they were not made aware of our time limit.

Our decision

22. We fully acknowledge the emotional difficulties Mrs R and her family have experienced during the period of care in question and the subsequent issues they faced accessing Mr R’s clinical records.

23. It is reasonable to expect that if Mrs R was unhappy with the care her husband received, she should have raised a complaint when she says she became aware in April 2023. Furthermore, once the Trust issued its response on 10 January 2025, she could have should have brought the complaint to us much sooner than 31 May 2025.

24. We recognise her decision to pursue the complaint with the GMC, but we have seen no reason why the complaint could not be brought to our office. Especially given Mrs R was made aware of our organisation by the Trust and was signposted to our website (which outlines our time bar legislation).

25. It is important individuals bring their complaints to our office as soon as possible as the longer time that passes, the more difficult it is for us to investigate issues or make recommendations to Trusts (given procedures may have already changed etc).

26. In conclusion, although we appreciate Mrs R has said she had issues accessing her husband’s clinical records and we understand the family would have been grieving following Mr R’s tragic death, we would still have expected Mrs R to have raised a complaint prior to his death in April 2023 when she says she had cause for concern.

27. Furthermore, we would also have expected Mrs R to continue to progress the case as quickly as possible once the complaints process was started. Ultimately, the family decided to pursue the complaint with the GMC rather than bring the complaint to our office.

28. Therefore, we have decided we will not take further action on Mrs R’s complaint. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We were very sorry to learn of Mrs R’s concerns about the care her husband Mr R received between 21 March and his tragic death on 4 June 2022.

2. We have decided not to consider Mrs R’s complaint further because she has come to us considerably outside of our time limit. We carefully considered the reasons Mrs R, gave for this. We did not think there was sufficient reason to set our time limit aside.

3. We recognise and we are grateful for the time and effort that has gone into making this complaint. We are sorry for any disappointment caused by our decision.