The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

4. Ms R complains about the care and treatment provided to her husband Mr E from August 2020 to February 2022 by The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust (the Trust). Specifically, she says the Trust:

• failed to discuss her husband’s scan results in an MDT meeting and did not request a repeat scan within an acceptable timeframe • failed to act on inflammation and abnormalities in test results • failed to carry out necessary blood, urea and electrolyte tests • discharged her husband without antibiotics or oxygen therapy and before reviewing the test results of the fluid drained from his chest • did not arrange a follow-up appointment when indicated • failed to ensure a tube delivering oxygen was safely positioned • failed to monitor her husband’s oxygen intake • changed the discharge plan without informing the family • discussed her husband’s prognosis and end of life plan prematurely • accepted her husband’s cause of death to be cancer despite no evidence of this and created a false cancer narrative.

5. Ms R also complains about the Trust’s handling of her complaint. She says the Trust failed to:

• address all the issues raised in her complaint • provide the findings of its internal investigation into the deprivation of oxygen on two separate occasions • address the role and decisions of the named doctors • disclose the 2020 CT scans and patient outcome report until 2024 • disclose MDT records • provide a chronological record set • correct false statements when challenged • explain discrepancies in the medical records • acknowledge the emotional and procedural impact on the family • address and confirm when her husband’s medical records were made available by the oncology team • tell her it had closed her complaint in April 2023.

6. Ms R told us her husband’s life, health and dignity were compromised due to substandard care, which ultimately resulted in his death.

7. Ms R said her family has endured prolonged emotional distress, procedural frustrations and a loss of trust in the healthcare system. She says the impact continues as they pursue accountability and the truth of why her husband did not receive the care and treatment he should have been afforded.

8. Ms R tells us she has been impacted by false narratives, contradictory and altered records. She has been frustrated by delays and obstructions in disclosing information.

9. Ms R says the secret closure of her complaint meant she could not escalate her complaint to PHSO in a timely manner, artificially manipulated the timeline and obstructed her access to justice. She says this also undermined the integrity of the Trust’s complaint handling process.

10. Ms R says the burden of independently gathering evidence and navigating bureaucratic resistance has been significant and deeply upsetting as it would appear the Trust closed ranks and refused to acknowledge its failings, giving them little hope the truth will ever be known.

11. Ms R seeks a formal acknowledgement of failings, apologies, service improvements and financial compensation.

12. Mr E had a previous diagnosis of lung cancer and was having surveillance scans as part of his follow-up care. He had been under the care of the Trust since 2016. He was admitted to hospital on 6 January 2022 and treated for a chest infection. He was discharged on 22 January but readmitted three days later having collapsed at home. Mr E sadly died on 3 February 2022.

15. The Act is a law that sets out our role, responsibilities and the things we must consider as the final step in the complaints process.

16. Section 9 (4) of the Act says we should not investigate a complaint if it is brought to us more than one year after the affected person first became aware of their reason to complain, unless we consider there is a good reason to do so.

17. Ms R complains about the care and treatment Mr E received in January and February 2022. Ms R knew she had cause to complain in February 2022. We know this because she requested Mr E’s medical records in February 2022 in advance of making her complaint to the Trust in November 2022. We consider Ms R’s date of knowledge for the concerns about her husband’s clinical care is February 2022.

18. With this and the Act in mind, to be in time, Ms R needed to bring her complaint about the clinical care to PHSO before February 2023. Ms R brought her complaint to PHSO in August 2025, this part of her complaint is two years and six months outside our 12-month time limit.

19. Ms R also complains about the Trust’s handling of her complaint. Ms R had written several letters to the Trust in 2023 and 2024 complaining about the missing records and unanswered concerns. We consider Ms R’s date of knowledge for this part of her complaint is January 2024. This is because she wrote a letter to the Trust on 13 January with concerns about the handling of her complaint.

20. We recognise Ms R continued to be unhappy with the way the Trust were handling her complaint after this date. Ms R continued to pursue her complaint with the Trust until July 2025 rather than bringing her complaint to PHSO.

21. It is likely further complaint handling issues would arise throughout this time as there was a disconnect between what Ms R wanted the Trust to do and what it was either able or willing to do. We think it is reasonable to say Ms R knew she had cause to complain about the Trust’s handling of her complaint from January 2024.

22. With this and the Act in mind, to be in time, Ms R needed to bring her complaint about complaint handling to PHSO before January 2025. Ms R brought her complaint to PHSO in August 2025, this part of her complaint is seven months out of time.

23. Ms R requested her husband’s medical records soon after he sadly died and made her complaint to the Trust in November 2022. The Trust responded to Ms R’s complaint on 31 March 2023. The Trust’s response letter invited Ms R to return to it if she had any further concerns. The letter also signposted Ms R to PHSO.

24. Ms R could have brought her complaint to PHSO as early as 31 March 2023 as she had a final response from the Trust at this point. This final response letter is the document we would need to see to be satisfied the Trust had already had the opportunity to address the complaint and allow us to begin a primary investigation.

25. We can see Ms R returned to the Trust with further concerns on 13 April 2023, she also complained the medical records she had requested were not complete. Ms R did not receive a response to this letter and so she sent a further letter five months later on 4 September 2023 reiterating her concerns.

26. Ms R received no response to this letter, and she sent another letter to the Trust on 13 January 2024 setting out which records were missing and made a subject access request (SAR). A SAR is a legal request made by an individual to obtain a copy of their personal data held by an organisation.

27. The Trust responded on 19 January 2024 with a holding letter acknowledging Ms R’s contact. The Trust apologised for the delay and cited shortage of staff due to sickness for the lack of response. Ms R chased the Trust again on 9 February and 27 March 2024 saying she would have no choice but to contact PHSO if she did not hear back from the Trust.

28. The Trust sent Ms R a letter on 12 April 2024 advising it had fully investigated her complaint and provided all medical records. This letter signposted Ms R to PHSO.

29. Ms R could have brought her complaint to us as early as 31 March 2023 when she received the first Trust response signposting to PHSO. Ms R decided to return to the Trust with further concerns as indicated she could do in the Trust’s letter. We think this was reasonable action for Ms R to take at this time.

30. The Trust did not respond to Ms R’s letters until 12 April 2024 at which time it confirmed it had fully investigated her complaint and asked Ms R to contact PHSO if she had further concerns.

31. We think reasonably Ms R could have brought her complaint to PHSO on or soon after 12 April 2024. The Trust had confirmed it had fully investigated her complaint and signposted her to PHSO. Ms R was unhappy with the clinical care her husband had received and the complaint handling and so had cause to contact PHSO. We asked Ms R why she waited until August 2025 to bring her complaint to PHSO after receiving the Trust’s response in April 2024.

32. Ms R told us at this point she had not received the SAR information or full medical records from the Trust. She says several issues remained unanswered including concerns about decision making, missing documentation and inconsistencies in the Trust’s own investigation. She says additionally the Trust continued to correspond with her in May and June 2024. She believes this is confirmation the local resolution process was still ongoing at this point.

33. Ms R says for these reasons escalation to PHSO at this time would have been premature. We do not agree. Ms R had been told by the Trust on 12 April 2024 its investigation was complete and advised her to contact PHSO with her further concerns.

34. Had Ms R contacted PHSO at this time we would have considered her complaint (even at this point the complaint was out of time, and a time consideration would have been carried out prior to any investigation taking place).

35. We could have also determined what parts of Ms R’s complaint had not been addressed and we could have asked the Trust for a response. The Trust’s letters which Ms R was in receipt of by 12 April 2024, provided answers to most of her complaint and would have been sufficient to start a consideration.

36. The Trust wrote to Ms R again in May and June 2024. The letter from the Trust dated 14 June 2024 again reiterates its investigation is complete and to contact PHSO for further concerns.

37. Ms R could have brought her complaint to PHSO at this point but chose to write to the Trust again five months later in November 2024.

38. On 28 November 2024, having received Ms R’s letter, the Trust contacted PHSO to apply for a section 10 referral. A section 10 referral is when the Trust brings the complaint to PHSO rather than the complainant bringing it (as is the expected course of action).

39. The Trust told PHSO despite several attempts to resolve Ms R’s complaint she had sent further correspondence and given it 28 days to respond. The Trust said it felt it was unlikely they would be able to reach a satisfactory resolution and this is why they were applying for the section 10 referral.

40. The Trust wrote to Ms R on 29 November 2024 to advise it had made the referral to PHSO because their relationship had irretrievably broken down and due to the nature of Ms R’s concerns it felt it could not provide further assistance to her.

41. PHSO rejected the referral on 10 December and advised the Trust to tell Ms R to refer her complaint herself. The Trust contacted Ms R on 11 February 2025 and advised her to take her complaint to PHSO directly.

42. We asked Ms R why she did not contact PHSO on or soon after 11 February 2025. Ms R told us she did not contact PHSO at this time as she had not received any documentation from the Trust in relation to the section 10 referral.

43. Ms R told us she contacted the Trust asking for a copy of the referral letter and supporting documents. She says the Trust responded on 19 February 2025 with the Trust’s referral request email to PHSO.

44. Ms R told us she then wrote a formal escalation letter to the Trust on 27 March 2025 and another in July 2025 which both went unanswered. Ms R told us these escalation letters were prompted in part by information she found out in September 2024 that the Trust had withheld key medical records.

45. Ms R says her concerns were still unresolved by early 2025 and several issues remained outstanding. Ms R says this confirms local resolution was still ongoing at this stage. We do not agree. The Trust had sent very clear communications to Ms R that it had exhausted its complaints process as early as April 2024. Ms R continued to pursue the Trust until July 2025 despite this.

46. Ms R told us she contacted PHSO on 20 May 2025 though it was not to escalate her complaint to PHSO at this stage. She says her contact with PHSO in May 2025 was to request information relating to the Trust’s self-referral.

47. Ms R told us because the Trust had not provided this information she needed to request it from PHSO to understand what had been sent by the Trust on her behalf. She says only after receiving this information she proceeded to formally contact PHSO regarding the complaint itself.

48. Ms R contacted PHSO about her complaint on 21 August 2025 regarding her complaint.

49. Ms R told us she did not receive a complete set of medical records from the Trust and there are aspects of her complaint she was unaware of until she received her husband’s full medical records in September 2024 from the GP.

50. Ms R says she was unaware there was an abnormality reported on a scan in August 2020 and this was only revealed to her in September 2024 when reading the full medical records.

51. Part of Ms R’s complaint in November 2022 was about the adequacy of the surveillance scans being carried out by the Trust. Had Ms R brought her complaint to us in time and given us the opportunity to investigate her concerns we would have requested Mr E’s records. These older scans would likely have been reviewed as part of our investigation into whether the Trust had carried out appropriate follow-up surveillance.

52. Ms R was unhappy with the care provided to her husband after he sadly died in February 2022. Ms R knew she had cause to complain at this time. This is evidenced by the fact she requested Mr E’s medical records in February 2022 and raised her complaint to the Trust in November 2022.

53. We recognise Ms R chose to request and review Mr E’s medical records however, this is not a requirement of our process. We consider a person can complain as soon as they become aware they have reason to. This does not require them to conduct their own investigation or review the records in detail before doing so.

54. There was a significant gap of one year, five months and twelve days after receiving the Trust’s letter in April 2024 in which Ms R could have brought her complaint to us but did not do so.

55. With all the above in mind, we have not seen any evidence to justify Ms R’s delays. Her reasons for not bringing her complaint to us once she received the Trust’s response in April 2024 are not enough to set aside our time limit.

56. While we recognise this may be disappointing for Ms R, it is important we consider and act within the law and we are sorry for any further upset this decision may cause.

57. We thank Ms R for bringing her complaint to our attention and giving us the opportunity to consider it.

1. We have carefully considered Ms R’s complaint about The Queen Elizabeth Hospital King’s Lynne NHS Foundation Trust (the Trust). We are very sorry to hear about the sad loss of Ms R’s husband. We recognise Ms R has had a difficult time.

2. We have decided not to consider Ms R’s complaints further because they have come to us considerably outside of our time limit. We are not persuaded there is sufficient reason to set the time limit to one side in this case.

3. We acknowledge our decision may be disappointing for Ms R and we are sorry for any disappointment caused. We explain the reasons for our decision below.