East Lancashire Hospitals NHS Trust

East Lancashire Hospitals NHS Trust

4. Mr N complains about aspects of care and treatment his mother-in-law, Mrs P received from the East Lancashire Hospitals NHS Trust (the Trust) between March and May 2022. Specifically, he says the Trust failed to investigate an injury to Mrs P’s groin or correctly manage her food intake. He also says the Trust did not manage Mrs P’s hygiene or put measures in place to prevent and treat pressure sores/ulcers.

5. As a result, Mr N has said Mrs P was malnourished and suffered severe ulcers to her legs, ultimately, leading to her death. He says this left the family deeply upset and frustrated and unable to have any closure.

6. As an outcome to resolve his complaint they are seeking an apology, service improvements and a financial remedy.

North West Ambulance Service NHS Trust

7. Mr N complains about aspects of care and treatment; Mrs P also received from West Ambulance Service NHS Trust (the Ambulance Trust) between 17 and 18 May 2022. Specifically, he says the Trust attended to Mrs P on four occasions but failed to bring the appropriate equipment and staff.

8. As a result, he says Mrs P was caused a great deal of pain, suffering and distress.

9. As an outcome to resolve his complaint they are seeking an apology, service improvements and a financial remedy.

10. The period of care being complained about is 3 March 2022 and 21 May 2022 when Mrs P tragically died. Issues with the Ambulance Trust occurred between 17 and 18 May 2022.

13. The Ombudsman’s powers are set out in the HSCA. This is the law that governs our work. Section 9(4) of the HSCA 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.

14. Sadly, Mrs P was admitted to hospital in March 2022. This is when Mrs N and his wife said they initially became aware of the reason to complain. However, they have also said they had further reason to complain up until 21 May 2022, when Mrs P sadly died. We call this the ‘date of knowledge’. For the complaint to have come to us in time, it would have needed to have been brought to our Office within 12 months of the date of knowledge, therefore by 21 May 2023.

15. We first received the complaint when Mr N submitted his completed complaint form to us on 12 September 2025. This means the complaint came to us two years and four months outside of our 12-month time limit.

16. When any complaint comes to us outside of our time limit, we must consider the time taken by the person complaining and the time taken by the organisation to respond. We spoke with Mr N to understand the reasons why he could not bring his complaint to us sooner. We also considered the time the Trust took to respond to Mr N’s complaint.

17. From the information shared with us we can see Mrs N first complained to the Trust on 11 April 2023; this was nearly nine months after the latest date of knowledge. The Trust sent a written response to Mrs N, six and a half months later, on 23 October 2023. It is unclear when Mr N first complained to the Ambulance Trust, but it issued its response on 23 June 2023.

18. It appears Mr N raised further concerns with the Trust and local resolution meeting took place in October 2024. After this it appears Mr N was in communication with his advocate, and he contacted our office on 27 February 2025. We wrote to Mr N explaining there was insufficient information and he needed to make the complaint in writing. It also appears we asked for confirmation the local resolution process was over.

19. On 30 June 2025, the Trust wrote to Mr N and explained the local resolution process had been exhausted and it did not feel anything further could be done to resolve his complaint.

20. We asked Mr N about the delay, and he explained he did not initially raise a complaint with either the Trust or the Ambulance Trust as he and the family were dealing with the death of Mrs P. Given the undoubted impact this would have had on the family, we accept the initial delay in raising a complaint was reasonable.

21. However, following the Ambulance Trust’s response in June 2023 and the Trust’s response in October 2023, Mr N said it took him considerable time to go through Mrs P’s clinical records. Mr N said he felt this was important as he wanted to feel prepared when proceeding with the complaint. He also explained the confusion regarding what organisation was providing what care to Mrs P, which also delayed matters.

22. Mr N also explained following the local resolution meeting with the Trust in October 2024, he was in contact with his advocate to discuss whether to bring the complaint to us. Mr N also explained that the advocate informed him the complaint was still within our time limits.

23. We recognise the complaints process can be lengthy and time-consuming, and it can feel exhausting. We also understand how busy life can be when returning to normal after such a difficult time. Yet, we would have expected the complaint to be brough to us much sooner.

24. Although, we appreciate Mr N wanted to feel prepared when pursuing his complaint, it is not reasonable to expect someone to have to go through and understand lengthy clinical records. Furthermore, Mr N was made aware of us and our time limits in the Trust’s responses in June and October 2023. It is unfortunate that Mr N’s advocate may have informed him his case was still within our time limit but Mr N could have pursued this himself.

25. Furthermore, after Mr N initially approached us in February 2025 and we informed him the complaint needed to be made in writing and the local resolution process needed to be concluded, it took another seven months to bring the complaint back to us. This was two months after the Trust had issued its response informing him that it was not willing to review the complaint again.

In summary

26. From the dates outlined above, although, we appreciate Mr N was pursing his complaint with various organisations and there were significant periods between the Trust and the Ambulance Trust issuing their response(s), we would have expected him to bring his complaint to our office much sooner than September 2025.

27. From the initial date of the events occurring between March and May 2022 it took nearly three and a half years to bring the complaint to us. We consider a period of this length to constitute a delay and had he acted sooner, the complaint would have come to us in time. We have thought carefully about the explanations Mr N has given, and do not consider these exceptional reasons to justify putting our time limit to one side.

28. We are very sorry for any disappointment caused by our decision. We are grateful to Mr N for bringing his complaint to us and for speaking with us so openly about what happened. We understand this period was very difficult for Mr N and his family and we know how important his complaint is. We must apply our time limit fairly. For the reasons explained, we do not see good reason to set aside our time limit. We hope this statement clearly explains the reasons why we will not be considering this complaint further.

1. We were very sorry to have learned of Mr N’s concerns about his mother in law’s care. We recognise that what happened continues to cause Mr N and his wife considerable ongoing upset and distress, and we extend our condolences to them both.

2. After careful consideration, we have decided not to consider Mr N’s complaint further as it falls outside of our time limit.

3. We sincerely thank Mr N for sharing his experience with us. We are very sorry for any disappointment caused by our decision, which we explain in more detail below.