Dartford and Gravesham NHS Trust

The Trust

4. Miss R complains about the following aspects of care and treatment provided to her father, Mr S, between June 2023 and June 2024. She says:

• the Trust perforated her father’s bladder and this was not identified promptly • the Trust failed to operate on her father’s bladder • the Trust did not provide adequate nutrition.

SECA

5. Miss R complains SECA failed to transport her father to hospital for treatment on 23 June 2024.

6. Her father sadly died on 29 June 2024. Miss R believes that her father’s bladder perforation led to repeated infections, sepsis, ongoing pain and significant weight loss and believes his death could have been prevented. Miss R says this has caused him and his family a great deal of distress.

7. To resolve her complaint, Miss R would like an acknowledgment of failings and service improvements. She would also like a financial remedy.

8. On 26 July 2023, Mr S, underwent a transurethral resection of bladder tumour (TURBT), a procedure used to diagnose and treat abnormal growths or tumours within the bladder. Tissues removed during the surgery were sent for analysis, which confirmed a diagnosis of superficial bladder cancer.

9. On 21 September, Mr S, had a repeat TURBT and samples were taken from a number of sites within his bladder for further analysis. Following this procedure a catheter was inserted into his bladder to remove any blood clots, as well as allowing urine to drain.

10. To treat his bladder cancer, Mr S was commenced on Bacillus Calmette-Guerin (BCG) immunotherapy administered through a catheter on 8 November. During a subsequent appointment for BCG on 15 November, Mr S presented with signs consistent with a urinary tract infection.

11. A computed tomography (CT) scan of his abdomen and pelvis on 13 December, confirmed a small perforation of the bladder and a localised leak on the right side.

12. To repair the perforation, Mr S was scheduled for surgery on 19 April 2024, but this procedure was postponed.

13. On 29 April, Mr S attended the Emergency Department (ED) by ambulance due to low blood pressure and low oxygen levels. Blood tests showed he had raised infection markers. Blood was noted in his stool sample and he was also severely dehydrated resulting in acute kidney injury (AKI), a sudden and often reversible reduction in kidney function. He was treated for sepsis with intravenous antibiotics, although the source of the infection was not identified at that time and he was later discharged.

14. His condition deteriorated further on 23 June and he was readmitted to hospital on 24 June. Sadly, Mr S died on 29 June.

17. The law gives us our powers to investigate complaints about NHS services in England. Section 9(4) of this Act says we should not investigate a complaint if it is brought to us more than one year after the person became aware of the issues, unless we consider it reasonable to do so.

18. When Miss R completed her complaint form to us, she documented 11 December 2024 as the date she became aware she had a reason to complain. This is what we call date of knowledge (DOK).

19. We spoke to Miss R to clarify the circumstances surrounding the DOK. It was established that the correct DOK was 11 December 2023, which corresponds with the period in which the CT scan confirmed her father’s bladder perforation and localised leak.

20. Miss R indicated on her complaint form that her father’s perforated bladder was not healing and that he had developed sepsis and significant weight loss. She states that she raised concerns with the Patient Advice Liaison Service (PALS) on three occasions and had also contacted a Member of Parliament (MP). She also explained that she sought a transfer for her father to another hospital in order for him to receive appropriate care for his perforated bladder.

21. From reviewing the Trust’s response, we can see that there was a period of contact with both PALS and an MP in May 2024 about Mr S’s treatment pathway after his surgery to repair his perforated bladder was cancelled.

22. Based on all the information provided, including her contact with PALS and an MP, it is evident that Miss R was aware she had reason to complain from as early as December 2023.

23. For Miss R’s complaint to have been made within our time limit, she would have needed to bring the complaint to us by 11 December 2024, within 12 months of the DOK.

24. Miss R submitted her complaint to us on 5 December 2025, which is nearly one year outside of our 12-month time limit. Miss R says that she submitted a complaint to us sometime in 2024, however, there is no record indicating that a complaint was received from her in 2024.

25. If a complaint is received outside the 12-month time limit, we must consider whether there are reasonable grounds to waive the time limit. We spoke with Miss R to understand the reasons she did not bring her complaint to us sooner. We also considered the time taken for SECA and the Trust to provide their final responses.

26. The information provided shows that Miss R complained to SECA on 23 June 2025 and SECA issued its final response on 15 September 2025. Following receipt of that response, Miss R took nearly 3 months to bring her complaint to us.

27. Miss R complained to the Trust on 29 June 2025 and the Trust issued its final response on 9 October 2025. Following receipt of that response, Miss R took nearly 2 months to bring her complaint to us.

28. Given that the DOK was 11 December 2023, there was a delay of approximately 18 months before Miss R raised her concerns with SECA and the Trust in June 2025. This means that at the time she raised her concerns with SECA and the Trust, she was already beyond our 12-month time limit. Miss R did not provide any specific reasons to explain these delays or the delays following the receipt of the final responses in bringing her complaint to us.

29. From speaking with Miss R, it is clear what happened to Mr S had a profound impact on her life, and we know how important this complaint is to her. We are very grateful to Miss R for bringing her complaint to us and for speaking with us so openly about what happened.

1. We have carefully considered Miss R’s complaint about the Trust and SECA. We are very sorry and deeply saddened to read about the death of her father, Mr S. We extend our sincere condolences to Miss R and her family for their loss.

2. We have decided not to consider Miss R’s complaint further. This is because the complaint falls outside of our time limit. We do not see sufficient reason to set our time limit aside and explain the reasons for this decision in this statement.

3. We recognise and are grateful for the time and effort that has gone into making this complaint. Our decision in no way diminishes the seriousness of the concerns raised or the distress these events have caused Miss R and her family.