Worcestershire Acute Hospitals NHS Trust

4. Mrs O complains that in April and May 2023 the Trust:

• discharged Mr O from hospital on 13 April 2023 without a diagnosis and provided insufficient magnesium sachets upon discharge • failed to provide nutritional support whilst in hospital, and incorrectly calculated his score on the Malnutrition Universal Screening Tool • poorly managed his risk of developing a pressure ulcer • provided poor nursing care, including Mr O being left in his own excrement • communicated with Mrs O in a way that caused her distress • failed to identify Mr O’s pneumonia, leading to sepsis.

5. Mrs O also complains the Trust did not follow its policy when undertaking the SJR investigation, including failing to involve her in the process and communicate with her effectively.

6. She says the clinical failings caused her husband’s death. She adds that her mental health deteriorated due to what went wrong, and she has lost faith in the NHS.

7. Mrs O would like the Trust to compensate her for the impact of the failings in her husband’s care. She would also like it to take steps to improve its service so that the same mistakes do not happen again.

9. The law which gives us our powers to investigate complaints about the NHS is the Health Service Commissioners Act 1993. Section 9(4) of this law says that a person must bring their complaint to us within 12 months. We do have the discretion to put this time limit to one side when we can see good reasons for the delay.

10. When a considering whether there were good reasons for the delay in approaching our service, we look at:

• the time it took the organisation to complete its handling of the complaint • any personal circumstances that prevented the person from bringing the complaint to us sooner.

11. If there are any lengthy delays in raising or pursuing the complaint, or in bringing the complaint to us, we are unable to set this time limit to one side unless there are good reasons for these delays.

12. The events complained about took place in April and May 2023. Mrs O approached our service with full and final responses to her complaint on 21 August 2025. This means the complaint came to us between one year and three months and one year and four months outside the time limit set out in the law.

13. Because the complaint came to us outside the time limit, we have considered whether there were good reasons for this delay. Where there were delays that were longer than we would expect, we asked Mrs O for more information about why she did not progress the complaint sooner.

14. Mrs O was dissatisfied with her husband’s care in May 2023. We know she was unhappy at that time because she told us, in an email dated 1 July 2026, she contacted the Trust’s Patient Advice and Liaison Service (PALS) in May.

15. We reviewed the time it took the Trust to investigate her complaint, and we are satisfied the following periods of time are fully explained by the Trust’s complaints process:

• November 2023 to March 2024 • October 2024 to August 2025.

16. There were delays in raising and pursuing the complaint with the Trust. We identified the following periods of delay:

• April/May 2023 to November 2023 (six-to-seven-month delay) • March to October 2024 (seven-month delay).

17. We asked Mrs O about the reasons for these two periods of delay in raising and pursuing her complaint. We have considered these explanations and, for the reasons outlined below, these do not sufficiently explain the length of the delays.

18. Between April and November 2023, Mrs O says she initially contacted the PALS team in May. She says she contacted them by telephone and asked about the process for raising a complaint. She then says she wrote a letter without delay. We have seen no evidence of a letter being written at the time Mrs O says she contacted PALS. Her first written complaint appears to have been on 17 November 2023.

19. We asked Mrs O about the delay in raising a formal complaint. She explained it was because of poor advice from the PALS team about how to raise a complaint. She says she was not aware the Trust had a complaints department and the Trust should have directed her to this. We agree that NHS Trusts should direct complainants to the correct department when the complaint has not been resolved via the PALS team. That said, this does not mean a delay of six months in pursuing this was reasonable.

20. We reviewed the Trust’s website, as it was at the time, via the National Archives’ government website archive. At the time Mrs O was raising her concerns, the Trust’s website had a dedicated page explaining how to raise a complaint. This page included the Complaint Team’s contact details and the details of how to access support via an advocacy service. It is reasonable to have expected Mrs O to have taken the initiative to explore how she could raise the complaint when she had not heard from the PALS team. This could have included visiting the Trust’s website, where the information was readily available.

21. We considered whether there may have been a barrier to Mrs O accessing the internet, however we have not seen evidence this was the case. Mrs O has not told us she is at risk of digital exclusion, and she was able to submit her complaint to us using our website.

22. Mrs O also says she was not aware of any time limits for relating to complaints about NHS care. Whilst we don’t expect people to be immediately aware of time limits for coming to our service, this does not mean that they should delay in raising a complaint due to this. Our contact details were also on the Trust’s complaints page as the contact for who to get in touch with if the person is unhappy with how the complaint is being handled. Had she contacted us, we would more likely than not have advised on the timeline before November 2023 and how delays could impact on us considering the complaint. This information was also available on our website at that time.

23. Whilst we acknowledge the Trust may have communicated poorly with Mrs O, she still had access to the Trust’s contact details, specifically for its Complaints Team, and our contact details. This information was available on the Trust’s website. The website was easy to navigate with the details accessible via the ‘contact us’ option on the website. It is reasonable to expect her to have recognised she had not heard from the Trust and to have taken proactive steps to find out how to contact the Trust via its website. We do not consider this is a reasonable explanation for such a lengthy delay in pursuing her complaint.

24. With regards to the delay which occurred between March and October 2024, Mrs O says she did not receive the complaint response until April. We accept this may have happened and that this explains the delay between March and April.

25. Mrs O says that between April and October she, by chance, met the managing director of the Trust at a meeting regarding another matter in June. She says this person offered to meet her to discuss the complaint. She says she tried to arrange this but was unable to and so sent the further correspondence to the Trust in October.

26. We are not satisfied this explains the delay in pursuing her complaint further. It is reasonable to expect someone to take steps to pursue their complaint when they are unhappy with the response and have not heard from the organisation. We do not consider it reasonable to not make further contact for a period of six months.

27. Mrs O knew she was unhappy with the Trust’s response on receipt in April but did not take steps to contact the complaints team about this. She then had the chance meeting with the manager in June, two months later, and contacted his PA. Given she wanted to attend a meeting to discuss these matters in June, it is reasonable to assume she already knew what she was unhappy about and could have complained to the Trust about this sooner.

28. Mrs O could also have accessed NHS advocacy if it was proving difficult to write the complaint. The details for this were readily available on the Trust’s website and were also given to her in the Trust’s complaint acknowledgement letter in November 2023. She was also given our details in this letter.

29. We do not consider Mrs O’s explanation of the delay is sufficient to explain how long it took to approach the Trust again to raise her dissatisfaction with its first complaint response.

30. Mrs O has also complained about the two SJR reports. We have decided not to take further action on her complaints about these reports because we would be unable to reach a meaningful conclusion. This is because we cannot consider the clinical aspects of the reports due to the matters themselves coming to us outside the time limit.

31. We could potentially consider the complaint she has about the Trust’s communication and engagement with her during this process. However, the most likely outcome we could achieve is an apology for poor communication and ask it to take steps to improve its service. The Trust has already provided this apology and outlined the steps it will take to improve the SJR process. We are satisfied this is appropriate to put right the impact of what went wrong, and there is nothing further we could reasonably achieve if we were to investigate this aspect of her complaint.

32. We recognise the loss of Mrs O’s husband was devastating for her family. Our decision does not detract from this and we have made no comment on the merits of her complaint.

1. We have carefully considered Mrs O’s complaint about the care Worcestershire Acute Hospitals NHS Trust (the Trust) provided to husband, Mr O. We have decided we cannot take further action on her complaint about his clinical care because the complaint came to us outside the 12-month time limit. We have not seen good reasons to put this time limit to one side.

2. We have also decided not to take further action on her complaints about the Trust’s Structured Judgement Reviews (SJRs). This is because we would be unable to reach a meaningful conclusion and outcome regarding any of the clinical aspects of her concerns about the SJR. The Trust has already apologised for a shortfall in communication during these investigations and outlined the service improvements it has made. There is nothing further we could reasonably achieve as an outcome for Mrs O if we did investigate her complaint about the communication and engagement during the SJR process.

3. We recognise these events were very distressing for Mrs O. Our decision does not comment on the merits of her complaint and does not detract from the distress she experienced due to these events.