North West Anglia NHS Foundation Trust

3. Mrs Y complains about aspects of the care and treatment provided to Miss Y in the days leading her to death in February 2013. Specifically, Mrs Y complains:

• The Trust failed to assess Miss Y’s risk of malnutrition during her admission to hospital • The Trust pierced Miss Y’s lung during an operation on 13 February and failed to diagnose this at the time • A nurse left Miss Y on her own after she became unresponsive on 14 February • The Trust delayed arranging a scan after Miss Y became unresponsive • Despite showing signs of infection beforehand, the Trust did not treat Miss Y with antibiotics until 17 February • During the admission, the Trust failed to diagnose Miss Y with chronic pancreatitis.

4. Mrs Y says the failings caused Miss Y’s death. She says she is traumatised by the circumstances of her daughter’s deterioration and death.

5. Mrs Y would like the truth about what happened to Miss Y. She would also like financial remedy.

6. Miss Y was admitted to hospital at the end of January 2013. She was suffering from vomiting and had lost a significant amount of weight.

7. In the early hours of 14 February, Miss Y fell from her hospital bed. Within a few hours, she became unresponsive.

8. On 16 February, the Trust arranged to transfer Miss Y to a critical care unit at another Trust. Very sadly, she died a few days later.

9. Mrs Y complained to the Trust via an advocate on 20 February 2013 and it replied to her complaint on 22 May. She took legal action against the Trust in 2016.

10. Mrs Y brought her complaint to us on 17 February 2026.

13. The law says we cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. When we receive a complaint, we consider if it is within our time limit. This means we look at whether the complaint was brought to us within one year of when the complainant knew they had a reason to complain. If the complaint is outside our time limit, we consider the reasons for this. Finally, we look at whether the delay in coming to us was reasonable in the circumstances.

14. We can see Mrs Y was aware of many concerns in 2013 following Miss Y’s sad death. Mrs Y raised her concerns with the Trust at the time. However, we understand new information came to light while Mrs Y was taking legal action against the Trust between 2016 and 2019. This new information led her to believe there had been additional failings.

15. We recognise how distressing it would have been for Mrs Y to learn new information about the circumstances of her daughter’s death six years later. In our consideration of the time it has taken Mrs Y to bring her complaint to us, we have treated 2019 as the date she became aware of the full extent of her complaint. Even on this basis, Mrs Y’s complaint is six years outside of our time limit.

16. We recognise Mrs Y was actively engaged in the process of taking legal action in 2019. It is understandable that she was not immediately focusing on bringing a complaint to us at this time. If Mrs Y had come to us while she was taking legal action, it is likely we would have advised that we could not consider her complaint while this process was ongoing.

17. We understand from Mrs Y that legal action was ultimately unsuccessful, and the process came to an end in August 2019.

18. We think it reasonable to say Mrs Y had all the information she needed to approach us after the legal process ended and within a year of seeing the new information about the circumstances of Miss Y’s death.

19. Mrs Y explained she was unsure about what to do once the legal action had been unsuccessful. We recognise Mrs Y would have felt uncertain about her next steps at this time. Mrs Y had our details and had she contacted us, we could have advised her of our time limits and asked her to send her complaint to us as soon as possible.

20. Mrs Y explained she received support from an advocate when she complained in 2013. She said when she contacted the advocacy organisation in 2019, she was informed the advocate who had helped her in 2013 had left. We recognise this meant Mrs Y no longer had the benefit of someone who was familiar with her case. We think at this time, Mrs Y could have asked the advocacy organisation if another advocate could have supported her. We do not consider the original advocate leaving prevented Mrs Y from bringing her complaint to us or explains a delay of six years.

21. We understand Mrs Y has pursued her concerns about the Trust with other organisations, including the police, at various points since Miss Y died. We recognise this reflects Mrs Y’s strength of feeling on the circumstances of her daughter’s death. Unfortunately, despite wishing to pursue the matter, Mrs Y did not approach our office for six years. We have not seen evidence to explain why she could not have approached us sooner, either alongside or before pursuing other avenues.

22. We understand there have been many practical and emotional matters for Mrs Y to deal with since Miss Y died. We understand she has been managing a lot of this on her own. We are sorry to hear how much Mrs Y has had to cope with.

23. We have carefully considered the reasons Mrs Y has given for the delay in bringing her complaint to us after the legal process ended. We do not consider that the factors reasonably explain why she could not have approached us sooner. Mrs Y was aware of our service, could have sought support from another advocate or contacted us directly for advice, and remained able to actively pursue her concerns through other organisations.

24. We are very sorry for Mrs Y’s sad loss, and we understand the last thirteen years have been extremely difficult for her. We have carefully considered her circumstances when deciding whether to exercise discretion and put our time limit aside. Having looked at the information available to us and considered Mrs L’s explanations, we have not seen that the circumstances were a significant barrier to her bringing her complaint within the time available.

25. We thank Mrs Y for the effort she has gone to in bringing us her complaint and sharing information with us. Our decision is not intended in any way to diminish her experience. It is important we consider and act within the law and we hope our statement clearly explains the reason why we cannot consider the complaint further.

1. We thank Mrs Y for her complaint about North West Anglia NHS Foundation Trust (the Trust). We were sorry to hear of her concerns about the care the Trust provided her daughter, Miss Y. We offer our sincere condolences to Mrs Y for her sad loss.

2. We have seen Mrs Y’s complaint falls outside of our time limit by at least six years. We have carefully considered the reasons for this and have decided we should not put our time limit to one side. We understand how important the complaint is to Mrs Y and that our decision will be disappointing for her. We have explained the reasons for our decision below.