A practice in the Dudley area

3. Mrs D complains about aspects of the care provided to her mother, Mrs O, by the Practice between August and October 2022. She specifically complains the Practice delayed in assessing and investigating the reasons for her mother’s symptoms, despite her history of cancer.

4. She also complains about aspects of the care the Trust provided to her mother from September 2022 until her death on 13 November 2022. She specifically complains the Trust:

• communicated poorly with Mrs O and her family regarding tests between September and November 2022, and failed to obtain consent for these investigations • failed to diagnose cancer and commence treatment • failed to identify the source of Mrs O’s infection and provide appropriate treatment • provided inadequate care, including a failure to manage her food and fluid intake, repositioning, and assess and manage her swallowing difficulties • unsafely discharged Mrs O from hospital on 4 October 2022 when she was not medically fit and without appropriately planning the care she would receive after her discharge • communicated poorly with Mrs O and her family during her hospital admissions between September and November 2022 • failed to assess and manage Mrs O’s falls risk and mobility needs, leading to a fall in hospital on 28 October 2022, which caused injuries • transferred Mrs O to a second hospital for a biopsy in a minibus when she was not medically fit for the transfer • failed to tell Mrs O and her family she was approaching the end of her life and failed to appropriately plan and implement palliative care.

5. Mrs D says these failings caused her mother distress and a loss of dignity in the final months of her life. She adds the failings caused her family distress and they have been unable to grieve properly due to there being so many unanswered questions about Mrs O’s death.

6. She would like both organisations to acknowledge what went wrong and take action to improve their services. They would also like them to compensate her family for the impact these failings had.

8. The Health Service Commissioners Act 1993 gives us our powers to investigate complaints about NHS services. Section 9(4) of this law says we cannot investigate a complaint that is brought to us later than 12 months after the person became aware of the problem(s), unless there are good reasons for the delay. The clock starts when the person becomes aware of the matters they are complaining about.

9. These events took place between August and November 2022. Mrs O initially approached her GP in August and was not referred to the Trust until 20 September. Mrs O was admitted to hospital on 25 September. She was discharged on 4 October and readmitted on 17 October. She remained in hospital until her death on 13 November.

10. We consider Mrs D was aware of these concerns no later than the date of Mrs O’s death on 13 November 2022. This is because she raised these concerns with the Trust nine days after her death. We also consider she would have been aware of the concerns about the Practice when it became clear Mrs O may have had cancer, rather than musculoskeletal pain, which happened in September 2022.

11. Mrs D approached us with final responses to her complaint on 23 June 2025. This is when the clock stopped for the time limit. The complaint about the Trust came to us 19 months outside the 12-month time limit. The complaint about the Practice came to us 21 months outside the time limit.

12. When a complaint comes to us outside the time limit set out in the law, we have some limited discretion to put this time limit to one side if we can see good reasons for the delay. When we consider whether we should do this, we consider:

• the time it took the organisation(s) to respond to the person’s complaint • any personal circumstances which prevented the person bringing the complaint to us sooner.

13. Where there are long delays that are not reasonably explained by these factors, we are less likely to be able to conclude there was good reason for the delay and put the time limit to one side.

14. When Mrs D first raised her complaint, NHS England agreed to co-ordinate a response between the Trust and the Practice. This means the milestones in progressing this complaint were the same for both complaints. Following this, Mrs D decided to progress the complaints independently, and we have separated our consideration of the delay during this time for both organisations.

15. We are satisfied Mrs D raised her complaint without delay in November 2022. She received a co-ordinated response on 23 August 2023. Between November 2022 and August 2023, NHS England and her the local ICB were co-ordinating a response from both the Practice and the Trust. The complaint responses were significantly delayed, and this was outside of Mrs D’s control.

16. Both the ICB and NHS England have acknowledged the time it took to send these complaint responses was due to a backlog of complaints at both organisations. We have seen evidence Mrs D actively chased these responses during this period of delay and we are satisfied this delay is explained by the complaint handling process.

17. Mrs D was unhappy with the complaint responses sent in August 2023. Following receipt of the complaint responses she requested Mrs O’s medical records from the Trust. She had also previously requested records from NHS Digital, which also took several months to action. Mrs D has confirmed all medical records were received by March 2024. Following receipt of the records, Mrs D then approached our service on 10 June.

18. When Mrs D approached us in June with her outstanding questions about her mother’s care, the complaint was not ready for us because the organisations had not issued final responses to the matters raised. On 1 July we explained this to Mrs D in a telephone call and advised her about the 12-month time limit. Mrs D did not raise her outstanding concerns with the Trust until April 2025.

19. Between August 2023 to April 2025, Mrs D did not raise her outstanding concerns with the Trust. This amounts to a delay of 20 months in returning to the Trust after she had received its response. Similarly, she did not approach the Practice again until July 2025, meaning there was a delay of 23 months in pursuing her outstanding concerns with the Practice. These delays cannot be explained by complaint handling, so we asked Mrs D if there were any circumstances during this time that prevented her from raising these concerns sooner.

20. Mrs D explained that there were several personal circumstances that prevented her pursuing the complaint sooner. She explained:

• there was a six-month delay in receiving Mrs O’s medical records which she wanted to cross-reference with the complaint responses • navigating the medical records took a long time because there was over 1000 pages and none of them were in chronological order • she spent a lot of time analysing the gaps in the complaint responses • she began purchasing a home in summer 2023 and, in February 2024, moved into a house with no central heating or hot water, and her focus was on making the home habitable • her father became unwell and stopped taking his medication in late 2023. She and her sister were his only support, and his behaviour was difficult to manage. This was their priority during this time • her wellbeing was poor during this period of time due to her home being unhabitable and her caring responsibilities to her father • she had a mole removed in July 2024 and was waiting to find out whether she had cancer • her dog was unwell and had a lot of care needs that disturbed her sleep, he was sadly put to sleep in January 2025 • she was challenging her council tax banding between February and July 2025 and had to collate a lot of evidence and meet strict deadlines.

21. We have considered whether the family wanting to cross-reference the complaint responses with Mrs O’s medical records, and the time it took for them to receive these records, reasonably explains the delay between August 2023 and April 2025. We consider that receipt of the medical records was not necessary in order to raise the outstanding concerns the family had. The family could have raised these matters sooner, alongside the request for the medical records, and raised any outstanding issues after receipt of the records. Had this happened, it is likely we would have considered this delay as being explained by complaint handling.

22. Even if we were to conclude the delay in receiving the medical records was a reasonable explanation for not progressing the complaint between August 2023 and March 2024, this does not explain the further delay of 13 months between receiving these records and raising the complaint with the Trust.

23. We also considered Mrs D’s account of the medical records being long and not provided in a chronological order, making it difficult to navigate these and collate a response. Whilst we understand this may have taken longer than expected to navigate, it does not reasonably explain a delay of 13 months between receipt of the records and the further complaint sent to the Trust.

24. We were sorry to learn of the difficult personal circumstances faced by Mrs D and her family during the time between when they received the complaint responses in August 2023 and submitting a further complaint in April 2025. We acknowledge these events would not have been easy and could reasonably explain a delay of a couple of months in pursuing the complaint. However, the delay here was 20 months. We cannot reasonably conclude these circumstances explain such a long delay in pursuing the complaints about the Trust and the Practice. For such a long delay, the circumstances would need to be exceptional for us to conclude the delay was reasonable.

25. What is also of note is that when Mrs D approached us in June 2024, she spoke with us on 1 July 2024 via telephone. We advised her of the time limit for bringing complaints to our service during this call. Following this, she did not raise the complaint again with the Trust until nine months later.

26. We cannot reasonably conclude Mrs D’s personal circumstances prevented her pursuing the complaint with the Trust from the point at which she spoke to us in July 2024. This is because she demonstrated she was in a position to pursue her complaint by contacting us.

27. We also do not think that the removal of her mole in July 2024 reasonably prevented her from pursuing the complaint for a period of nine months. We recognise this would be very worrying, but we cannot see this explains such a long delay. We also acknowledge that caring for and losing a beloved family pet would have been very distressing for Mrs D, but this does not reasonably explain the length of the delay in this case.

28. In addition, we cannot conclude pursuing her challenge to the council tax banding significantly delayed her complaint. This took place between February and July 2025, and Mrs D raised a detailed complaint with the Trust in April. The most this could explain would be a delay of two months between February and April.

29. In April 2025 Mrs D wrote to the Trust with her outstanding concerns. The Trust replied within eight days to advise it would not be considering her complaint further due to the time limit set out in the NHS Complaint Regulations. Mrs D pushed the Trust for a further response on 30 April, and the Trust replied with copies of the NHS Complaints Regulations and its complaints policy on 8 May.

30. Mrs D then contacted us on 23 June. Between June and August her case was open to us, and we can see she was actively pursuing final responses from both the Practice and the Trust. We are satisfied that the time between April and June is broadly explained by complaint handling because we can see Mrs D was actively pursuing final responses to her complaint during this time.

31. In summary, this complaint came to us between 19 and 21 months outside the 12-month time limit. The complaints process took between 30 and 32 months to complete. Whilst 10 months is explained by the delays on the part of the ICB and NHS England, there were long periods of delay in pursuing the complaint following receipt of the first complaint responses in August 2023. These delays are not reasonably explained by the complaints process or the personal circumstances detailed by Mrs D. For this reason, we are unable to take further action on her complaint.

32. We recognise that these circumstances were very distressing for Mrs D and her family, and our decision in no way comments on the merits of her complaint.

1. We have carefully considered Mrs D’s complaint about the Dudley Group NHS Foundation Trust (the Trust) and a GP Practice in the West Midlands (the Practice). We have decided we cannot investigate her complaint. This is because she brought the complaint to us between 19 and 21 months outside the 12-month time limit and we have not seen good reasons for these delays.

2. We recognise these events were devastating for Mrs D and her family. Our decision in no way detracts from that impact, nor does it comment on the merits of the complaint.