A practice in the Luton area

3. Mr H has complained about the lack of appropriate care and treatment from the organisations, that spans a period from 2021 to date. The issues we are considering relate to complaints he made between May 2023 and February 2024.

4. He says what happened has affected his whole life and left him with disabilities. The outcomes he seeks are apologies, acknowledgment of failings and a financial remedy.

5. Mr H sustained a Lisfranc injury in 2021. This is a fracture, dislocation, or severe sprain of the midfoot. It occurs when the bones or ligaments connecting the forefoot and hindfoot are damaged or displaced.

6. Since that time he has had multiple health issues across many specialisms, which are ongoing today.

7. Mr H made complaints that have concluded the local resolution process with the organisations. He complained to the Practice on 26 May 2023 and received a response on 27 February 2024. He complained to the Trust on 10 November 2023 and received responses on 14 March and 8 April 2024. He complained to the MSK Provider on 13 February 2024 and received a response on 13 March 2024.

8. On 8 April 2025 Mr H brought the responses to this office and completed a complaint form asking us to carry out an investigation.

11. The law says a person needs to make their complaint to us within a year of becoming aware of the problem (we call this the date of knowledge). We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

12. We consider the date of knowledge to be the point at which the person had awareness of the claimed failing(s) (when they realised they were unhappy and felt something had gone wrong, so had grounds for a complaint). It is not when the claimed injustice (what happened as a result of the claimed failings) became serious enough they decided to complain about it.

13. Mr H has shared a lot of information with the organisations and with us. His health issues have gone on for a long time, and he has raised a lot of issues with the clinical teams providing his care and treatment. He has also sent emails to the complaints departments explaining his situation, and sharing details of the second opinions he has taken.

14. It has been difficult to identify from the evidence Mr H sent to us what the exact dates of knowledge were. We asked Mr H about his dates of knowledge and he acknowledged that his dates of knowledge were when he made the complaints. He qualified this by saying at this point he did not understand the seriousness and impact of the claimed failings. He says later reports and second opinions brought this to his attention.

15. It is reasonable for us to conclude that the dates of knowledge must have been before Mr H raised the complaints. For this reason we have decided to accept the dates of knowledge as being the dates Mr H made his complaints, as outlined in paragraph seven.

16. We would not change the date of knowledge to a later date because of the further private and second-opinion reports Mr H obtained. This is for the reasons explained in paragraph 12.

17. Mr H contacted us in August 2023 to tell us he was unhappy with the care and treatment from the organisations. Our records show we communicated with him over the next few months, explaining that we needed the organisations to have completed their local resolution process. We asked him what responses he had had.

18. On 26 October 2023 we suggested Mr H use an advocate to support him with the process. This was because, from the information he was sharing, it was difficult for us to understand the issues and whether Mr H had completed the local complaints process. We told him that organisations have six months to respond to complaints. We also told him about our time limit, as outlined in paragraph 11.

19. Mr H replied on 4 November 2023 saying he would be using friends and family to support him. He said six months had passed since he had complained to the Practice so ‘I will call you soon as my GP surgery's time of six months has passed’.

20. We did not hear from Mr H again until April 2024 when we told him to send us all the responses he had received so we could see if we could carry out an investigation that covered all the organisations.

21. We did not hear back from Mr H until a year later, in April 2025. Mr H sent us the responses on 8 April 2025 along with a complaint form asking us to carry out an investigation.

22. The complaints were then more than one year after Mr H’s date of knowledge so they fell outside our time limit. We asked Mr H to explain the reasons for the one year gap, as outlined in paragraphs 20 and 21, to see if we should set aside our time limit.

23. Mr H told us he thought the complaints were still being investigated by the Trust. He explained the Trust had not fully addressed all his concerns and so he was waiting for local resolution to conclude.

24. We have not seen anything in the evidence provided to make us think that local resolution was ongoing. We think it would have been reasonable for Mr H to have forwarded the responses he had in April 2024, as we had requested. This would have allowed us to begin our process within the time limit. We can see that both the Trust and the MSK Provider had signposted Mr H to us in their responses.

25. We can see that in the intervening period between us asking for the responses (April 2024) and Mr H sending them (April 2025) he did communicate with the Trust. He sent copies of private reviews and second opinions. He contacted clinical teams and complaint teams asking about his care and treatment.

26. It does not seem to us that these were continuations of the same complaint. It is clear from the correspondence that the Trust was not able to understand what the issues were or what Mr H wanted from raising these issues. The Trust suggested Mr H use an advocate to help make clear what his concerns were. We consider this was reasonable on the part of the Trust. It does not lead us to think the complaints he already had responses for were still being investigated, or give sufficient explanation for the one-year delay in sending us the responses.

27. Mr H told us he telephoned the Trust’s complaints office and was given contradictory information. He said he was initially told he should wait for a further response, and then told months later his complaint had been closed.

28. We do not have any independent evidence of what was said in these calls. We can see the final response from the Trust dated 8 April 2024 signposted him to us, and we consider it would have been reasonable for him to send his responses in April 2024 as we had asked. We have not found the explanations in paragraphs 23 to 27 reason enough to set aside the time limit.

29. Mr H told us there were other factors during the period between April 2024 and April 2025 that prevented him bringing his complaint to us. He said:

• he was continuing to experience serious health problems and deterioration • he found the process confusing and difficult to manage • he believed he had a year from the final complaint response to bring his complaint to the Ombudsman • he approached several solicitors for assistance, but they did not take on his case.

30. We were sorry to hear what a challenging time this was for Mr H, and that he was affected by his health. It can be difficult to understand and prioritise the complaints process when there are other life issues affecting you.

31. Advocacy organisations are there to help in such circumstances, and we think Mr H could have sought such help to support him in bringing his complaint to us, or bringing any new issues to the Trust. As outlined in paragraph 18 we suggested Mr H use an advocate, before his complaint became out of time.

32. Mr H told us the Trust, instead of addressing his concerns, also suggested he use an advocate and this confused him. We consider it was a reasonable suggestion, as organisations need information presented in a way that they can understand the issues being raised. We continue to think it would have been reasonable for Mr H to have taken this offer of help.

33. Mr H has since sought family support with his complaint, which also would have been a reasonable option for him to follow sooner, when we and the Trust explained what we needed to know to progress his complaint.

34. As Mr H was able to consult solicitors to try to pursue a legal remedy during the period, we have not seen any barriers to him also asking for support with the complaint process.

35. It is regrettable Mr H had the incorrect belief about our time limit. We had shared the correct information in October 2023, along with a link to the information on our website.

36. For these reasons we do not think the explanations in paragraph 29 good reason to set aside our time limit.

37. We have also considered the time the organisations took to respond to Mr H’s complaints. The regulations say the organisation investigating a complaint should send the complaint response within ‘the period of six months commencing on the day on which the complaint was received’.

38. The Practice took nine months to reply. The Trust took five months to reply, and the MSK Provider took one month to reply. The Trust and the MSK provider responded their responses within the timescale outlined by the regulations.

39. The Practice responded four months outside the expectations of the regulations. We recognise waiting for this response will have been frustrating for Mr H. We do not think this is what led to the complaint falling outside our time limit. The gap of one year between us asking for Mr H to provide the responses and to properly make his complaint, and when he actually did this, is what led to the complaint falling outside our time limit.

40. We do not reach the conclusion that we should set aside the time limit because of the time the Practice took to respond.

41. To conclude, we think it would have been reasonable for Mr H to have taken some action to prevent the complaint from falling outside the time limit. We think it would have been reasonable for Mr H to have used support to help him provide the information we told him we needed for our process.

42. We have not seen anything in the explanations Mr H gave to make us think there are compelling reasons for us to set aside the time limit. We think that having already completed the complaints process, it would have been reasonable for him to bring his complaints to us in line with the process we had explained.

43. We were very sorry to learn about what happened, and the impact this had on Mr H. We understand how important the complaint is to him, and we are grateful to Mr H for sharing his concerns.

44. It is important we act within the law, and that we apply our current approach and process fairly and consistently. We hope this statement clearly explains the reasons why we will not be considering the complaint further.

1. Mr H’s complaints fall outside our time limit. We carefully considered his reasons for not bringing the complaints to us sooner. We did not think these were sufficient to set aside our time limit and so we will take no further action.

2. We thank Mr H for taking the time to tell us about what happened. We were sorry to read about his experience and the ongoing impact on him. We hope this statement explains the reasons for our decision.