Nottingham University Hospitals NHS Trust

3. Mr W complains about aspects of the care the Trust provided to his son, Mr L, between October 2022 and March 2023. He says the Trust:

• did not make it clear to Mr L he needed to monitor his temperature and be aware of the risk of septicaemia when he started chemotherapy in October • did not identify the increased risk of chemotherapy-associated neutropenic sepsis after discharging Mr L with a falling white blood cell count and oral thrush on 15 February • on discharging Mr L, did not ensure he was adequately monitored at home or warn him about changes in his condition to look out for • failed to take bloods before administering antibiotics to treat possible neutropenic sepsis after Mr L’s admission on 21 February, meaning clinicians did not know the cause of his infection and could not know it had been treated • did not read an amended CT report which warned of the possibility of bleomycin (a chemotherapy drug) toxicity until 27 February, two days after Mr L had received further treatment with bleomycin.

4. Mr W says Mr L’s condition worsened until his treatment was changed to palliative care when he died. He has been left feeling guilty that the lack of advice from the Trust meant Mr L developed neutropenic sepsis at home and earlier treatment may have prevented it developing into sepsis. He is concerned his death may have been avoidable and was not peaceful. This has had a lasting impact on his family, and he has been left with additional responsibilities as a result of the bereavement.

5. Mr W would like the Trust to acknowledge its failings, apologise for the impact this had, and improve its processes. He would also like us to consider making a financial recommendation.

6. We include this brief background to put the complaint into context. It is not intended to reflect all of the detail Mr W gave us about his experience.

7. Mr L started chemotherapy in October 2022. He had an inpatient admission at the Trust in February 2023. Sadly, Mr L died in March. A post-mortem report was produced in April. In August, the Trust issued its Patient Safety Incident Response (PSIR) report.

8. Mr W was in the process of exploring legal action. As part of this, in October 2024, the legal firm had a medical report from a clinician. We understand Mr W saw this in December.

9. Mr W contacted us in early 2025 about how he could bring his complaint to us. He then complained to the Trust in March. The Trust responded to the complaint in August and signposted Mr W to us. He came back to us in November 2025.

12. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mr W to understand the reasons why he could not do so. We have also considered the time the organisation has taken to respond to Mr W.

13. Mr W says his date of knowledge, the date when he knew there was a problem to complain about, is December 2024. We are not persuaded that this is accurate.

14. Mr L died in March 2023. The Trust’s PSIR report said the Trust had informed Mr L that there was a concern that he had developed bleomycin-induced lung toxicity and had deteriorated because of additional bleomycin. It said it had a ‘Being Open’ discussion with Mr L in the presence of Mr W.

15. The PSIR report notes ‘Whilst there is no doubt that knowledge of the original scan change would have changed the management for [Mr L] it is more difficult to comment on whether the final outcome would have changed.’

16. Mr W decided to explore legal action in 2023 as he suspected something had gone wrong. He says Mr L had insisted that if he died from medical negligence, his family should pursue a compensation claim. We appreciate they were acting in line with his wishes at that time.

17. Mr W says he pursued legal action immediately after the interim death certificate was released. He told us his legal team still felt that there was a case to be answered after the post-mortem.

18. Mr L’s death was reported to the coroner due to the concerns regarding the bleomycin. He had a post-mortem examination which concluded that there was no evidence of bleomycin induced lung injury. This report is dated April 2023.

19. Mr W says the legal team still felt there was a case to be answered and advised that an investigation by our office whilst their case was proceeding may have been detrimental to them. He says ‘it was only after receiving the Expert Witness’s Final Report that I concluded that [Mr L] died because of a failure in communication of the need to monitor him while at home, and a failure by the hospital to make sure that this was done.’

20. Mr W put December 2024 as his date of knowledge on his complaint form. He said he only had certainty about what led to Mr L’s death in December 2024, more than 20 months after his death, as part of the legal action he was exploring.

21. Mr W had a sense something had gone wrong and this had led to Mr L’s death. We would not necessarily have expected him to be able to specify what happened. We therefore cannot say he did not know there was a cause for concern in 2023.

22. We appreciate Mr W may not have had certainty until he had the report from the legal firm in 2024, and that the report prompted his concerns to evolve. However, he disputed the Trust’s account in the PSIR report so must have felt there was an issue then, if not at the point of the April 2023 post-mortem report or when Mr L died in March 2023 and it prompted his legal action.

23. We therefore consider his date of knowledge was around this time in 2023, not December 2024 as he says. By definition, the fact he was pursuing a negligence claim in March 2023 is indicative of him believing there was a problem. By his account, this belief was being supported by the legal firm in April 2023. His complaint is therefore outside of our time limit by more than one year, and was out of time when he first contacted us in January 2025.

24. The Trust produced its PSIR report within six months of Mr L’s death. Its response to Mr W’s complaint was issued within six months, in line with the NHS Complaints Regulations. We cannot see that the Trust’s complaint handling is a significant factor in the case being delayed.

25. Instead, it appears that the time Mr W spent pursuing the legal process is the reason why his complaint is outside of the time limit. Pursuing the legal route rather than the complaints process was a choice Mr W made. Unfortunately, we cannot say this is a good reason to put the time limit to one side.

26. For the reasons set out above, we cannot justify putting the time limit aside to consider the complaint further. We appreciate this is not the outcome Mr W wanted. We hope we have clearly explained why we have decided not to investigate this complaint.

1. We have carefully considered Mr W’s complaint about the Trust. We were very sorry to hear his concerns about the care his son, Mr L, received before he sadly died. We would like to offer our condolences for his loss.

2. Unfortunately, the complaint falls outside of our time limit and we have decided there is no good reason for us to put our time limit aside to consider it further.