Manchester University NHS Foundation Trust

3. Miss A complains about the care provided to her grandmother, Mrs B, by the NHS Trust (the Trust) when she attended A&E on 20 December 2022. Specifically:

• after being brought to A&E by ambulance with suspected sepsis, Mrs B was left in the corridor for approximately two hours without any medication being administered to her • Mrs B was not given any antibiotics until two hours after she arrived in A&E, and no specific explanation was provided about this delay.

4. Miss A says the inadequate care that her grandmother received in the hours before she died on 20 December 2022 has had a profound impact on the lives of her living children, so much so that they were unable to pursue the complaint further with the Trust. It has caused lasting emotional damage that is ongoing. The Trust’s complaint response has exacerbated this as it states that the Trust does not feel that Mrs B’s death was preventable. Miss A disagrees with this and says the impact of these sad events are lasting and profound for all her family. Their day-to-day lives are impaired with the sadness of what could have been.

5. As a set of outcomes, Miss A wants acknowledgement of failings by the Trust regarding her grandmother’s care and changes in procedure to prevent it happening again. Miss A also wants a financial remedy of £12500.

7. 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 Miss A to understand the reasons why she could not do so. We have also considered the time the Trust has taken to respond to Miss A.

8. We know from the evidence considered that Mrs B sadly died unexpectedly on 20 December 2022, just a few hours after being taken to hospital. This tragic event must have been a great shock to Miss A and the rest of Mrs B’s family. Understandable, Miss A and her family needed to take some time to process what had happened and try to come to terms with their bereavement.

9. Miss A’s aunt did not make a formal complaint to the Trust about Mrs B’s care until 12 October 2023 which is approximately ten months later. This is a significant delay in the context of our time limit, but we understand from Miss A that other family members had also sadly died during 2022. This and Mrs B’s unexpected death at the end of that year meant that the next few months were an immensely hard time for Miss A and her family. Therefore, in the circumstances, we are prepared to accept that this initial ten-month delay in submitting a complaint to the Trust was not unreasonable.

10. The Trust replied in writing to the complaint from Miss A’s aunt on 2 November 2023 just a few weeks after it had been submitted. If Miss A’s aunt were unhappy with the Trust’s reply, we consider the letter made it clear that she could re-approach the Trust for further local resolution or contact us as a next step. Contact details were provided for the Trust complaints team and us.

11. Unfortunately, there is no evidence of Miss A’s aunt or anyone else in the family taking any further action until Miss A contacted us with her complaint on 21 October 2025 nearly two years after the Trust’s only response to the complaint. Therefore, based on our time limit test as set out in paragraph 7 of this statement, Miss A’s complaint is approximately 22 months out of time.

12. Given this, we have asked Miss A to explain the reasons for this additional and lengthy delay in bringing her complaint to us, to try and establish if there are sufficient grounds for us to waive the time limit on her complaint.

13. Miss A says her aunt thought the Trust’s complaint response letter from November 2023 was the end of the complaints service. Miss A also says her aunt did not realise the significance of potential failings in the care of Mrs B by the Trust. Furthermore, as Miss A’s aunt did not feel she could pursue the complaint any further, she delayed in forwarding the complaint to Miss A.

14. Miss A added that she did not feel her aunt understood that there was a realistic opportunity to have the complaint reviewed independently, but this was not a deliberate decision to delay matters. The effects of the bereavements on family members did not end after the funerals and continued well beyond 2022. Miss A does not believe that her relatives could pursue a complex complaint with us. Miss A says that by the time the complaint was passed to her, she wanted to understand and establish what options remained available. Finally, Miss A has highlighted that she is employed by the Trust she is complaining about. Therefore, she is conscious of challenging her employer and this made her reluctant to take over the complaint immediately from her aunt.

15. Firstly, while we do not expect Miss A or her aunt to be immediately familiar with the NHS complaints process or our process, our view is that the Trust’s complaint response letter dated 2 November 2023 could not have been any clearer regarding potential next steps for Miss A’s complaint. Also, if Miss A’s aunt was compelled to make a complaint to the Trust in the first place, we consider she must have at least had some concerns about the care provided to Mrs B. Either Miss A’s aunt was satisfied with the Trust’s reply or she was not.

16. We appreciate that Miss A effectively inherited this complaint from her aunt which could cause a brief delay in her bringing it to us, but if Miss A’s aunt felt unable to pursue matters any further, we consider that a brief conversation, email or letter to Miss A would have explained this and Miss A should then have been able to promptly weigh up the available options and decide about next steps with sight of the Trust’s letter.

17. We do not know when the complaint was passed to Miss A by her aunt, but even accounting for the tragic circumstances that she has described, we consider this course of action was realistically possible much sooner than happened. We appreciate that grief affects different people in different ways and Miss A has had a considerable amount to deal with since 2022, but even if no one in the family was able to take matters forward after the Trust’s complaint response, we consider Miss A could have asked a third party such as an advocate to do that on her behalf.

18. We also understand why Miss A was conscious about pursing a complaint about the Trust with it being her employer, but presumably, this issue has always been there and remains. We acknowledge that this issue might take a short period of time to weigh up, but not the amount of time that elapsed here. We would also point out that if another family member or third party pursued matters with the Trust or us on behalf of Miss A, then the Trust would not necessarily be aware that the affected person was related to Miss A.

19. Having considered Miss A’s complaint about the Trust, we do not discount the exceptionally difficult times that she has gone through with her family. More than one member of her family died during a relatively short space of time during 2022 and the impact of this has been emotionally damaging and profound to many people in her family. We hope that Miss A and her family can eventually overcome the long-lasting effects of these upsetting events.

20. Nevertheless, the events involving Mrs B’s care are now nearly four years ago and Miss A’s complaint to us is significantly out of time. While we accept that Miss A has provided some legitimate reasons that account for the first delay in submitting a complaint to the Trust, unfortunately, we do not consider the reasons put forward by Miss A regarding the second longer delay in submitting her complaint to us fully account for this length of delay which is nearly two years.

21. In summary, we consider that Miss A’s complaint is out of time for our purposes. We are not sufficiently persuaded by the reasons given to account for the second delay in submitting her complaint to us between November 2023 and October 2025. As such, there are insufficient grounds for us to waive the time limit in this case.

1. We have carefully considered Miss A’s complaint about the NHS Trust. We consider:

-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.

2. We are sorry to hear about what happened to Mrs B when she attended hospital in December 2022. We recognise these tragic events have greatly impacted on Miss A and her family.