A practice in the Surrey Heath area

4. Mr Q complains, from February 2024, Dr C and staff at the Surgery failed to diagnose his mother’s pancreatitis and arrange treatment.

5. He says these missed opportunities meant staff only identified her pancreatitis when it was too late to treat. This meant Mrs P died and Mr Q experienced avoidable bereavement.

6. Mr Q complains, in his mother’s hospital visits to the Trust in February and March 2024, staff delayed diagnosing and providing treatment for her pancreatitis. He also complains staff did not arrange sufficient pain relief as part of her palliative care.

7. He says the missed opportunities to identify her pancreatitis meant staff only diagnosed it when it was too late to treat. This meant Mrs P died and Mr Q experienced avoidable bereavement. He adds the failings in his mother’s palliative care meant she experienced avoidable pain, which was difficult for him to witness.

8. Mr Q wants both organisations to apologise about the impact of their failings and make service improvements.

9. Mrs P spoke to and had consultations with her GP about abdominal pain she reported throughout February 2024. She later attended the Trust’s surgical assessment unit on 28 February. She attended the Trust’s Emergency Department on 3 March. Staff admitted her to hospital as an inpatient. Mrs P remained in hospital until she died in mid-March.

10. Mr Q complained to the Trust about Mrs P’s care on 13 January 2025. He complained to the Surgery about the care it provided on 14 January. The Surgery replied to his complaint on 17 February. The Trust replied on 10 March. Mr Q made a follow up complaint to the Trust on 12 June. The Trust replied on 25 June.

11. Mr Q made his complaint to us through completing a complaint form on 23 February 2026.

13. The law (Health Service Commissioners Act 1993) 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.

14. We discussed this with Mr Q to understand the reasons why he did not complain to us within one year. We also considered the time it took the Surgery and the Trust to respond to his complaints.

15. The impact Mr Q describes linking to the failings he alleges at both organisations includes bereavement associated with his mother’s death. He also told us poor palliative care at the Trust meant his mother experienced avoidable pain before her death, which he saw.

16. He would have seen these things and been aware of his mother’s death by the day she died. This also aligns with what Mr Q said in his complaint form about when he was aware of his complaint, which was mid-March 2024.

17. This means we saw a period of over 23 months from when he was aware of these issues until he made his complaint to us. On this basis, he raised his complaint with us over 11 months outside of our time limit.

18. We usually consider it reasonable where a complainant has submitted their complaint to the relevant organisation within the NHS’s time limit. In Mr Q’s case, this meant he had a year from the time he was aware of his complaint to complain to the two NHS organisations involved.

19. Mr Q complained to the Surgery and the Trust ten months after he was aware of his complaint. Given he told us he did not complain earlier due to bereavement, and he still complained within these timescales, we saw good reasons to explain this passage in time.

20. From mid-January to 10 March 2025, Mr Q was awaiting responses to his complaints from the organisations. As this passage in time is explained by the Surgery and the Trust responding, we consider there was nothing more Mr Q could do to progress his complaint. This meant we saw good reasons to explain the passage in time on his case up to this point.

21. When he got the latter of the two responses, the Trust advised Mr Q about being able to refer his complaint to us. So, we consider he could reasonably have approached us from this point. It is from this stage we did not see good reasons to explain the passage in time in Mr Q complaining to us.

22. Mr Q told us, after receiving these responses, he enquired with solicitors about taking on his case. However, none of the solicitors he approached would take on his case on a no fee basis. He said it took time to get these responses. With legal options not then open to him, he then complained to us.

23. We do not consider him making enquiries with solicitors after receiving the Trust’s response would have prevented him exploring a complaint with us. In fact, Mr Q called us on 1 May 2025. We reviewed this call record. He confirmed the Trust had signposted him to us if he was not happy with its response.

24. In the call, we explained what Mr Q needed to do to properly make his complaint to us. Any complaint to us must be made in writing. On this basis, we explained he should complete one of our complaint forms summarising his complaint and return it to us. We also asked him to send us copies of the responses he received from the Surgery and the Trust.

25. We also advised him about our time limit. We sent him an email to access information about complaining during the call. We explained, when he had sent us this documentation, we could then set up his case and place it in the allocation queue to await a caseworker.

26. Mr Q confirmed he understood what he needed to do in the call. He said he would fill in a complaint form, attach his responses, and return this information to us.

27. Our records show Mr Q emailed us nine months later, on 8 February 2026. He said he heard nothing from us and asked if his case was still in a queue or now being investigated.

28. We followed up by calling him on 10 February. We referred to our previous conversation with him. To make his complaint properly, we explained he needed to send us a complaint form and the responses we asked for. He then later submitted his complaint in writing on 23 February.

29. This evidence aligns with what Mr Q told us at the beginning of our primary investigation. That is, about speaking to us initially and missing the instruction we gave about how to submit his complaint to us.

30. Having reviewed the available evidence, we consider we gave Mr Q clear instructions on 1 May 2025 on what he needed to do to complain. He confirmed he understood these instructions.

31. He did not act on these instructions. This explains the passage in time on his case from 1 May 2025 to 23 February 2026 when he could have progressed it. This is a significant period approaching ten months. It is also the difference between Mr Q making his complaint slightly outside of our time limit to it being made nearly one year outside of our time limit.

32. As we cannot see reasons preventing him complaining during this period, and it is explained by him not acting on our instructions, we did not see good reasons to justify this passage in time. This means we did not see reasonable grounds to justify setting aside our time limit to consider the case further in light of this delay.

33. We recognise this will be disappointing for Mr Q. We hope we have clearly explained the reasons why we cannot investigate his complaint. We also hope this statement assures him we only reached our decision after carefully considering the information he gave us and our time limit.

1. We recognise Mr Q has been through a difficult time. Sadly, his mother, Mrs P, died at the Trust. Mr Q told us he has found bereaving his mother very difficult.

2. We have carefully considered his complaint. Having completed our primary investigations, we saw the complaint falls outside of our time limit. We have not seen sufficient reasons to put our time limit aside to consider it further.

3. We appreciate this will come as a disappointment for Mr Q. We explain the reasons for our decision within this statement. We hope this assures Mr Q we only reached our decision after careful consideration of the information he gave us.