Oxford University Hospitals NHS Foundation Trust

4. Mr C complains about the care and treatment he received from Oxford University Hospitals NHS Foundation Trust during admissions between January and April 2024.

5. Specifically, Mr C says the Trust: • did not maintain accurate allergy records and safely manage his medication needs and adverse drug reactions • did not provide appropriate pain management, clinical monitoring and post-operative care following surgery did not make reasonable adjustments for him as an autistic person and did not meet his communication needs • did not obtain informed consent or involve him appropriately in decisions about his treatment and care • cancelled CT scans, blood tests and anti-embolism measures without explanation and discharged him following intensive care without adequate assessment of his ability to manage safely at home 6. Mr C is seeking an apology, an explanation of what happened, service improvements and a financial remedy to resolve his complaint.

7. Between January and April 2024, Mr C received care and treatment from the Trust following oral and maxillofacial surgery. During this period, he underwent surgery, was admitted to intensive care and later transferred to other inpatient wards before being discharged home.

8. Mr C says the Trust did not maintain accurate allergy records or safely manage his medication, resulting in adverse reactions, including a dystonic reaction. He also says his pain was not managed appropriately following surgery and that he did not receive appropriate clinical monitoring and post-operative care.

9. Mr C also says the Trust did not make reasonable adjustments for him as an autistic person, did not meet his communication needs, and did not appropriately involve him in decisions about his care or obtain informed consent.

10. Mr C further says the Trust did not appropriately coordinate his care following surgery. He says investigations and scans were cancelled, discharge planning was inadequate, and he did not receive appropriate follow-up after leaving hospital.

13. The NHS Complaint Regulations explain that a complaint must be made to the NHS no later than 12 months after the date on which a person knew of a reason to complain. If a complaint is made after this and the NHS do not see a good reason to consider delays, the service may not look at the complaint.

14. Similarly, the Health Service Commissioners Act (the law which sets out the Ombudsman’s powers and responsibilities) says that we should not investigate a complaint if it is brought to us more than a year after the date they knew they had a reason to complain (section 9.4 of the Act).

15. These points are referenced in our own policy which informs our approach to decision making; that a complainant must raise their complaint with the NHS within a year of becoming aware of the reason to complain. Also, if a complaint is made to us out of time, but the complainant has complied with the timescales within the NHS complaints process, this is an important factor when looking at whether or not we should exercise our discretion.

16. Informed by this, we begin by considering each stage of the complaint and identify where there are delays. We engage with the complainant to better understand the reasons for any delay(s). This allows us to understand the time taken for the complainant to take action to make their complaint, and the circumstances that caused their delay.

17. We have carefully considered Mr C’s reasons for complaining to us after a considerable amount of time since the dates of the events complained about.

18. Having explained the process, we next go onto establishing a summary of the delays. We have identified the following periods of time and delays in the complaint process.

Timeline of the complaint process

19. Mr C complains about events between January 2024 and April 2024. During this period, he says he became aware of concerns regarding his medication, pain management, communication, informed consent, discharge planning and follow-up care.

20. Mr C, with support from his mother, raised a formal complaint with the Trust on 24 January 2024. The Trust issued complaint responses dated 24 April 2024 and 31 May 2024, the latter following correspondence from his Member of Parliament.

21. We have not seen evidence showing Mr C actively pursued his complaint with the Trust between 31 May 2024 and 21 April 2025. The next documented correspondence is Mr C's email of 21 April 2025, asking the Trust to reconsider his complaint.

22. The Trust issued its final complaint response on 26 August 2025.

23. Mr C brought his complaint to the Ombudsman on 4 November 2025. This was approximately two months after receiving the Trust's final response.

24. Based on the information available, we consider Mr C knew he had reason to complain during the events in early 2024, as demonstrated by the complaint he raised with the Trust at that time. Although he re-engaged with the Trust in April 2025, we have not seen evidence showing he actively pursued the complaint during the intervening period. We therefore identify the following periods of delay: • Approximately 11 months between the Trust's complaint response of 31 May 2024 and Mr C’s next documented contact on 21 April 2025.

• Approximately four months between Mr C's renewed complaint of 21 April 2025 and the Trust's final response on 26 August 2025.

• Approximately two months between the Trust's final response and Mr C complaining to the Ombudsman.

Our consideration of the delays

25. Mr C’s mother raised concerns with the Trust in January 2024. The Trust issued complaint responses dated 24 April 2024 and 31 May 2024. Mr C subsequently wrote to the Trust again on 21 April 2025, asking it to reconsider his complaint.

26. The Trust issued its final response on 26 August 2025, approximately four months after receiving Mr C's further correspondence. This exceeded the target response times set out in the NHS Complaints Policy. However, we do not consider this period of complaint handling to have materially contributed to the complaint being brought to us outside the statutory time limit.

27. We recognise Mr C had no control over this delay and even if the Trust had responded sooner, it is likely the complaint would still be out of time.

28. We discussed the reasons for the delay to better understand why Mr C did not progress his complaint sooner. Mr C told us he believed he had continued contacting different people within the Trust between May 2024 and April 2025 but had not received responses.

29. We have not seen evidence he was pursuing his complaint during this period. The next documented correspondence is Mr C's email of 21 April 2025, requesting that the Trust reconsider his complaint.

30. Mr C brought his complaint to us on 4 November 2025, approximately two months after receiving the Trust's final response dated 26 August 2025.

31. We carefully considered whether there are compelling reasons to set aside our time limit.

32. Mr C explained that he is autistic, experiences communication difficulties, and continues to experience physical and psychological consequences from the events complained about. We recognise these factors may have made pursuing his complaint more difficult.

33. The evidence shows Mr C identified his concerns shortly after the events and raised detailed complaints with the Trust during 2024. His mother and Member of Parliament also assisted him in pursuing those complaints, and Mr C later contacted the Trust directly requesting further consideration. This indicates that he was able to engage with the complaints process.

34. We also considered whether Mr C only became aware he had reason to complain sometime after the events. We do not consider this applies. The concerns he raises relate to matters he knew about during his admissions in early 2024 and which formed the basis of his original complaint. Although he says the consequences have continued, continuing effects do not extend the statutory time limit where the reasons for complaint were already known.

35. Taking all the available evidence into account, including the support Mr C received from his mother and Member of Parliament, we are not persuaded there were exceptional circumstances preventing him from progressing this complaint sooner.

36. Although Mr C says he contacted various people within the Trust between May 2024 and April 2025, we have not seen documentary evidence demonstrating that the complaint remained actively pursued during that period.

Summary

37. We recognise this has been a stressful time for Mr C. At the point of complaining to the Ombudsman, the complaint was six months out of time. After careful consideration of the delay reasons provided to us, we do not consider there are good reasons for us to put aside the time limit. Therefore, we are unable to consider Mr C’s complaint.

1. Mr C complained to us about the care and treatment he received from Oxford University Hospitals NHS Foundation Trust (the Trust) between January and April 2024. We are sorry to learn of his concern. Mr C says the Trust failed to safely manage his medication, pain and post-operative care, did not make reasonable adjustments for his autism or meet his communication needs, and that these failings have caused him ongoing physical pain, psychological distress and significant impacts on his daily life.

2. We have carefully considered Mr C’s complaint, but we cannot investigate it. This is because he has complained to us outside of the 12-month time limit to complain to the Ombudsman.

3. We recognise our decision will be disappointing for Mr C who is seeking to resolve matters and hope the information in this statement clearly explains the reasons for our decision.