James Paget University Hospitals NHS Foundation Trust

4. Mrs O is unhappy with the respite care which her son, Master Y, received at the Trust (the Trust) between 1 February 2022 and 23 April 2024. Specifically, Mrs O says that the Trust:

· did not fulfil its contracted respite hours · removed Mater Y’s respite care abruptly on 23 April 2024 with no transition period · removed documents regarding Master Y’s care from their home · made unprofessional comments regarding the provision of the respite care, and · did not appropriately document a fall which Master Y had while under supervision of the respite carer in which he needed to be taken to A&E.

5. Mrs O says that the failures of the Trust have resulted in a great impact on her as she has seen a decline in her physical and mental health. Mrs O also says that she has been impacted financially and has lost time which could have been spent with her daughter.

6. Mrs O says that the impact on Master Y has been that he has not received the amount of respite care which he should have done.

7. As an outcome to the complaint, Mrs O seeks financial redress.

8. Master Y was assessed by the Trust as being eligible for respite care between 1 February 2022 and 23 April 2024. Mrs O is unhappy with the amount of respite hours received compared to what Master Y was eligible for and the subsequent withdrawal of the respite care.

9. Mrs O is also unhappy with the actions of respite carers during this period regarding documents being taken from their home and insufficient actions taken when Master Y had a fall at home.

Inadequate hours of respite care

14. 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.

15. Mrs O is unhappy the Trust did not fulfil the correct amount of respite care hours that Master Y was assessed as being eligible for between 1 February 2022 and 23 April 2024. Master Y was assessed as being eligible for 12 hours of respite care per month. Mrs O does not know how many hours were actually provided but says that it was lower than agreed.

16. We have discussed our time limit with Mrs O to understand why she could not bring the complaint to us sooner. We also considered the amount of time which the Trust took to respond to Mrs O’s complaint.

17. Mrs O has confirmed she became aware of her cause to complain about the amount of respite hours that Master Y was receiving in February 2022. This means that to comply with our time limit, Mrs O’s complaint should have been brought to us by February 2023.

18. When looking at the timeline of the complaint and Mrs O’s letters of complaint to the Trust, we can see that Mrs O raised her complaint on 1 May 2024 which is approximately 2 years later.

19. The Trust responded to Mrs O’s complaint on 6 January 2025.

20. Mrs O brought her complaint on to the Parliamentary and Health Service Ombudsman (PHSO) on 4 February 2025. At that time, PHSO advised Mrs O to explore the possibility of an alternate legal remedy (ALR) before resubmitting her complaint to us. The complaint was closed by PHSO on 28 May 2025 for this reason. Mrs O returned to PHSO after exploring the ALR route on 23 July 2025.

21. We considered whether any delays in the complaints process were caused by the Trust’s handling of the complaint. While the Trust took eight months to provide a response to Mrs O’s complaint, this delay does not justify or account for the total time that passed before the complaint was brought to PHSO.

22. There was also a brief period of delay between 28 May 2025 and 23 July 2025 caused by PHSO during which the case was closed while Mrs O explored the ALR route. However, this period is negligible and does not impact the out-of-time decision.

23. We have reviewed Mrs O’s reasons for the time it took for her to complain from when she became aware of her reasons to complain 1 February 2022 to when she complained to the Trust on 1 May 2024.

24. Mrs O told us on 4 December 2025 via telephone, that she did not raise the complaint formally with the Trust until 1 May 2024 because she raised the issue informally during multidisciplinary team (MDT) meetings. These meetings are forums for clinicians with different specialities to discuss a patient’s care, but they are not part of the formal complaints process.

25. Mrs O could not provide any further information as to why there was no formal complaint raised prior to 1 May 2024. As such, we have not seen good reason why Mrs O could not bring the complaint to the Trust sooner.

26. In view of the delay in Mrs O raising the complaint to the Trust, we are not persuaded there are sufficient grounds to set aside our time limit and consider the complaint further. Given how long Mrs O has been pursuing her complaint, we fully acknowledge our decision will be disappointing for her.

27. As such, this complaint is significantly out of time.

Removal of respite care

28. Mrs O is unhappy that the provision of respite care ended abruptly on 23 April 2024. They state that they were advised about this on the same day and that there was no transition period.

29. In its response, dated 6 January 2025, the Trust acknowledged the removal of respite care was sudden and apologised for this.

30. The Trust adds that the reason for the sudden removal of the respite care was due to a lack of availability of a carer. Furthermore, in its response, the Trust explains the process of normal practice that a new carer would shadow the existing carer before they start providing the patient care. This was not possible in this case.

31. The Trust advised that due to Master Y’s respite carers own medical conditions, they had to reduce their working hours. The Trust recruited a new respite carer, however they did not have sufficient experience to be able to care for a child as young as Master Y. Due to Master Y’s carers health, they had to reduce their hours immediately and the shadowing for experience could not take place.

32. Our advisor has reviewed all of the relevant records and has confirmed that there is no clinical guidance available to show how the removal of respite care should take place, or if there should be any transitional periods.

33. We asked our advisor if the communication of the removal of the respite care was within relevant policy or guidance. Our advisor advised that as there is no relevant policy or guidance, they cannot comment on this.

34. Our advisor did clarify that it is reasonable to have a short delay in them knowing that they will need to withdraw care and communicating this to the patient or family where the Trust are trying to find alternative options. This could have happened in this case.

35. We have carefully considered, Mrs O’s complaint about the removal of the respite care and the communication regarding this. We have seen nothing to indicate the Trust acted inappropriately or that it acted outside of good clinical practice.

36. Whilst we appreciate that the removal of the respite care would have been distressing for the family, there is no guidance to show that the Trust should have acted any differently than they did. Our advisor has confirmed our view that the Trust acted and communicated reasonably when removing and communicating the removal of the respite care with Mrs O.

37. As such, we have found no indications of maladministration.

Removal of shared care documents

38. Mrs O is unhappy that a respite carer removed Master Y’s shared care documents from their home without their knowledge or consent.

39. In its response, dated 6 January 2025, the Trust advised that documents are periodically brought to the hospital so that they can be scanned and added to the patient’s electronic health record. This is to keep the records up to date and to prevent complications if the physical copy was to be lost.

Our advisor has reviewed the relevant records and has confirmed that there is no clinical guidance available regarding shared care documents being removed from a patient’s home.

40. We have carefully considered, Mrs O’s complaint about the removal of shared care documents. We have seen nothing to indicate the Trust acted inappropriately or that it acted outside of good clinical practice, and we have found no indications of maladministration.

41. We appreciate that finding that the shared care documents were no longer in their home would have been distressing for Mrs O

Master Y’s fall at home

42. Mrs O is unhappy that following a fall that Master Y had at home under the supervision of a respite carer, the care did not transfer Master Y directly to hospital and did not record the accident appropriately.

43. In its response, date 6 January 2025, the Trust confirm that it was noted in Master Y’s home-based respite care document that he had a fall, the A&E attendance was noted in his medical record and the respite carer notified Mrs O so that they could have Master Y assessed.

44. Further in its response, the Trust advised that the respite carer could not have escorted Master Y to A&E in their own vehicle, instead, they would be expected to notify a family member instead.

45. We asked our advisor if Master Y’s, ‘about me and my family’ and ‘the book about me’ documents had been appropriately completed to allow the respite carer to know what to do in an emergency. Our adviser confirmed that the documents had been completed appropriately.

46. We asked our advisor if the Trust acted within any relevant policies or guidance when documenting Master Y’s fall, and how the respite carer acted. Our advisor confirmed that the Trust had documented the fall correctly in the shared care documents and Master Y’s medical records. Our advisor also confirmed that the respite carer would not have been able to escort Master Y to A&E in their own vehicle in line with the Trust’s policy.

47. However, our advisor did indicate that the Trust did not complete an incident on the Trust’s electronic incident reporting system. This would have triggered a review of Master Y’s care to identify any potential learning.

48. In its response, dated 6 January 2025, the Trust acknowledge this. The Trust apologise that this was not completed and add that this has been done retrospectively. Furthermore, all respite carers have been reminded of the importance of logging incidents correctly.

49. We appreciate it was frustrating for Mrs O that the incident was not reported. We have considered the actions of the Trust and whilst we consider this to be a shortcoming in service, we do not consider this to fall so far short of the expected standards to be a shortcoming. In addition to this, the Trust has acknowledged Mrs O’s frustration and has taken action to ensure this does not happen in the future. We consider this is a proportionate response to this part of the complaint, in line with our Principles of Good Complaint Handling.

50. Our Principles of Good Complaint Handling say that an organisation should identify any potential failings along with the impact that any potential failings may have had. The organisation should then act to remedy any potential failings which we feel has been done in this case.

51. As such, we have found no evidence of an unremedied injustice.

Communication

52. Mrs O is unhappy that whilst communicating the removal of Master Y’s respite hours, a clinician made inappropriate comments.

53. Mrs O says that the comments made by the clinician made her feel like the respite care was being provided as a ‘favour’ to her and Master Y, rather than being because Master Y was eligible.

54. In its response, dated 6 January 2025, the Trust acknowledges Mrs O’s feedback and offered an apology for the way which the communication made Mrs O feel. The Trust went on to assure Mrs O that it had taken the respite care contract seriously.

55. Our Principles of Good Complaint Handling say that an organisation should identify any potential failings along with the impact that any potential failings may have had. The organisation should then act to remedy any potential failings which we feel has been done in this case.

56. We have found that there is no unremedied injustice following the Trust’s apology.

57. We recognise that this will be disappointing for Mrs O, given the impact that this has had on her wellbeing. We thank Mrs O for bringing her concerns to us.

1. We have carefully considered Mrs O’s complaint about James Paget University Hospitals NHS Foundation Trust (the Trust). We are sorry to hear how Mrs O has been affected by the concerns she has brought to us.

2. We have not seen any indications that things went wrong. This means that that from the evidence we have considered, it appears that the Practice provided appropriate care and treatment to Master Y and communication with Mrs O.

3. We will explain the reasons for our decision in this statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mrs O for sharing her experience with us. It is important to acknowledge that although we are unable to look at the concerns she has raised, this does not detract from the experience Mrs O had, or the impact this had on her and Master Y.