South Western Ambulance Service NHS Foundation Trust

4. Mr D complains about the decision the Trust’s paramedics made on 16 January 2021. He complains, when visiting his mother following a 999 call, the paramedics decided not to take her to hospital.

5. Mr D says this decision delayed his mother’s access to care for gall bladder failure, and she later died. He then had to deal with the issues associated with bereaving his mother.

6. Mr D wants the Trust to acknowledge it got things wrong and improve its service.

7. The Trust’s paramedics saw Mrs D at home on 16 January 2021. They responded to a call about Mrs D experiencing abdominal pain. After assessing her, the paramedics gave her advice about taking pain relief and drinking enough fluid. They did not take her to hospital.

8. Mrs D went to hospital nine days after the ambulance crew’s visit. Sadly, she died in hospital later in January 2021.

9. Mr D wrote to the Trust to complain about what happened on 5 March 2021. The Trust investigated and responded to his complaint on 25 July 2021. He made a further complaint to the Trust on 7 October 2025 through his MP. The Trust responded to this complaint on 4 November 2025.

10. He made a further complaint to the Trust on 29 January 2026, which the Trust responded to on 3 March 2026. While awaiting this response, Mr D complained to us on 26 February 2026.

12. 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.

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

14. In his complaint to us, Mr D said he was aware there was a problem with the care the Trust gave his mother on 16 January 2021. He noted Mrs D had been incoherent for 48 hours when the paramedics arrived, and they refused to speak or listen to him. He felt they had left Mrs D behind when they departed.

15. He conveyed this view again when we spoke to him during our primary investigations. At the time, he was concerned he would need to look after Mrs D at home when the paramedics left. This was at a time he said she was very unwell.

16. Based on the above, we consider Mr D believed something was wrong with the ambulance crew’s decision at the time. That is, even if he was not fully aware of the entire impact he described to us.

17. Based on when he became aware of the problem, Mr D complained to us 61 months later. This means he raised his complaint to us 49 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 organisation’s time limit. In Mr D’s case, this means he had a year from the time he was aware of his complaint to complain to the Trust, which is an NHS organisation.

19. We saw he did this. He complained promptly to the Trust within two months of his awareness of his complaint. Until the Trust replied, we cannot see there was anything he could do to progress his complaint. This means we saw good reasons to explain the passage in time on his case until 25 July 2021. This is when the Trust replied to his complaint.

20. We then saw a period of just over 50 months until any further progress in the complaint process. This is when Mr D complained to the Trust again on 7 October 2025. This is a significant period. It is the main period explaining why he raised his case outside our time limit and so far outside of our time limit.

21. Therefore, we focused on considering whether there are good reasons to explain this passage in time. Having done so, we did not see there were.

22. We appreciate Mr D told us he sent his complaint to one of the paramedics who saw his mother. He explained the paramedic said they did not receive it, which meant he had to forward it again and caused a delay. We cannot see this explains the passage in time on his case from July 2021.

23. Despite this delay, the Trust’s complaint file shows it had received Mr D’s complaint in March 2021. One of its patient experience officers spoke to him on the phone on 26 March 2021. They clarified his complaint. This then led to the Trust reviewing Mrs D’s care records and consulting the paramedic crew who saw her to investigate Mr D’s complaint and share the outcome in July 2021.

24. We appreciate Mr D also told us it was only through raising a query with the coroner’s office he became aware of the complaints process. The coroner’s office signposted him to complain to the Trust’s headquarters. He said he then managed to complain and get a response from the Trust.

25. In his letter dated 5 March 2021 complaining to the Trust, he referred to his interactions with the coroner’s office. He named a specific coroner’s officer he had spoken to about the Trust’s report to the coroner about Mrs D’s care and death. He said the officer told him details in the Trust’s report were wrong. He said he found this unsatisfactory and complained the Trust gave her poor care.

26. This shows he had spoken to the coroner’s office before he made his first complaint to the Trust. He subsequently complained to the Trust, and he received the associated response in July 2021. So, this factor does not explain the passage in time after July 2021 when Mr D did not progress his complaint through the complaint process.

27. As other reasons he did not complain earlier, Mr D also cited a lack of information about how to complain in general, and that NHS England (NHSE) said it would not deal with his complaint. We do not see these are good reasons to explain the time he took in progressing his complaint.

28. If a complainant remains unhappy after receiving a response from an organisation, we expect them to try and find out how to complain. A lack of knowledge about the complaints process on its own is not a valid reason to put our time limit to one side.

29. When the Trust replied to Mr D in July 2021, it shared the outcome of its investigation on the phone. The Trust’s records do not indicate staff explained to Mr D about complaining to us in the call. After staff explained the outcome, he confirmed he was unhappy with the Trust’s findings. He did not ask further questions or clarify next steps because he said he had already written to the health secretary.

30. While the Trust did not give information on how to progress his complaint, as Mr D was unhappy with its response, we would have expected him to enquire about the next relevant stage to escalate his complaint. If not at the time of the Trust’s call, this would include seeking this information after getting the responses he said he received from parties like NHSE confirming they would not look at his complaint. We saw no evidence Mr D did this.

31. We also appreciate the Trust has publicly available information on its website about complaining. This includes explaining that if the Trust does not resolve a complainant’s complaint to their satisfaction, they can contact us. It provides our contact details.

32. So, we consider there was available information about how he could progress his complaint, or straightforward steps Mr D could have taken to obtain this information from July 2021. Had he obtained this information at the time, he would have known where to direct his enquires. This means we see no barrier to him progressing his complaint through the correct channels from this point.

33. Considering all the above, this means we did not see valid reasons explaining why he could not or did not progress his complaint in the 50-month period from July 2021. As we cannot see good reasons to justify this significant passage in time, we did not see reasonable grounds to set aside our time limit. This means we cannot consider Mr D’s complaint further.

34. We recognise this will be disappointing for Mr D, and he hoped we would investigate the care the Trust gave his mother.

35. 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 D has been through a challenging time. Sadly, his mother, Mrs D, died less than two weeks after the events he complains about. We appreciate this has been extremely hard for Mr D.

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 D. We explain the reasons for our decision within this statement. We hope this assures Mr D we only reached our decision after careful consideration of the information he gave us.