Summary: We will not investigate Mr X’s complaint about his late brother’s care and treatment during April to August 2021. This is because a significant amount of time has passed since the events Mr X is complaining about occurred and it would have been reasonable for Mr X to complain to us sooner. We are also unlikely to be able to make the findings sought by Mr X about his brother’s cause of death.

The complaint

1. Mr X complains on behalf of his late brother, Mr Y about his care and treatment between April 2021 to August 2021.
2. Mr X complains about the way North West Ambulance Service NHS Trust (the Ambulance Trust) transported his brother to hospital on two occasions in 2021. He says the Ambulance Trust twice sent an unsuitable ambulance which could not accommodate his brother’s needs. As a result, his brother had to be transferred in an undignified and public way. Mr X says that, despite accepting errors from the first occasion, the Ambulance Trust repeated its mistakes.
3. Mr X complains that his brother arrived in hospital in August 2021 with grade 3 pressures sores. He believes these were caused by neglectful care by the care agency provided by Knowsley Metropolitan Borough Council (the Council) and district nurses from Mersey Care NHS Foundation Trust (the Community Trust).
4. He is also unhappy with the way his brother was discharged home by the Council and Liverpool University Hospitals NHS Foundation Trust (the Trust). Mr X says the discharge was unsafe, his brother’s wounds had not been properly treated and he was returned to the care of those who had safeguarding concerns raised about them. He says his brother’s capacity to decide his discharge arrangements was not scrutinised enough.
5. Finally, Mr X is also unhappy with the Council’s handling of the safeguarding enquiry.
6. Mr X says that, as a result, his brother did not receive the standard of care he was entitled to. He further believes his brother contracted an infection due to the pressure sores, which contributed to his death shortly after. Mr X says he has been caused a great deal of distress. Mr X is seeking systemic improvements to ensure the same thing does not happen to another family.

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The Ombudsmen’s role and powers

7. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)

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How I considered this complaint

8. I have considered the information provided by Mr X, the Trusts and the Council. I also considered the Ombudsman’s Assessment Code. I shared my draft decision with Mr X considered the comments he made.

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What I found

What happened

9. Mr Y’s care needs were met by daily care visits from a care agency and regular visits from district nurses.
10. In April 2021, Mr Y was admitted to Royal Liverpool University Hospital (the Hospital) by ambulance. Mr X raised concerns about the way Mr Y was transferred.
11. In August 2021, Mr Y was admitted to the Hospital again. Mr Y’s second transfer by ambulance was also complicated.
12. During his admission, the Hospital raised safeguarding concerns that Mr Y had severe pressure ulcers. A tissue viability nurse visited Mr Y on the ward and said the wounds were moisture lesions.
13. After a short admission, Mr Y was discharged home. Mr X says this was an unsafe discharge and questions Mr Y’s capacity to decide his discharge arrangements. It is unclear whether a referral was made to the district nurses to notify Mr Y had been discharged. Mr Y did not receive any further visits from the district nurses after discharge.
14. A few days, Mr Y was readmitted to hospital. Shortly after, Mr Y died. The cause of Mr Y’s death was recorded as chronic obstructive pulmonary disease (COPD) and pneumonia. Mr X is concerned Mr Y had sepsis from pressure sores.
15. In March 2022, Mr X raised multiple complaints about Mr Y’s care and treatment.
16. In August 2022, the Council shared the outcome of its safeguarding enquiry with Mr X.
17. In August 2023, Mr X complained to the Ombudsmen. Following this, Mr X received a formal complaint response from the Council in March 2024.

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My assessment

18. The Ombudsmen usually will not investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done.
19. Mr X complains about Mr Y’s care and treatment between April 2021 to August 2021. Both Mr X and Mr Y were aware of the matters complained about at the time.
20. Mr X has explained that he was unable to complain about his brother’s care between September 2021 to February 2022, due to grief and poor health. I acknowledge this would have impacted on Mr X’s ability to pursue his complaint for this period. However, this does not explain a second further delay by Mr X in late 2022.
21. From March 2022, Mr X was able to actively pursue his complaints with multiple organisations. He received written complaint responses between March 2022 to May 2022. Mr X received the outcome of the Council’s safeguarding investigation in August 2022. Mr X did not complain to the Ombudsmen for another year.
22. Mr X was aware of the problem and had received responses more than 12 months before raising his concerns with the Ombudsmen. He has not provided a good reason for this delay.
23. While Mr X says he had to wait for the Hospital Trust to arrange a meeting and the Council recently took a long time to respond to his complaint, these would not have prevented Mr X complaining to us in 2022. Mr X says the organisations contributed to the delay, however he had received all final responses and was not awaiting any further replies between August 2022 to August 2023.
24. Mr X also said changes with his advocate and supporting his granddaughter with personal issues contributed to the second delay. While these may have had some impact, I am not persuaded these factors would have stopped Mr X being able to raise his concerns with us sooner.
25. Mr X was signposted to the Ombudsmen in multiple complaint responses in 2022 and also had support from a Healthwatch advocate from March 2022. Therefore, I am satisfied Mr X knew how to escalate his concerns and was able to do so. It would have been reasonable for Mr X to bring this complaint to us at the time. There is no good reason to exercise discretion to investigate matters that took place this long ago.
26. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start an investigation if the prospect of conducting an effective investigation is reduced. In this case, it has been over three years since the matters complained about occurred. The significant amount of time passed impacts on our ability to consider the complaint now.
27. When a lengthy period of time has passed, it can directly affect any attempts to gather information at a much later stage. For example, people’s memories and recollections fade and it can be much harder to obtain accurate accounts of an incident which occurred years before. This could impact on the Ombudsmen’s ability to consider this complaint now.
28. Further, Mr X is seeking a definitive answer as to whether Mr Y had pressure ulcers or moisture lesions. Given that different professionals at the time did not agree over this point, when they had the benefit of examining Mr Y, it is unlikely that we would be able to resolve this three years later.
29. We would also not be able to comment on Mr Y’s cause of death. Any disagreement about cause of death would need to have been raised at the time and potentially involve a coroner. Complaining to the Ombudsmen is not the appropriate route for such concerns.

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Final decision

30. We will not investigate Mr X’s complaint about his brother’s care and treatment in 2021. Around three years have passed since the events that are the subject of this complaint occurred. In my view, it would have been reasonable to expect Mr X to approach us sooner than he did. This complaint is late and I can see no good reason to consider it now. We are also unlikely to be able to resolve Mr X’s key concerns about his brother’s death at this late stage.

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Investigator's decision on behalf of the Ombudsman