Summary: The Ombudsmen will not investigate Ms T’s complaint about the care of her father from 2015 to November 2017. The complaints are late and there are insufficient grounds to accept them now.

The complaint

1. Ms T complains about the care of her father, Mr X, from 2015 to the time of his death in December 2017. Ms T complains:
1. That Royal Borough of Greenwich (the Council) failed to provide suitable support or take proportionate steps to protect Mr X from abuse and neglect from other family members:

• During Mr X’s admission to hospital from June to August 2016;
• While Mr X was cared for at home in August 2016;
• During Mr X’s admission to hospital from August to September 2016;
• While Mr X was cared for at home in September 2016;
• During Mr X’s admission to hospital from September to November 2016;
• While Mr X was cared for at home from November 2016 to January 2017;
• During Mr X’s admission to hospital from January to February 2017;
• While Mr X was in a hospice from February to April 2017;
• While Mr X was in a care home from April to November 2017.
2. About the care provided by Briset Corner Surgery (the Surgery):
• In the summer of 2015;
• While Mr X was cared for at home in August 2016; and,
• While Mr X was cared for at home in September 2016.
3. About the treatment provided by a Community Mental Health Team from Oxleas NHS Foundation Trust (Oxleas Trust):
• In the summer of 2015;
• While Mr X was cared for at home in September 2016;
• While Mr X was cared for at home from November 2016 to January 2017; and,
• While Mr X was in a care home from April to November 2017.
4. About the care provided to Mr X by Lewisham and Greenwich NHS Trust (L&G Trust) over the course of hospital admissions:
• From June to August 2016;
• From August to September 2016;
• From September to November 2016;
• In January 2017; and,
• From January to February 2017.
5. About the care provided to Mr X by staff at Greenwich and Bexley Community Hospice (the Hospice):
• In the community in December 2016;
• During his admission to the Hospice inpatient unit from February to April 2017.
6. About the care provided to Mr X by staff from Westcombe Park Care Home (the Care Home) during his admission from April to November 2017.

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The Ombudsmen’s role and powers

2. The Ombudsmen cannot 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. (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

3. I considered Ms T’s written complaint. I contacted each of the organisations and asked for information about how it had handled Ms T’s complaints, and I considered the information they provided. I shared a draft decision statement with Ms T which explained my provisional view. I considered the comments and documents Ms T provided in response.

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What I found

4. In 2016 Mr X lived at home with his wife. He had physical and mental health problems. Staff from Oxleas Trust were involved in his mental health care in the community, and he was registered with the Surgery. Mr X:

• Was an inpatient at an L&G Trust acute hospital from June to early August 2016, then returned home. Staff from the Council were involved in arranging Mr X’s discharge;
• Was an inpatient at the same hospital from late August to early September 2016, then returned home;
• Was an inpatient at the same hospital again from late September to late November 2016, then returned home. When Mr X returned home he was under the care of the Hospice’s community team;
• Attended A&E at an L&G Trust hospital in late January 2017 then returned home;
• Was an inpatient of the L&G Trust acute hospital from late January to early February 2017, then returned home;
• Was an inpatient of the Hospice’s inpatient unit from late February to mid April 2017;
• Was a resident of the Care Home from mid April to late November 2017;
• Was an inpatient of the L&G Trust acute hospital in December 2017;
• Returned to the Care Home but sadly died in December 2017.

Complaints

The Council

5. Ms T complained to the Council in August 2016. At that time her complaint focused on the attitude and behaviour of a social worker involved in Mr X’s care. The Council replied in early September 2016. It did not identify any failings.
6. Ms T approached the Local Government and Social Care Ombudsmen (LGSCO) in February 2018 with a complaint about the Council. LGSCO decided it would be too soon for it to become involved. It noted Ms T had tried to complain to the Council in August and September 2017, but the Council had apparently not received these. Further, LGSCO noted that Ms T’s complaint concerned different matters from her complaint in 2016. In addition, LGSCO noted that the Council was undertaking a safeguarding investigation but said Ms T’s current complaint was about different issues.
7. In the middle of March 2018 Ms T’s MP wrote to the Council and noted that Ms T had raised serious concerns about Mr X being treated inappropriately and harmfully. The Council wrote to the MP and sent a copy of its complaint response of September 2016. It did not provide any further comment or analysis.
8. The Council wrote to Ms T about a month later in relation to concerns she had raised in January 2018. It said these had been investigated under its safeguarding procedures. The Council did not identify any failings.
9. Ms T wrote to the Council again at the start of September 2018. She raised the same concerns as she brought to the Ombudsmen for this complaint. The Council replied in the middle of October 2018. It concluded that the investigations detailed in its letters of September 2016 and April 2018 covered all of Ms T’s concerns. Therefore, the Council said it had nothing further to add and directed Ms T to LGSCO.

The Surgery

10. Ms T complained to the Surgery in November 2018. The Surgery did not reply to her.

Oxleas Trust

11. Ms T complained to Oxleas NHS Foundation Trust twice:

• In October 2017. Oxleas Trust said Mr X had not provided his consent so it could not take her complaint forward;
• In November 2018. Oxleas Trust said the late Mr X’s wife, Mrs X, had not provided her consent so it could not take the complaint forward.

L&G Trust

12. Ms T contacted L&G Trust with concerns on several occasions in 2016, 2017 and 2018. L&G Trust looked at some of these informally, through PALS. In June 2018 it said it could not investigate Ms T’s formal complaint because Mrs X had not provided her consent.

The Hospice

13. Ms T complained to the Hospice in March 2018. The Hospice replied the following month and said it would not take any further action as Mrs X did not have any concerns about Mr X’s care.

The Care Home

14. Ms T complained to the Care Home on several occasions in 2017. Staff met with her on one occasion but did not take any further action because Mrs X was satisfied with the care Mr X was receiving.

Analysis

15. We expect complaints to be made to us within 12 months of a person becoming aware of the issues they wish to complain about. If the complaints come to us outside of that time we consider them to be ‘late’. In some circumstances we may still be able to investigate even if a complaint is late.
16. Ms T complained to the Ombudsmen in the middle of March 2019. This means that all of her concerns, including those about the most recent events in November 2017, are late.
17. I have carefully considered whether there are good reasons we should investigate Ms T’s complaints even though they are late. I considered the efforts Ms T made to pursue her concerns with each organisation. I also looked at the times Ms T came to LGSCO and the Parliamentary and Health Service Ombudsman (PHSO) before March 2019. I looked at what she complained about and what she was told at those times. Further, I considered whether an investigation would have a realistic prospect of reaching a sound, fair and meaningful decision, given the time passed since the events.

The Council

18. Ms T originally complained to LGSCO in February 2018. At this point her complaints about events from February to November 2017 would not have been late. However, the issues Ms T raised at that time do not match to the issues she raised in this complaint to the Ombudsmen. Rather, Ms T complained about a hospital discharge in 2016 and about how the Council consulted with various family members. As such, these complaints were already late in February 2018.
19. Following this contact with LGSCO Ms T contacted her MP and received a response from the Council in April 2018. It was then five months later, in September 2018, that Ms T complained to PHSO. This complaint included all the issues of this current complaint, including those about the Council.
20. In view of Ms T’s previous contact with LGSCO I consider she could have returned to LGSCO with her complaints about the Council sooner. There is evidence that Ms T was capable of making and pursuing complaints about a range of organisations from August 2016. I have not seen compelling evidence that Ms T could not have complained to the Ombudsmen sooner for all aspects of her complaint about the Council.

The Surgery

21. Ms T originally contacted PHSO in March 2017. At this point her concerns about the Surgery’s actions in August and September 2016 were not late. However, PHSO noted that Ms T had not yet complained to the Surgery and advised her to do so. The only evidence I have seen of a complaint to the Surgery is a letter in November 2018.
22. In the intervening period Ms T made and pursued complaints to other organisations, and had further contact with the Ombudsmen’s offices. Therefore, I am not persuaded that Ms T could not have complained sooner, for all aspects of her complaint about the Surgery.

Oxleas Trust

23. When Ms T originally contacted PHSO in March 2017 her complaints about Oxleas Trust’s actions from September 2016 to March 2017 were not late. However, PHSO noted that Ms T had not yet complained to Oxleas Trust and advised her to do so.
24. From the evidence I have seen Ms T complained to Oxleas Trust seven months later, in October 2017. She received a response in November 2017 and contacted PHSO to ask for advice three months later, in February 2018. In March 2018 PHSO told Ms T it would be premature for it to consider her complaint until she had made a formal complaint and had a response. Ms T then made a new complaint to Oxleas Trust eight months later, in November 2018.
25. In the main intervening periods – from March to October 2017 and from March to November 2018 – Ms T made and pursued complaints to other organisations, and had further contact with the Ombudsmen’s offices which provided advice.
26. Therefore, I am not persuaded that Ms T could not have complained sooner, for all aspects of her complaint about Oxleas Trust.

L&G Trust

27. When Ms T contacted PHSO in March 2017 none of her complaints about L&G Trust were late. However, PHSO noted that Ms T had not yet complained to L&G Trust and advised her to do so.
28. Ms T complained to L&G Trust about three months later, in June 2017. L&G Trust declined to investigate. Ms T then contacted a Board member in December 2017, but this was about new concerns.
29. Ms T returned to PHSO in February and March 2018. PHSO gave some advice to make further attempts at complaining to L&G Trust. Ms T made another complaint to L&G Trust in June 2018. Ms T spoke to PHSO in the same month. It advised her to send the response in and said it could then consider it.
30. Ms T submitted a complaint to PHSO in September 2018. However, due to considerations about other organisations, PHSO decided this was premature.
31. From the evidence I have seen, in the 18 months between March 2017 and September 2018 Ms T only made limited attempts to complain to L&G Trust and did not return to PHSO as soon as she received its decisions not to investigate. Ms T was complaining to other organisations in the interim and I am not persuaded that she could not also have pursued this complaint with greater urgency. Therefore, I have not seen clear evidence that Ms T could not have complained sooner, for all aspects of her complaint about L&G Trust.

The Hospice

32. Ms T first complained to the Hospice in March 2018. Her complaint included concerns about what happened in the first weeks of Mr X’s admission to the Hospice, which was over a year before. The Hospice replied in late April 2018 and said it would not look at her concerns.
33. Ms T approached PHSO in May, June and September 2018. However, I cannot see that she raised a complaint about the Hospice on these occasions.
34. Throughout this period Ms T was raising complaints with a variety of organisations and had a knowledge of the Ombudsmen. As such, there is no clear explanation for why Ms T could not have complained to the Ombudsmen about the Hospice sooner.

The Care Home

35. From the papers I have seen Ms T made a verbal complaint to the Care Home in July 2017. Staff met with her to discuss her concerns later that month.
36. Ms T contacted the Care Home again in August, October and November 2017. Her MP then wrote to the Care Home in March 2018, noting general concerns. The Care Home replied at the end of the month.
37. Ms T approached PHSO in May, June and September 2018 but I cannot see that she raised her concerns about the Care Home. As with the other organisations, there is no clear explanation for why Ms T could not have complained to PHSO about the Care Home sooner.

Prospect of a meaningful investigation

38. In large part Ms T’s concerns are quite broad, in regard to both the claimed failings and the claimed impact of each failing. Much of her concerns rest on her interpretation of events and her views about how professionals should have interpreted events. It is not the Ombudsmen’s role to conduct reviews of long periods of care. Rather, the Ombudsmen look at the way complaints about specific, significant events were handled and whether the correct processes were followed.
39. Given the length of time that has passed it seems probable that an investigation would need to rely on the records the organisations made at the time along with Ms T’s recollections, and the daily notes she kept. It is unlikely the professionals would have a reliable recall of these events to supplement the notes they made at the time. The records from each organisation are likely to specific to the task or decision at hand.
40. It is unlikely the contemporaneous records would contain a level of detail that could satisfy Ms T’s queries, or which could a clear account of how and why all key decisions were made. Therefore, it seems unlikely an investigation would be able to reach meaningful decisions.

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Decision

41. The Ombudsmen will not investigate Ms T’s complaints about Mr X’s care from 2015 to November 2017. The complaints are late and there are insufficient grounds to accept them now.

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Investigator's decision on behalf of the Ombudsman