Summary: We will not investigate Miss X’s complaint about her mother’s care and treatment during September and October 2022. This is because a significant amount of time has passed since the events Miss X is complaining about occurred and it would have been reasonable for Miss X to complain to us sooner.

The complaint

1. Miss X complains about the care and treatment provided to her mother, Ms Y, in September and October 2022. Miss X complains about her mother’s care by University Hospitals of Leicester NHS Trust (Trust A) when she was admitted to Glenfield Hospital. She also complains about her mother’s inpatient care by Leicester Partnership NHS Trust (Trust B) during her admission to Loughborough Hospital. Miss X complains about the way her mother’s discharge was handled by Trust B and Leicestershire County Council (the Council), including the decision to place her mother in a residential care bed, instead of a nursing care placement.
2. Miss X is unhappy with the care Ms Y received during her stay at Charnwood Oaks Care Home (the Care Home) and says it failed to act on the family’s concerns. Miss X complains about insufficient and delayed medical interventions by Forest House Surgery, an out of hours locum GP from Derbyshire United Healthcare and visiting community nurses from Trust B.
3. Miss X says the was a collective failure to ensure her mother received appropriate care. She says the decision to place Ms Y in residential care meant she did not have access to appropriate end of life medication. As a result, Ms Y died in pain and distress. Miss X says her mother’s end of life care has been extremely upsetting for the family.
4. Miss X would like answers to her questions and systemic improvements to prevent the same mistakes happening again.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complaint to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and the Health Service Commissioners Act 1993, section 9(4).)

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How I considered this complaint

7. I considered evidence provided by Miss X and the organisations, as well as relevant law, policy and guidance.
8. Miss X had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened

9. In August 2022, Ms Y was admitted to Glenfield Hospital, where she was diagnosed with advanced cancer. Ms Y then transferred to Loughborough Community Hospital.
10. In late September 2022, Ms Y was discharged to a residential bed at the Care Home for palliative care. This was a short-term NHS funded placement so Ms Y’s needs could be assessed. As this was a residential placement, Ms Y’s medical needs were managed by visiting community nurses from Trust B and Forest House Surgery. An out of hour locum doctor from Derbyshire United Healthcare also visited Ms Y to administer medication.
11. On 2 October 2022, Ms Y was showing signs of pain and distress. The Care Home called the community nurses, who arrived after 30-40 minutes and administered end of life medication. Later that day, Ms Y died.
12. Miss X complained about her mother’s care. In January 2023, the Care Home replied to Miss X’s complaint.
13. Trust A responded to Miss X’s complaint in December 2023 and sent a further complaint response in 2024.
14. In August 2023, Miss X raised complaints with the Council. The Council issued three complaint responses, with its final response being sent to Miss X in May 2024.
15. In November 2023, Trust B replied to Miss X’s complaints about her mother’s care in Loughborough Hospital.
16. In September 2024, Derbyshire United Healthcare replied to Miss X’s concerns about the out of hours GP not putting a syringe driver in place.
17. In November 2024, Miss X complained to Trust B about its community nursing service. In January 2025, Trust B responded to her complaint.
18. In February 2025, Forest House Surgery replied to Miss X’s complaint about its involvement in her mother’s care.
19. In June 2025, Miss X complained to the Ombudsmen.

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My assessment

20. Miss X complains about her mother’s care and treatment between September and October 2022. Both Miss X and Ms Y were aware of the matters complained about at the time. Miss X started raising complaints from January 2023.
21. Miss X has explained that she found the complaint process complicated, onerous and stressful. Multiple organisations were involved in Ms Y’s care and it has taken Miss X some time to navigate this. Miss X responded to the organisations with further concerns. As such, there are multiple complaint responses from the Council, Care Home and the Trusts over a prolonged period.
22. Miss X says delays by the organisations contributed to her delay bringing her complaint to us. The Council took around five months to complete its investigation report. However Miss X received this in March 2024 and a final response in May 2024, which signposted her to the Local Government and Social Care Ombudsman (LGSCO). Miss X was able to bring her complaint about the Care Home and the Council to LGSCO from May 2024 but did not do so until June 2025. There was also a delay in Trust A’s complaint handling in early 2024, however again this does not account for the full delay complaining to us.
23. I acknowledge this has not been a straightforward complaint process due to the number of organisations involved. However, Miss X was signposted to both Ombudsmen in several letters since 2023. In November 2023 and twice afterwards, Trust’s B’s complaint responses also flagged that the Ombudsman has time limits. At this point, I would have expected Miss X to have contacted the Ombudsman for advice, particularly as a year had already passed since Ms Y had died.
24. Therefore, I am satisfied Miss X knew how to escalate her concerns and was able to do so. It would have been reasonable to expect Miss X to bring this complaint to us sooner than she did. There is no good reason to exercise discretion to investigate matters that took place this long ago.
25. Miss X says she contacted the Parliamentary and Health Service Ombudsman (PHSO) by phone in March 2025 but was told she needed to have completed her outstanding complaints before they could consider it. At this point, 2.5 years had passed since Ms Y died and Miss X was already very late approaching the Ombudsman. While she had an ongoing complaint with Trust A at this time, this was because she had chosen to raise further complaints with the Trust, following a year long gap in contacting them, instead of escalating her complaint via the Ombudsman.
26. Miss X has explained her father died during the complaint process, and her siblings had health issues. Miss X says dealing with this added further difficulties. I acknowledge this would have been upsetting for Miss X and had some impact on her ability to pursue her complaint. However, Miss X was able to actively complain to multiple organisations during this time, therefore it is reasonable that she could have approached the Ombudsman sooner too.
27. 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.
28. 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. Trust B’s complaint responses confirm it does not have records of some decisions and that several staff members have since left the organisation.

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Decision

29. We will not investigate Miss X’s complaint about her mother’s care and treatment in 2022. 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 Miss X to approach us sooner than she did. This complaint is late and I can see no good reason to consider it now.

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Investigator's decision on behalf of the Ombudsman