Listening and responding to concerns and complaints policy

Contents

1 Policy on a page

• Front-line colleagues should actively seek feedback from patients and the public using their services and any concern or complaint should be welcomed in an open and non-defensive way. Throughout the complaints investigation attempts must be made to try and resolve any concern or complaint with a view of them being an opportunity for service development and improvement.
• Patient advice and liaison service (PALS) (cited in the patient safety, carer and communities team) should be the first point of contact to attempt to resolve the matter for the patient or family or carer (see PALS policy).
• All concerns raised through PALS should be dealt with swiftly and within no more than ten working days (see PALS policy).
• All concerns and complaints should be dealt with promptly and efficiently, and learning should be identified to improve service delivery and patient care.
• The risk factor per concern and complaint will be deduced by the patient safety, carer and communities lead at their daily meeting with the team’s administrator. All formal complaints must be acknowledged in writing within three working days and a full response sent out within the timescale as agreed with the complainant (The maximum timescale is 60 working days).
• The acknowledgement letter is also the means of establishing the complainant’s consent to the sharing of their information.
• All complaints to be investigated jointly by an appointed care group lead within the relevant care group and a member of the complaint investigation team. “Action is needed in order for learning to take place and this requires people working together in a joined-up way” (PHSO 2015).
• All complaints should include an outcome plan that is monitored by the relevant care group and overseen by the head of complaints to ensure that all actions are completed, and that learning is embedded. Where appropriate actions should be audited to measure their effectiveness.
• The complaints team are able to provide support for colleagues who are asked to provide comments in response to a complaint.
• The outcomes of complaints should be shared with the relevant colleagues and discussed at appropriate care group meetings and other trust meetings.

1.1 Flowchart

A complaint is raised. Please refer to section 7.2 of the policy (how to raise a complaint).

For formal complaints refer to appendix A of the policy (formal complaint flow chart).

For concerns refer to Patient Advice and Liaison Service policy in section 16.

2 Introduction

Rotherham Doncaster and South Humber NHS Foundation Trust (thereafter referred to as the trust) places a high priority upon the handling of concerns and complaints and aims to promote and support a culture in which all forms of feedback are listened to and acted upon in order to learn lessons and implement improvements to services.

The trust recognises the importance of having a trust-wide systematic, accessible and impartial process for dealing efficiently and effectively with concerns and complaints from patients and their relatives. By listening to, and receiving feedback from, our patients and their relatives, this allows the trust to further improve patient safety and the quality of the care and services we provide.

The standards follow the relevant requirements as given in the local authority, social services and National Health Service Complaint Regulations (2009) and the Health and Social Care Act (2008) (Regulated Activities) Regulations (2014) (the 2009 and 2014 Regulations). It must be read in conjunction with the more detailed guidance modules that are available on the Parliamentary and Health Service Ombudsman (PHSO) website.

This trust also recognises and accepts its responsibilities outlined by the Care Quality Commission’s Fundamental Standard; Regulation 16. Receiving and Acting on complaints “Guidance for providers on meeting the regulations” or Key Line of Enquiry (KLOE) Responsive 4. The intention of this regulation is to ensure that providers implement the necessary systems and processes to ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations (2014) (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service.

The trust aims to work in line with the Parliamentary Health Service Ombudsman (PHSO) NHS Complaint Standards Framework. The PHSO Complaint Standards) 2022) and sets out a single vision for colleagues and NHS patients (and people who support them) of what is expected when a concern or complaint is raised. This will help make sure that everyone experiences a culture that seeks out learning from complaints, and meets the outcomes also set out by the PHSO.

A key priority for the trust is to adhere to the four living principles within the PHSO Standards (2022) which are:

• promoting a learning and improvement culture
• welcoming complaints in a positive way
• being thorough and fair
• giving fair and accountable decisions and or responses.

The trust is thereby committed to ensuring that concerns or complaints raised by people using its services, their carers and families are acknowledged and dealt with fairly, effectively, and in a timely manner. The trust will identify learning opportunities from the findings of our investigations and from those directly involved in the complaint.

No one should be inhibited or disadvantaged when making a complaint and anyone making a complaint will be treated fairly and equally. The trust will ensure that systems are in place so that patients, their relatives, and carer are not treated any differently because of raising a concern or a complaint.

In dealing with complaints that are made against colleagues the trust will adopt a supportive and “just culture” approach and will not seek to blame individuals involved in complaints unless negligence, malpractice or other misconduct is proven.

This policy outlines the process by which concerns and complaints will be handled and that procedures are in place to address the issues and concerns raised, with the aim of achieving early resolution where possible, and to deal with formal complaints where this has not been possible. (see complaint process flow chart in appendix A)

Compliance with this policy and procedure is mandatory for all trust colleagues.

It should be read alongside Ombudsman NHS complaint standards (opens in new window)

3 Purpose

The purpose and aim of the policy is to ensure that the trust complies with the Parliamentary and Health Service Ombudsman (PHSO, 2009, updated 2022) and principles of good complaint handling these include:

3.1 Promoting a Just and Learning Culture

• Colleagues are empowered to deal with complaints as they arise in an open and non-defensive way.
• The learning from complaints is identified and used for service development and improvement.
• The trust seeks continuous improvement arising from feedback.
• Colleagues involved in complaints are given support.

3.2 Welcoming complaints in a positive way

• The complaints service is accessible, well published, open and transparent.
• Young people, adults with learning disability, autism, or their care, are able to access the complaints system.
• All complaints are well managed as quickly as possible and in a sensitive manner.
• Action to rectify the cause of the complaint is identified, implemented, and evaluated.

3.3 Giving fair and accountable decisions and responses

• Responses are open and transparent.
• Meaningful apologies are offered as appropriate.

3.4 Being thorough and fair

• Complainants are kept informed of the progress and outcome of the investigation.
• Action to rectify the cause of complaint is identified, implemented, and evaluated.

And reiterates “the need to ensure that patient and patients expectations lie at the heart of any system or approach to complaint handling, and the need for a framework of good practice in complaint handling that is relevant to providers of both health and social care.” This quote together with a ‘user led vision (see below) is taken from the “My expectations for raising concerns and complaints,” report, developed by the PHSO and Healthwatch England following the Francis report (2013) on Mid Staffordshire and the Clwyd-Hart review (2013) into the NHS complaints system.

The vision lays out a series of ‘I statements’ (see link to the infographic below that describes what good outcomes for patients look like if complaints are handled well):

• I felt confident to speak up
• I felt that making my complaint was simple
• I felt listened to and understood
• I felt that my complaint made a difference
• I would feel confident making a complaint in future

Please see page 5 of the ombudsman my expectations for raising concerns and complaints (opens in new window).

The easy read format of ombudsman my expectations for raising concerns and complaints (opens in new window).

4 Scope

This policy covers all activities of the trust and is appropriate to all colleagues including temporary colleagues.

4.1 Issues which cannot be dealt with under this procedure

• A complaint made by an employee of the trust about any matter relating to their employment.
• A complaint made by an NHS or local authority social care body which relates to the exercise of its functions by another NHS or local authority social care body.
• A complaint which has previously been investigated under these or previous regulations.
• A complaint which is the same issue as a complaint that has previously been made and was resolved.
• A complaint that has been or is being investigated under the previous complaints regulations, or by the parliamentary health service ombudsman.
• A complaint arising out of the trust’s alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000.

5 Definition

These definitions should be considered within the context of “no issue is too big to be a concern, and no issue is too small to be a complaint”.

It is however sometimes difficult to clearly differentiate between a concern and a complaint and must therefore be considered on a continuum.

6 Responsibilities, accountabilities and duties

The trust board is responsible for ensuring that the trust follows the principles of sound governance. This includes development of systems of clinical governance and risk management and reviewing the effectiveness of internal controls. The trust board, therefore, has a responsibility to ensure that it receives assurance that this policy is being implemented, that lessons are being learnt, and they monitor the progress of any area of development and or improvement.

6.1 The chief executive

The chief executive has ultimate overall responsibility for complaints. The chief executive will: embody the ethos of “learning from concerns and complaints” and will harness the importance of welcoming concerns and complaints in a positive and learned way.

6.2 The chief nurse

The chief nurse is the nominated board member who ensures that the trust is adhering to the National Statutory Regulations for the handling of complaints and abiding by the CQC Regulations 16, the receiving and acting on complaints.

The chief nurse will:

• endorse a “Just and Learning Culture” within the trust
• promote the importance of welcoming concerns and complaints in a positive way
• ensuring that a culture of learning from concerns and complaints is embedded into practice

6.3 Deputy chief nursing officer

Deputy chief nursing officer is responsible for:

• informing the chief nurse of any serious complaints and significant trends in complaints, in order that these may be reported accordingly
• reporting on performance and any matters for escalation to the quality committee
• providing information, advice, and support to distressed members of the public or patients or carers where large-scale failures of services have occurred
• monitoring compliance with statutory responsibilities and regulators

6.4 Promises and quality manager

Promises and quality manager is responsible for:

• advising the relevant care group director, and deputy chief nursing officer of any directorate or corporate risks which need to be on the relevant directorate risk register (See the trust risk management framework for further guidance)
• escalating any delays with the respective care group director or senior leadership team (SLT) leads in supporting the timely response to complaints according to this policy
• informing the deputy chief nursing officer of any serious complaints and significant trends in complaints, in order that these may be reported accordingly
• monitoring that the procedures are followed in practice and review the procedures as and when required
• approving draft investigation response letters prior to submission to the chief executive

6.5 Patient safety, carer, and communities lead

Patient safety, carer, and communities lead has the responsibility to:

• meet daily (working days) with the patient safety, carer and communities administration to discuss each concern or complaint, and using the risk matrix, will determine each course of action (see appendix H Risk matrix)
• manage the procedures for handling and considering complaints in accordance with the arrangements under the regulations
• oversees and provides line management responsibilities of the Patient Safety, Carer and Communities team, the Patient Safety, Carer and Communities team comprise:
  • patient safety carer and communities investigators
  • patient safety carer and communities practitioners
  • patient safety carer and communities officers
  • patient safety carer and communities support and patient safety
  • carer and communities administration
• monitor complaint outcome plans, ensures completion, and reports progress to the promises and quality manager.
• ensure that clear and accessible information about the complaint’s procedure is widely available for patients and carers. This will include how people can contact the Parliamentary Health Services Ombudsman and the Care Quality Commission. Telephone and email contact details will be included in the trust’s complaints leaflet which will be made widely available throughout the trust
• identifies and collates learning to promote ongoing improvement and organisational learning
• monitor the live tracker and escalate weekly to the promises and quality manager when complaints are outside the agreed response times and reasons
• review and monitor trends in complaints and escalates to the promises and quality manager any areas of concern
• provide a monthly thematic report, highlighting any trends and emerging themes for the promises and quality manager

Ensure that systems are in place so that patients, their relatives, and carer are not treated differently as a result of raising a concern or a complaint.

• Escalate any comments or complaints received which describe events considered to be patient safety events to the promises and quality manager and or the patient safety, carer and communities lead.
• Ensure that all complaints are fully investigated and adhere to the required timeframes.
• Undertake complaints Investigations as required.
• Ensure that information is provided for the patient safety, carer and communities lead dashboard.
• Provide learning reports for inclusion in the clinical learning briefs.
• Ensure that when complaints involve doctors in training that information is provided to the director and deputy directors of postgraduate medical education.

6.6 Patient safety, carer and communities investigators

Patient safety, carer and communities investigators will:

• need to demonstrate their compliance with the steps seen in the flow chart (see appendix A)
• on receipt of the complaint, consent is required for the sharing of information and the permission for accessing their records, see section on consent
• should the complaint be from a third party, further information will be sought re the relationship with the patient and consent is required
• work jointly with the appointed care group lead throughout the course of the complaint investigation, this involves engagement with the complainant up until the complaint response letter has been completed and signed off
• continue to keep in contact with the complainant; with a view to determining with the complainant what the right course of action is to be undertaken, and resolving any matters that can be resolved locally
• collaborate with any specialist services such as tissue viability, continence etc that may have been involved in the episode of care referred to in the complaint
• provide support and expertise in complaints handling within the trust
• advise care groups and complainants of the complaints process, including advocacy services available in their area where appropriate
• work in partnership with advocacy groups and services representing complainants, to promote equality of access to the complaints process. It is recognised that advocacy is extremely important to both patients and complainants
• provides feedback to care groups on the outcome of investigations

6.7 Care group director and or senior leadership team

Care group director and or senior leadership team will:

• appoint a care group lead or service lead to be involved during the concern or complaint handling process
• oversee the complaints handling process within their service area
• aim to provide an early local resolution if appropriate
• review each complaint and feedback to the patient safety, carer and communities investigator
• ensure operational managers are aware of their responsibilities within this document, know where to find this procedure on the trust intranet site, and have the resources to implement this procedure

• ensure that all questions raised receive a sufficient and appropriate response by care group colleagues.
• ensure that any operational manager who has been involved in the complaint handling process provides responses to the relevant patient safety, carer and communities investigator within the given timescales
• ensure that learning takes place as a result of feedback within their

service area

• ensure that operational managers complete the outcome plans, where

appropriate, and inform the patient safety, carer and communities team when actions and or learning points are completed

• work with the patient safety, carer and communities investigators to ensure that complaints made about colleagues are managed in line with just culture principles
• provide support to colleagues, through the trust support networks.
• discuss with the appointed care group lead or service lead who will contact the complainant to discuss their satisfaction of the complaint response they have received

6.8 Appointed care group leads

Appointed care group leads, this can be a delegated senior leadership team (SLT) member or a designated care group lead, will:

• make the initial contact with the complainant to discuss their complaint and try to assist in reaching an immediate solution
• if an immediate solution cannot be resolved, they will advise the complainant that they will be the named contact during the investigation of the complaint.
• discuss and agree the timeframe in conjunction with the complainant.
• agree the preferred contact method by the complainant for example email, telephone, post
• work closely with the designated patient safety, carer and communities investigator throughout the course of the investigation
• together with the patient safety, carer and communities investigator compile a draft complaint response letter.
• contact the complainant to discuss their satisfaction of the complaint response they have received.
• offer the opportunity for the complainant to engage in future service development or existing forums

6.9 Operational managers

Operational managers will:

• ensure that no barriers, perceived or real, are presented to individuals wishing to make a complaint, this is in keeping with “Welcome Complaints in a Positive way”.

• ensure that notices are displayed in all public areas advising patients, family members carers, and the public how to complain
• ensure that contact information for the patient advice and liaison service (PALS) is included in all patient information leaflets
• where a concern cannot be resolved by the service, escalate to PALS or formal complaint as required
• provide responses within required timeframes
• ensure that, where the complaint concerns a colleague, the colleague is kept informed, supported, and supplied with a copy of the final response
• ensure that when a complaint is linked to a patient safety event that this is escalated to the Patient Safety, Carer and Communities team
• implement and monitor actions relating to lessons learnt from a complaint, within agreed timescales, to further improve the quality of services for patients, their families, friends, and carers
• make reasonable adjustments related to any complainant who may present with any of the protective characteristics

6.10 Patient safety, carer and communities administration

Patient safety, carer and communities administration will:

• manage the complaint inbox and receives each concern and complaint.
• establish with the rest of the Patient Safety, Carer and Communities team regarding who is writing each complaint, if it is third party and whether consent is required.
• complete an acknowledgement letter within 3 working days. The acknowledgement letter also requests that the complainant contact the patient safety, carer and communities team if they have concerns regarding the sharing of information and accessing their records
• seek further information regarding consent from the patient if the complaint is made by a third party
• log the complaint on Ulysses
• send a complaint pack to the respective care group SLT
• will await the appointment of the care group lead and will act as a conduit between the care group lead and the designated complaint Investigator
• should the care group director appoint a care group lead before there is a designated complaint investigator, and they make contact with the complainant, the complaint team secretary chases up a summary of their telephone conversation
• receive the draft formal response and the completed complaint form from the complaint Investigator for quality checking purposes for example grammar, spelling, formatting
• send the draft response to the care group SLT for confirmation of their support and approval of the draft response
• the care group SLT or the care group director will then review the draft complaint response, and should they approve of the response they will return it to the patient safety, carer and communities administrator
• send any draft complaint response that have been received from the care group leadership or care group director with some comments, the draft complaint response is sent back to the patient safety, carer and communities As soon as the draft complaint response letter has met with the approval from the SLT or care group director.
• send the approved complaint response to the patient safety, carer and communities lead for a quality assurance review.
• when the response letter has been quality assured the patient safety, carer and c communities lead and claims will forward the initial complaint and the response letter and outcome form to the patient safety, carer and communities
• forward the response letter and outcome form to the chief executive for final approval.
• receive the signed approved response from the chief executive’s office and issues formal letter to the complainant, with copy sent to all trust employees named in the complaint, and to the care group director, the letter is saved in the complaints file

6.11 Patients advice and liaison service (PALS) coordinator

PALS coordinator is available to discuss any comments and concerns with patients or the public and is also able to provide a range of information on associated support services. However, the PALS should only be utilised for the resolution of concerns. Any continued dissatisfaction expressed by patients should be referred to the patient safety, carer and communities team.

The PALS team also oversee all public feedback received from Care Opinion, a national platform procured to support promise 4 of the trust strategy and expand the ways in which we receive feedback and concerns. Whereby people share a story on the Care Opinion website, designated responders from each care group will reply and aim to reach a local resolution. Whereby this is not possible, there is the opportunity to step up to a PALS concerns, or the complaints process.

The trust works with the principle that the earlier the concern is mutually resolved the less need there would be to progress to a complaint, claim or litigation.

The PALS coordinator will with the agreement of the complainant, work closely with the care group to resolve complaints which might be more appropriately addressed via PALS.

6.11.1 How to access patient advice and liaison service (PALS)

Patient advice and liaison service (PALS)

Patient Advice and Liaison Service
Rotherham Doncaster and South Humber NHS Foundation Trust
Woodfield house
Cherry Tree Way
Tickhill Road site
Balby
Doncaster
DN4 8QN

• Phone: 0800 015 4334
• Email: pals.email@nhs.net

Open during normal office hours, Monday to Friday (excluding public bank holidays). Your telephone call will be free from a BT landline. Please note, telephone calls from other networks, for example, a mobile telephone, may be charged. If patients inform us that they are calling from a mobile telephone, we can return their call directly.

7 Complaint procedure and process

A guide to the management of complaints is provided in appendix A and B.

7.1 Who can complain

Concerns or complaints may be made by a patient, or any person who is affected, or likely to be affected by the actions, omissions or decisions by the trust, or by anyone on their behalf, with the patient’s permission.

A complaint that is made by someone acting on behalf of the person or who:

• is a child (The trust must be satisfied that there are reasonable grounds for the complaint being made by a representative instead of by the child, for example, the child is Gillick competent or if 16 has the mental capacity to make the complaint themselves
• is unable to make the complaint themselves because of physical incapacity or lack of capacity within the meaning of the Mental Capacity Act (2005)
• the person has died
• has requested the representative to act on their behalf

A complaint may be made on their behalf, as long as the complainant is conducting the complaint in the best interests of the patient and where the complainant is a suitable person to act on the patient’s behalf. However, discussions and advice should take place to determine that this is the case.

If the person making the concern or complaint is not the patient, then the trust will first seek the patient’s written permission to disclose personal information and progress the patient’s concern or complaint.

Should the PALS coordinator or the patient safety, carer and communities lead consider that the representative is not conducting the complaint in the best interests of a child or a person that lacks capacity, then the trust must not consider the concern or complaint and will inform the representative of the reason for this decision. The decision is made following careful consideration to all the relevant factors, such as closeness of the complainant’s involvement with the patient. Consent to respond to a concern or complaint will be sought from the person appointed to act on the patient’s behalf or from an interested party acting on their behalf prior to the disclosure of any information. If the PALS coordinator or the patient safety, carer and communities lead are not satisfied that the complainant is acting in the best interests of the patient, the complaint must not be considered under the regulations. The trust will notify the complainant in writing, stating the reason for the decision.

With children and young adults, the regulations refer to a child as anyone who has not yet reached the age of 18 years of age. With children, the representative making a complaint on their behalf must be a parent, guardian or other adult person who has parental responsibility for the child.

7.2 How can someone complain

Complaints can be made in a number of ways that are convenient to the complainant

For example, through formal routes for example email, telephone, letter, social or by care opinion or by informal routes via social media

Colleagues within the trust are empowered to use a range of methods to resolve complaints and are being trained to respond to a complaint with confidence and to take immediate action where required.

Every assistance will be given for those with any additional needs for example appropriating the interpreting services, British Sign Language (BSL) that would accommodate all those who may wish to raise a concern. All complainants should be treated fairly regardless of race, age, gender, disability, sexual orientation or religious views.

Support in providing feedback or making a complaint. Thus, reiterating the “We Welcome Complaints in a Positive way”. Making a complaint can be stressful and many people who might wish to complain do not because they do not know how to do so, or they find the process too intimidating. The trust therefore loses valuable feedback from its patients.

Complainants must receive a clear message that they will not be disadvantaged or adversely affected, either directly or indirectly because they have raised a concern or complain.

The Patient Safety, Carer and Communities team will support people who wish to raise issues. Support will continue to be provided through the complaints investigator who will maintain contact with the complainant and or advocate during the investigation and will support at the point of feedback. Signposting may also be done to other support organisations.

Colleagues raising concerns will be supported to share and speak up.

The patient safety, carer and communities team can help those individuals with specific needs, for example literacy, interpreting services, to enable everyone who wishes to give feedback to be able to do so.

7.3 Consent

In accordance with the Data Protection Act and Caldicott principles, any patient having capacity will be asked to provide consent before their records are accessed to investigate a complaint.

An acknowledgement letter is sent to the complainant within 3 working days of receiving the complaint.

The letter contains a paragraph that requests that should the complainant have any queries regarding the giving and providing of their consent to a. the sharing of their personal information and or b. the accessing of their personal records then they are required to contact the patient safety, carer and communities team.

The patient safety, carer and communities team will allow between 5 and 7 working days to receive any concerns regarding this matter.

Meanwhile the patient safety, carer and communities administrator contacts the respective care group director or senior leadership team for a designated lead that will assist in the complaint investigation. The designated lead(s) makes contact with the complainant within 1 to 2 days of the complaint being received. This first initial point of contact serves three purposes; the first one is to attempt to resolve the complainant’s concern or complaint, the second is to determine the detail within the complaint and the third is to remind the complainant about raising a concern if they did not consent to the sharing of information and the access of their records.

The timescales for each complaint investigation begins after it has been acknowledged that no concerns have been raised re consent.

Should there be no consent received, although the trust will still investigate the complaint for assurance purposes, a letter outlining closure of the investigation is sent to the complainant.

The trust will undertake an investigation without consent as the trust has a duty of care.

7.3.1 Relative or carer or representative

If a carer or relative or representative (including advocacy organisations or solicitors) submits a complaint on behalf of a patient written consent is required. A consent form for the release of confidential information will be sent with the acknowledgement, which should include information regarding patient confidentiality.

Advocacy organisations or solicitors complaining on behalf of patient are expected to have obtained the written consent before submitting the complaint.

If the patient does not have capacity to give consent. In that case, a representative who makes a complaint on behalf of a person who lacks capacity within the meaning of the Mental Capacity Act (2005), can be accepted as the patient’s representative by the trust, provided that the trust is satisfied that the representative is conducting the complaint in the best interests of the person on whose behalf the complaint is made. The representative can be, for example, a family member, friend, solicitor or advocate or member of the Care Quality Commission (CQC).

If consent is not received to proceed the investigation within 30 working days of the complaint being logged, the complaint will be closed, and the complainant will be informed accordingly. Concerns however may be investigated outside the complaints process if consented.  Concerns addressed within PALS will be closed after 30 days whereby further information is requested no further contact is received from the complainant.

7.3.2 Complaints received via a member of parliament

If a complainant has approached their MP who then submits a complaint on their behalf, implied consent is assumed. However, a consent form should accompany the letter from the MP in writing. Moreover, in cases where this has not occurred the chief executive office will make contact with the MP’s office.

The complaint will continue to be investigated should no written consent be provided under a duty of care.

7.3.3 Children

If the complaint is regarding a child, dependent on the age of the child, discussion to be held with the care group or clinical team leader or service manager involved with the young person. If the young person is unable to give consent the lead investigator should seek guidance from the Caldicott guardian.

7.3.4 Deceased patients

Where the patient is deceased, ensure the complainant is the lawfully entitled personal representative of the patient. If the death is to go to the coroner, please contact the patient safety, carer and communities lead in the first instance. If not seek guidance from the Caldicott guardian and information governance manager if this is not clear.

Advocacy organisations provide a useful service in assisting patients, patients, relatives, and carers to make a complaint, especially where a complainant is unable to make, or is disadvantaged in being able to make a complaint personally.

7.3.5 Complaints received from the Care Quality Commission (CQC)

The trust has a point of contact for CQC concerns or enquiries. Any complaints received will be reviewed and undertaken as part of the complaints response. However, if concerns are raised consideration will be given whether there is a need to escalate to an investigation under the Patient Safety Incident Response Framework (PSIRF).

When requested to do so, the trust will provide CQC with a summary of complaints, responses and other related correspondence or information.

7.4 Confidentiality

Patient confidentiality must be maintained and security of data relating to individuals must be protected in accordance with the General Data Protection Regulation (2018). No confidential information relating to complaints will be disclosed to any third party unless the trust has the complainant ‘s consent or some other lawful authority to do so.

7.5 Complaint process

The complaint process endorses a cross-sector framework for complaint handling that can be applied in a wide range of contexts. See appendix A Complaint handling flow chart.

8 Types of complaints

8.1 Complaints of a serious nature

At times the trust may receive a complaint which raises serious concerns about patient safety and may require urgent action or escalation. Enquires should be made to clarify if an Incident form has been completed and whether an Incident review will be undertaken.

The incident review will take precedent, and the complaint will be closed. The patient safety, carer and communities investigator will communicate with the complainant to explain how the findings of the Incident review will be fed back to the complainant.

8.2 Complaints and disciplinary investigations

Following the investigation of the complaint, if any issues of a disciplinary nature need to be considered, this will be carried out in accordance with the trust’s disciplinary procedure. This policy will only be concerned with resolving the complaint, not with investigatory disciplinary issues.

If the centre of the complaint relates to a colleague from an agency the patient safety, carer and communities investigator should communicate with the human resources department for further advice.

Any colleague involved in a complaint should be fully informed of any allegations at the outset and given an opportunity to reply to the patient safety, carer and communities investigator. They will be advised that they may seek the assistance of their professional association or trade union.

8.3  Legal cases and potential litigation

In its investigations, the trust should ensure they do not prejudice police enquiries or court proceedings.

On receipt of a complaint where legal action is being taken, or the police are

Involved or investigating, the government expects discussions to take place with the relevant authority (legal advisors, police), to determine whether progressing the complaint might prejudice subsequent legal or judicial action. If so, the complaint will be put on hold, and the complainant will be advised of this. If not, an investigation into the complaint should commence.

When there is a concurrent investigation for example legal or disciplinary proceeding or other statuary body, the trust will consider how the complaint should be handled and will only proceed where it believes that its investigation would not compromise or prejudice the concurrent investigation.

If, throughout the above process, a complainant indicates either in writing or verbally that they intend to take legal action or there are concerns that the complaint may lead to litigation this will be escalated to the patient safety, carer and communities lead and advice can be sought from the trust’s legal advisors.

8.4 Suspicions of fraud

When a complaint is received and there are suspicions of fraud this must be dealt with in line with the counter fraud, bribery and corruption policy, the trust’s counter fraud specialist or the director of finance should be contacted prior to any investigation commencing.

8.5 Complaints and safeguarding

In respect of allegations relating to the ill treatment of patients, this policy must be followed in line with other relevant policies including safeguarding adults manual and the procedure for managing allegations against people in positions of trust (PIPOT).

Allegations may come from patients themselves, their relatives, colleagues or outside agencies.

If, concerns are raised with regard to an adult at risk or relating to risks to a child advice should be sought from the trust safeguarding team.

If the complaint relates to a colleague the chief executive, chief nurse and or the chief medical officer must be made aware of all allegations of ill treatment. The chief executive, together with the chief nurse and chief medical officer will determine next steps which may include an immediate initial investigation to establish the nature and gravity of the complaint and to determine if any immediate action is required to safeguard the interests of the patient and to facilitate further enquiries.

The chief executive and chief nurse and or chief medical officer may decide that no further action is required.  If, however, it appears that a criminal offence may have been committed, a report will be made to the police.

Care should be taken to support colleagues who make allegations of ill-treatment and who have allegations made against them, and they should be advised who to contact if they have further concerns or worries.

When colleagues are required to attend a fact-finding enquiry, they are entitled to be accompanied by a trade union representative if they so wish.

8.6 Police involvement

Following a complaint or investigation of a complaint, if it appears or is alleged that a criminal offence may have been committed, the matter should be reported immediately to the chief executive or chief nurse or chief medical officer to advise on whether the police and if it is determined that police involvement is necessary who that will be undertaken by.

If the allegation is withdrawn, the chief executive or chief nurse or chief medical officer will consider the circumstances and decide on what action should be taken.

8.7 Complaints raised through social media

Social media is monitored by the communications department and any complaints raised will be referred to the patient safety, carer and communities team who will process or liaise with the person raising the complaint.

8.8 Joint NHS and multi agency complaints

In the event of a complex complaint, for example where the complaint relates to a number of different NHS services or organisations, there is a statutory duty of collaboration on the agencies to provide a coordinated response. There will be an initial discussion between agencies and one agency will be identified to lead the response. If there are valid reasons why this may not be possible, for example if it will unduly delay the response, the complainant should be informed, and it is their decision whether they have a joint or separate response. There will be a discussion and agreement with the patient safety, carer and communities lead and the promises and quality manager

If the complaint is received by the trust, the complainant’s consent must be sought before forwarding the complaint to other organisation(s).

See appendix E and F joint complaints between agencies.

8.9 Complaints and executive leadership

8.9.1 Where the chief executive is named in a complaint

The chairperson of the trust will be informed, who will determine if external support or advice is appropriate to aid investigation of the complaint. If external support is not deemed to be required, the chairperson will delegate an appropriate lead director to coordinate the investigation.

8.9.2 Where a director is named in a complaint

The chief executive will be informed, who will delegate an appropriate lead director to coordinate the investigation.

8.9.3 Where the chief medical officer is named in a complaint

The chief executive will be informed, who will determine if external support and or advice is appropriate to aid investigation of the complaint. If external support is not deemed to be required, the trust’s deputy chief executive will lead the investigation, with appropriate medical advice.

Depending on the nature of the complaint and the wishes of the complainant, the complaint may be dealt with directly and without the need for a written response. This will ensure prompt and appropriate action and help to resolve the complaint at a truly local level.

Complaints will be investigated appropriately in line with the ethos and procedures set out within the policy and within the timescale agreed with the complainant wherever possible. If an investigation cannot be completed on time, direct contact will be made with the complainant as soon as this is apparent, an apology provided, and an extension period agreed and confirmed in writing.

8.10 Discriminatory complaints

Complaints may be made against an individual because of their colour, sexuality, gender, race, ethnic origin, religion, or age. The trust will identify any complaint which amounts to harassment and or abuse and the patient safety, carer and communities lead will discuss any possible discriminatory complaints with the promises and quality manager and determine whether the complaint should be progressed through the complaints process.

Where a complaint contains discriminatory language, but does raise some legitimate issues about clinical practice, procedures, and communication, these will be reviewed using the complaints process, without prejudice to the outcome of the review. However, the complainant will be advised that discriminatory language will not be tolerated.

8.11 Habitual, serial or unreasonable complainants

In a minority of cases, there can be serial complainants who become persistent and or display unacceptable behaviour in pursuit of their complaint, despite reasonable attempts being made to resolve matters. This can result in a disproportionate amount of time and resources and may place undue strain upon the colleagues that are required to deal with them.

In determining arrangements for handling such complainant’s colleagues should identify the stage at which a complainant has become unreasonably persistent and or manifesting unacceptable behaviours but also recognise that even serial complainants may have issues which contain some substance. The need to ensure an equitable approach and to provide an open and honest response is, therefore, crucial.

Making judgements as to the validity or not of a complaint requires careful assessment and it is important to ensure that no material element of the complaint is overlooked.

See appendix D that identifies complaints that may be considered unreasonable and suggests ways of responding to these.

It is also important that the fundamental right of a patient to make a complaint is preserved and not compromised.

9 Responding to complaints

Colleagues are encouraged to actively promote how people can raise a concern or complaint and then use this to identify and resolve issues quickly within their local service area. This is in line with “being thorough and fair”.

Where this is possible the trust will formally record details of discussions held and actions agreed with the person raising the concerns.

The trust will ensure that colleagues are being trained, equipped, and empowered to act decisively to resolve concerns and complaints.

All trust colleagues are aware to take each concern and or complaint seriously, with empathy and compassion, and answered as quickly as possible.

9.1 Formal complaints, stage 1, local resolution

Where local resolution has not been possible through the PALS service, continual support should be given to the complainant to raise their concerns. Each concern or complaint will be treated according to its individual nature and the wishes of the complainant, reinforcing the ethos of ensuring that the whole experience of making a complaint is simpler, more user-friendly, and far more responsive to people’s individual needs.

If, after all efforts have been made through the PALS service and the complainant remains unsatisfied and wants to raise a formal complaint, the colleagues from PALS will provide details and if appropriate offer to record and submit the concerns on behalf of the complainant.

Following the receipt of a concern or complaint, the patient safety, carer and communities administration and the patient safety, carer and communities manager will discuss the concerns and complaints received on each working day and agree through the guidance of a risk matrix the relevant actions to be taken.

When it has been established that a formal complaint requires investigation an Investigator from the patient safety, carer and communities team will be allocated.

The patient safety, carer and communities administration will send a letter of acknowledgement to the complainant within 3 working days. The letter also requests that should the complainant have any concerns regarding consenting to the ‘sharing of information and or accessing their records they should contact the patient safety, carer and communities team via e mail or by telephone.

The patient safety, carer and communities administration will subsequently request a relevant care group lead from the respective care group director or senior leadership team.

The complaint handling investigation team will be composed of joint working between the patient safety, carer and communities investigator and the designated care group lead and may involve any representation from respective specialisms where appropriate.

Within 1 to 2 working days the care group lead will contact the complainant with a view to providing the complainant with another attempt at early and local resolution.

The Statutory Instruments 2009, No. 309 states:

• “Complaints not required to be dealt with 8-(1) c(ii) is resolved to the complainant’s satisfaction not later than the next working day after the day on which the complaint was made.”

If this contact is not successful in resolving the complainant’s concern or complaint the care group lead will affirm the importance of the complainant raising any concerns regarding the provision of their consent.

The conversation between the complainant and the care group lead with the complainant will be to verify the salient points within the complaint letter that requires answering and will ensure that the expectations or timeframes have been discussed and agreed.

The investigation will maintain regular contact with the complainant or advocate, the complainant having already agreed a timescale for the handling of their complaint with the investigator and the care group lead. The patient safety, carer and communities investigator and the appointed care group lead will undertake a review of the care records, and where appropriate will meet with the relevant colleagues, gather information from other sources if applicable, and together answer the points raised in the complaint.

When the investigation is complete, the patient safety, carer and communities investigator will submit a draft complaint response of their findings, recommendations, and an outcome plan based on the recommendations, identifying areas for improvement where relevant and how this will be achieved. The draft response letter should be written so that the complainant can understand it.

The outcome plan should accompany the draft response letter during the quality checks. The outcome plan should include whether the investigation has identified that the findings indicate it is either fully upheld, partially upheld or not upheld.

Fully upheld indicates that the trust have made mistakes or provided a poor service that amounted to maladministration or service failure, and this has had a negative impact on an individual which has not yet been put right.

Partially upheld indicates that the trust got something’s wrong, but not all the issues that had been complained about, or the mistakes did not have a negative impact on anyone.

Not upheld would indicate that the findings illustrated that the trust acted correctly in the first place or that any mistakes that could have occurred have been put right for the person or people affected.

The draft complaint response letter then goes through a series of quality checks before being signed off by the relevant care group director. Final proof reading is conducted by the patient safety, carer and communities lead, and the approved complaint response letter is then sent to the chief executive. The final response will be approved by the chief executive (or if relating to the chief executive, by the chair). The final response to the complaint should include:

• using plain language with any abbreviations, technical or clinical terms fully explained
• summary of the nature and substance of the complaint
• comments on the investigation process
• an answer to each point raised by the complainant
• a summary of the conclusion from the investigation
• an explanation of the events complained about, this should be in some detail including information such as dates
• an explanation about the usual standard to be expected and whether this standard has or has not been met and why
• an appropriately worded apology where things have gone wrong, and an account of lessons learned, action taken or planned to improve the service for the individual and or to reduce the risk of a recurrence

9.2 Formal complaints, stage 2, referral to the Parliamentary Health Service Ombudsman (PHSO)

If a complainant remains dissatisfied and the trust believes it has taken all reasonable steps to resolve the complaint, the complainant should be advised of their right to refer their complaint to the Parliamentary Health Service Ombudsman (PHSO). Information on how to make a complaint to the PHSO is included in the complaint response letter.

10 Timeframes for responding to concerns and complaints

10.1 Reporting

The local authority social services and NHS complaints (England) Regulations (2009) stipulate that a complaint should normally be made within 12 months of the event or within 12 months of the complainant becoming aware of a cause for complaint.

Discretion may be used to investigate complaints that fall outside these timescales if the complainant has good reasons for not making the complaint within this time limit and it would still be possible to investigate the complaint effectively and fairly.

The patient safety, carer and communities lead will discuss this with the relevant care group director before rejecting any complaint that falls outside this time period.

10.2 Timescales for completion

The trust will attempt to resolve concerns and complaints at the first point of contact and all colleagues are responsible for making reasonable attempts to do so. Where the complaint requires investigation, it will be escalated to a dedicated investigator.

10.3 Acknowledgement

All complaints must be acknowledged within 3 working days which is the responsibility of the complaints team.

10.4 Contact with the complainant

Contact will be made with the Complainant within 1 to 2 working days by the appointed care group lead and details of that contact is sent onto the complaint admin. Regular contact with the complainant is to be encouraged by both the patient safety, carer and communities investigator and designated care group lead.

10.5 Investigation timeframes

• Local Resolution or Informal complaint (PALS), 10 days.
• MP concerns, 10 days or 30 if made a formal complaint.

The timeframe of the complaint investigation is agreed at the first initial contact by the complainant and the appointed care group lead. This maximum timeframe for response to a concern or complaint from the date of receipt is 60 working days.

The timing of the commencement of the timeframe begins as soon as it is established that the complainant has had no concerns regarding the sharing of information and the access of their records.

The response time may be paused in specific circumstances. These may include:

• when information is being awaited from the complainant and there are delays in obtaining this
• where consent has been requested and not received
• where key colleagues are on leave or have left the trust and will need to be contacted as part of the investigation
• if disciplinary proceedings are taking place and a request has been made to halt the complaints process
• when safeguarding or other investigations are taking place, and the process may need to be delayed
• where the timeliness of a response may be deemed insensitive or inappropriate, for example, over Christmas period or a significant anniversary

The local authority social services and NHS complaints (Regulations) (2009) removed statutory timescales in responding to complaints. The timescale for resolution will be dependent upon the severity and complexity of the complaint. This will be assessed by the patient safety, carer and communities lead.

11 Receiving and storing complaints

When a complaint is received a file relating to the complaint and subsequent investigation will be opened on the l drive. Complaint information should never be recorded in the clinical record. A complaint may be unfounded or involve third parties and the inclusion of that information in the clinical record will mean that the information will be preserved for the life of the record and could cause detrimental prejudice to the relationship between the patient and the healthcare team.

The patient safety, carer and communities team is responsible for keeping a copy of all documentation and correspondence relating to the complaint on the trust’s shared drive. Complaint files are disclosable should a legal claim be made to the trust following the outcome of a complaint. Complaint files will also be shared with the Parliamentary Health Service Ombudsman on request.

Complaint files will be kept for 10 years from completion of action before being destroyed in accordance with the Records Management Code of Practice for Health and Social Care (2016).

12 Training and other resource implications

All colleagues should be made aware of the listening to and responding to concerns and complaints policy by their managers as part of local induction.

All colleagues must be made familiar with local complaints handling practices.

This will include details of how patients and or their families or representative can make complaints and to whom, the process for complaints about areas of potential risk and those that constitute serious incidents.

All patient safety, carer and communities investigators must undertake identified complaints training.

The training needs analysis for this policy can be found in the training needs analysis document which is part of the trust’s mandatory risk management training policy located under policy section of the trust website.

As a trust policy, all colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through a variety of means such as:

• all user emails for urgent messages
• one to one meetings or supervision
• continuous professional development sessions
• posters
• daily email (sent Monday to Friday)
• practice development days
• group supervision.
• special meetings
• intranet
• team meetings
• local induction

13 Process for the monitoring of complaints and monitoring of performance

13.1 Process for the monitoring of complaints

The process of monitoring includes:

• reviewing themes and trends in complaint reporting
• the monitoring of compliance with outcome plans arising from complaint investigations and seeks assurance of risk mitigation for any actions not achieved in the agreed time frame
• providing assurance to the board of directors in relation to complaint management, the sharing of lessons learnt, and any action taken to mitigate any identified risks

13.2 Progress against complaints received, including stages of progress and timescales for responses

• How: Report.
• Who by: The patient safety, carer and communities lead.
• Reported to: Promises and quality manager.
• Frequency: Weekly.

13.3 Number of complaints acknowledgements response times categories and themes

• How: Patient safety report.
• Who by: Promises and quality manager.
• Reported to: Quality Committee.
• Frequency: Bi-monthly.

13.4 Number of complaints acknowledgements response times categories and themes

• How: Complaints dashboard.
• Who by: Patient safety, carer and communities lead.
• Reported to: Care group quality meetings.
• Frequency: Monthly.

13.5 How the trust listens and responds to concerns and complaints

• How: Patient safety report.
• Who by: Patient safety, carer and communities lead
• Reported to: Quality Committee.
• Frequency: Bi-monthly.

13.6 How the trust makes improvements as a result of raising a concern or complaint

• How: Individual complaints, outcome plans, patient safety report and clinical learning brief.
• Who by: Promises and quality manager and or patient safety, carer and communities lead.
• Reported to: Care group meetings
• Frequency: Bi-monthly and, or monthly.

Complaints performance data and learnings identified from complaints are reported in the patient safety report.

An annual complaints report is produced and published on the trust website in accordance with legislation.

Risks arising from complaints will be escalated and reviewed in accordance with the risk management process.

13.7 Monitoring of performance and data collection

The trust, via the patient safety, carer and communities (complaints) service, will maintain a record of:

• each concern or complaint received
• the subject and outcome of each concern or complaint
• whether the trust regards the complaint as having been upheld or partially upheld
• lessons learned and followed up actions taken

To ensure that a consistent approach is undertaken by the patient safety, carer and communities investigators, each patient safety, carer and communities investigator is expected to both work in accordance with the listening and responding to concerns and complaints and be familiar with the complaint handbook. The complaint handbook contains the statutory instruments and the PHSO new standards that are an integral aspect of ensuring effective complaint handling, as well as other resources that could guide the patient safety, carer and communities investigators. Each complaint will be discussed during one-to-one meetings with their line manager for quality and safety assurances.

Each complainant, where appropriate, will be invited to complete a satisfaction survey after receipt of the trust’s final response letter. The survey will be based on “My Expectations”, a series of statements seen from the complainant’s perspective published by the PHSO. The results will be reported to the board.

14 Learning and improving from concerns and complaints being raised

The trust strongly believes that Information from concerns and complaints are key to improving the quality of care, treatment, services, and facilities provided by the trust.

Good complaints handling is not limited to providing a response or remedy to the complainant but should also focus on ensuring that the feedback received through complaints is used to learn lessons and contributes to service improvement.

On a weekly basis the patient safety, carer and communities lead will provide the promises and quality manager and the care groups with a report on the status update on all open complaints within their services including any delays and the reasons.

Following the investigation of a complaint, each complaint will receive a response letter that will:

• include details of any risk reduction measures, lessons learnt, and actions taken as a result of the complaint in their final report
• where appropriate, include an outcome plan with an identified lead person and target completion dates
• monitor progress of the outcome plan until complete
• report progress to the patient safety, carer and communities team. Where no learning or actions are identified from the investigation, a nil return must be sent to the patient safety, carer and communities team, as confirmation that learning and actions have been considered. Whilst the patient safety, carer and communities team will facilitate and co-ordinate this process, it is essential that the appropriate care group or department takes responsibility for implementation of risk reduction measures and dissemination of information amongst colleagues and across care groups, as appropriate

Care groups should ensure that learning from complaints is included as part of their governance reporting structure. The patient safety, carer and communities investigators team will provide data on closed and open actions to ensure that all actions are followed up. Where appropriate actions and or changes in practice should be audited within the care group to ensure they are effective, linking with the clinical audit team as necessary. The Quality and Safety Committee and trust board will receive a quarterly and annual report providing qualitative and quantitative data and learning from complaints. In addition, learning from complaints is shared with the care groups, to ensure that this links with other improvement working within the trust:

• thematic analysis will be undertaken monthly and will form part of a rolling data set looking at;
  • number and subject of complaints, and the teams involved.
  • identification of themes or trends
  • complainant satisfaction
• complaints information will be reported as part of the patient safety report
• a sample of complaints files will be reviewed by the promises and quality manager on a quarterly basis
• an outcome plan will be produced for those complaints where learning is identified. This learning needs to translate into improvement strategies that are developed and monitored through care group arrangements from wards and teams through to board level. These will be monitored by the complaints team

The quality committee will be responsible for monitoring the effectiveness of the policy including:

• ensuring the process of investigating complaints is consistent, reliable and meets national quality standards
• reviewing trends in complaints and appropriate risk management actions
• identification of significant risks for inclusion on the trust’s risk register
• consideration of lessons which can be learned from complaints, particularly for service improvement and ensuring lessons learnt in one service line are shared across all services
• consideration of the findings of the complainant survey which will be reported annually

The trust ensures that it provides information to the health and social care information centre via completion of the central return KO41(A) which is reported quarterly.

Equality and diversity data will be collected where possible by the patient safety, carer and communities team as required by the Department of Health. The investigator will provide such information to the complaints department, if known, about colleagues involved, this information forms part of the outcome plan.

The equality impact group will receive an annual report on those complaints relating to equality and diversity issues.

The patient safety, carer and communities lead will be responsible for providing reports for board, commissioners, the quality account, external regulators and internal reporting purposes as required.

An annual report will take place as one method of providing assurance regarding compliance with this policy.

15 Complaint satisfaction

With the regular contact with the complainant by the respective care group lead and by the patient safety, carer and communities investigator will ensure that feedback and accountable decisions are being made and are featured throughout the investigation process.

Feedback is an important and an integral part of the complaints management process. To view feedback in this way is in keeping with the trust’s promise 4, “Put patient feedback at the heart of how care is delivered in the trust, encouraging all colleagues to shape services around individuals’ diverse needs.”.

Feedback allows the trust to revisit the objectives of this policy and gathers assurances that fair and accountable decisions or responses have been made.

To ensure feedback is obtained a questionnaire is sent to every complainant along with their response letters.

Analysis of the feedback will be undertaken and used as part of service monitoring and review. The outcome of the complaint’s satisfaction surveys will be included in the annual complaints report.

15.1 Financial redress and ex-gratia

Where maladministration or poor service has led to injustice or hardship, the PHSO recommends public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should offer redress to them appropriately. Remedies should also be offered, where appropriate, to others who have suffered injustice or hardship as a result of the same maladministration or poor service. This can include financial redress and whilst not being appropriate in every case, the trust will consider proportionate remedies for those complainants who have incurred additional expenses as a result of poor service, or maladministration. This does not include a request for compensation involving allegations of clinical negligence or personal injury where a claim is indicated. The patient safety, carer and communities lead should consider the appropriateness of any remedy being and discuss this with the deputy chief nurse prior to any decision being made. Financial redress should be considered in line with the Parliamentary and Health Service Ombudsman scale (opens in new window).

16 Equality impact assessment screening

The completed equality impact assessment for this policy has been published on this policy’s webpage on the trust policy library and archive website.

16.1 Privacy, dignity and respect

16.1.1 Requirements

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

16.1.2 How this will be met

No issues have been identified in relation to this policy

16.2 Mental Capacity Act

16.2.1 Requirements

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

16.2.2 How this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

17 Links to any associated documents

• Being open policy (incorporating the duty of candour)
• Counter fraud, bribery and corruption policy
• Data security and protection breaches or information governance incident reporting policy
• Disciplinary procedure policy
• Healthcare record keeping policy
• Healthy workplaces colleagues support and stress at work policy
• Incident management policy
• Information governance policy (includes data protection policy content)
• Interpreters policy (provision, access and use of, for patients, service users and carers)
• Patient advice and liaison service (PALS) policy
• Risk management framework
• Safeguarding adults policy

18 References

• Care Quality Commission (2014), Complaints Matter.
• Care Quality Commission (2023) Regulation 16- Receiving and acting on complaints.
• Data Protection Act (1998) legislation.gov.uk.
• Department of Health (2004), Guidance to support implementation of the National Health Service complaints regulations.
• Freedom of Information Act (2000) legislation.gov.uk.
• Mental Health Act 1983; (2015), Code of Practice.
• NHS England, Assurance of Good Complaints Handling for Acute Care 2015.
• NHS Resolution (2010), NHSR Risk Management Standards Monitor Compliance Framework.
• Parliamentary and Health Service Ombudsman (PHSO) (2015): A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged.
• Parliamentary and Health Service Ombudsman NHS Complain Standards 2022.
• Right Honourable Ann Clwyd MP and Professor Tricia Hart (2013), A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture.
• Robert Francis QC (2013), the Report if the Mid Staffordshire NHS Foundation Trust Public Enquiry.
• The Local Authority Social Services and National Health Service Complaint Regulations (2009) Statutory Instruments.

19 Appendices

19.1 Appendix A Complaints process flow chart

The chart below provides the timeline for complaints. The timeframes are to be negotiated and agreed by each complainant. The maximum timeframe is sixty days. The suggested timings for each step can be seen below.

Day 0 is the day the complaint is received by the trust. Timescales are in working days excluding weekends and public holidays.

19.1.1 Investigation timeframe, 60 days

19.1.1.1 Day 0

• A complaint is received by the complaints team.
• The complaints team assesses severity and record details on Ulysses.

19.1.1.2 Day 0 to 1

• Day 0 to 1, The complaints team sends a complaint pack to all the care group Senior Leadership team (SLT).
• This will include the identified patient safety, carer and communities investigator contact that will work with the care group lead.

19.1.1.3 Day 1 to 2

• The care group will identify a lead who will contact the complainant to discuss their complaint and try to assist in reaching an immediate solution.
• If an immediate solution cannot be resolved, advise they will be the named contact during the investigation of the complaint.
  • Discuss and agree the timeframe in conjunction with the complainant. Agree the contact method preferred by the complainant, for example, email, telephone, post.

19.1.1.4 Day 2

• The patient safety, carer and communities team acknowledges receipt and where appropriate seeks patients consent to access their records if applicable.
• The patient safety, carer and communities investigator to agree the initial fact finding and responsibilities with the care group lead.

19.1.1.5 Day 2 to 44

• The patient safety, carer and communities investigator leads a joint investigation with the care group lead and once complete sends a draft formal response and the completed complaint investigation form to the patient safety, carer and communities administrator for quality checking purposes i.e. grammar, spelling, formatting.

19.1.1.6 Day 45 to 48

• The patient safety, carer and communities team administrator sends the draft response to the care group SLT for confirmation of their support and approval of the draft response.

19.1.1.7 Day 48 to 52

• The care group director or delegated deputy sends the draft complaint response to the patient safety, carer and communities team email address.
• The patient safety, carer and communities team forward the approved complaint response to the patient safety, carer and communities & claims lead for quality assurance review.
• Once quality assured, patient safety, carer and communities lead will forward the initial complaint and response letter and outcome plan to the patient safety, carer and communities team, who will forward it to the chief executive’s office.

19.1.1.8 Day 53 to 59

• The patient safety, carer and communities team sends the complaint response letter and action plan to the chief executive office for final approval against expectations.

19.1.1.9 Day 60

• The patient safety, carer and communities team receive signed approved response from the chief executive’s office and issues formal letter to the complainant, with copy sent to all trust employees named in the complaint, and to the care group director. The letter is saved in the complaints file.

19.1.1.10 Until actions complete

• The patient safety, carer and communities team add the learning and changes made from the investigations into the complaints action tracker (the tracker is reviewed via delivery reviews and in clinical leadership executive subgroups as appropriate).

19.1.1.11 Monthly

• The patient safety, carer and communities lead and claims provides a report for clinical learning brief of lessons learnt.

19.1.1.12 Within 21 days of issue

• The care group director or delegated senior leadership team member or care group lead contacts the complainant to discuss their satisfaction of the complaint response they have received.
• This is regarding the quality of the complaint handling and contact they have received. In addition, offer the opportunity for them to engage in future service development or existing forums.

19.2 Appendix B Parliamentary and Health Service Ombudsman (PHSO) guidance on consent

• Appendix B Parliamentary and Health Service Ombudsman (PHSO) guidance on consent (opens in new window)

19.3 Appendix C User-led guide for complaints

My expectations for raising concerns and complaints, a user-led vision for raising concern and complaints (opens in new window).

19.3.1 Key messages

The powerful contribution that users of services can make when they have the opportunity to contribute to the design of what “good” looks like.

The collaboration of everyone working together to improve the way concerns and complaints are handled.

The “I statements” are expressions of what patients might say if their experience of making a complaint was a good one, We need to listen and hear what.

Feedback must include the resolution of their complaint and about actions that have been taken (or not) in response to their concerns. It is here that a patient might receive a tangible demonstration that their complaint has been used to shape learning or improvement. Complainants are part of our learning.

What does the feedback say, do they have confidence in the system? What do we want to hear?

• “I felt confident to speak up and making my complaint was simple. I felt listened to and understood. I feel that my complaint made a difference. I would feel confident making a complaint in the future”

19.3.2 A vision for colleagues on the frontline

Use the vision as a guide to good practice when dealing with a patient complaint.

Use it as part of colleagues induction and a guide that colleagues use as a point of reference when deliberating over how to handle a complaint or reflecting after the fact on how they have handled a complaint.

The power of the vision lies in its illustration of the expectations patients have when making a complaint. As such it would allow frontline colleagues to put themselves in the shoes of their patients and clients and understand how their handling of a complaint might look to the recipient of their service.

19.4 Appendix D Unreasonably persistent complainants

The difficulty in handling unreasonably persistent complainants can place a strain on time and resources and cause unacceptable stress for colleagues. NHS colleagues are trained to respond with patience and understanding to the needs of all complainants, but there are times when there is nothing further that can reasonably be done to assist them or to rectify a real or perceived problem.

In determining arrangements for handling such complainants colleagues should identify the stage at which a complainant has become unreasonably persistent but also recognise that even persistent complainants may have issues which contain some substance. The need to ensure an equitable approach and to provide an open and honest response is, therefore, crucial.

This procedure should only be used as a last resort and after all reasonable measures have been taken, for example, all efforts to resolve complaints following the NHS complaints procedures have been exhausted.

This procedure should only be implemented following careful consideration by, and with authorisation of, the trust’s chair of the board and chief executive or nominated deputy and subsequently ratified by the trust board through the confidential agenda.

19.4.1 Definition of unreasonably persistent complaints and or requests for information

Complainants and or anyone acting on their behalf may be deemed to be unreasonably persistent where current or previous contact with them shows that they have met two or more (or are in serious breach of one) of the following criteria.

• Persisting in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted. For example, where investigation is deemed to be ‘out of time’ or where the Parliamentary Health Services Ombudsman has declined a request for independent review.
• Changing the substance of a complaint or persistently raising new issues or seeking to prolong contact by unreasonably raising further concerns or questions upon receipt of a response whilst the complaint is being dealt with. Care must be taken not to disregard new issues, which differ significantly from the original complaint. These may need to be addressed separately.
• Unwilling to accept documented evidence of treatment given as being factual, e.g. manual or computer records, or deny receipt of an adequate response despite correspondence specifically answering their questions or concerns. This also includes those persons who do not accept that the facts can sometimes be difficult to verify after a long period of time has elapsed.
• Focusing on a trivial matter to an extent which, is out of proportion to its significance and continue to focus on this point. It should be recognised that determining what is trivial can be subjective and careful judgement must be used in applying this criterion.
• Physical violence has been used or threatened towards colleagues or their families or associates at any time. This will cause personal contact to be discontinued and will thereafter, only be pursued through written communication. All such incidents should be documented and reported using the trust’s incident management policy, and notified as appropriate, to the police.
• The complainant has had an excessive number of contacts with the trust when pursuing their complaint, placing unreasonable demands on colleagues. Such contacts may be in person, by telephone, letter, fax or electronically. Discretion must be exercised in deciding how many contacts are required to qualify as excessive, using judgement based on the specific circumstances of each individual case.
• The complainant has harassed or been abusive or verbally aggressive on more than one occasion towards colleagues, directly or in-directly, or their families and or associates. If the nature of the harassment or aggressive behaviour is sufficiently serious, this could, in itself, be sufficient reason for classifying the complainant as unreasonably persistent. Colleagues must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this. All incidents of harassment or aggression must be documented in accordance with the trust’s incident management policy.
• The complainant is known to have electronically recorded meetings or conversations without the prior knowledge and consent of the other parties involved. It may be necessary to explain to a complainant at the outset of any investigation into their complaint that such behaviour is unacceptable and can, in some circumstances, be illegal.
• Display unreasonable demands or expectations and fail to accept that these may be unreasonable once a clear explanation is provided to them as to what constitutes an unreasonable demand, for example insisting on responses to complaints being provided more urgently than is reasonable or recognised practice, presenting similar or substantially similar requests for information.

19.4.2 Options for dealing with unreasonably persistent complainants and or persons requesting information

When complainants have been identified as unreasonably persistent, in accordance with the above criteria, the chair of the board and chief executive (or their nominated deputy) will decide what action to take. The chief executive (or deputy or representative) will implement such action and notify the individual(s) promptly, and in writing, the reasons why they have been classified as unreasonably persistent and the action to be taken. This notification must be copied, for the information, to others involved in the complaint, for example, practitioners, advocates, Independent Complaints Advocacy Service, Member of Parliament, etc. Records must be kept, for future reference, of the reasons why the decision has been made to classify as unreasonably persistent and the action taken. The chair of the board and chief executive (or delegated deputies or representatives) may decide to deal with unreasonably persistent complainants in one or more of the following ways.

Once it is clear that one or more of the criteria in section 3 has been seriously breached, it may be appropriate to inform the individuals, in writing, that they are at risk of being classified as unreasonably persistent. A copy of this procedure should be sent to them, and they should be advised to take account of the criteria in any future dealings with the trust and its colleagues. The complainant should be advised that they can seek advice from the Independent Complaints Advocacy Service or the Parliamentary Health Services Ombudsman with regard to taking their complaint further.

The trust should try to resolve the complaint before invoking this procedure by drawing up a signed agreement with the complainant, involving the relevant colleagues if appropriate, setting out a code of behaviour for the parties involved. If this agreement is breached, consideration would then be given to implementing other actions as outlined below.

The trust can decline further contact either in person, by telephone, fax, letter or electronically, or any combination of these, provided that one form of contact is maintained. Alternatively, a further contact could be restricted to liaison through a third party. A suggested statement has been prepared for use if colleagues need to withdraw from a telephone conversation.

Notify complainants in writing that the chairman or chief executive (or delegated deputies or representatives) has responded fully to the complaint, has exhausted local resolution, and that continuing contact on the complaint will serve no useful purpose. This notification should state that no further correspondence will be sent and that further communications will not be responded to.

Inform complainants that in extreme circumstances the trust reserves the right to refer unreasonably persistent complaints to the organisation’s solicitors or the information commissioner and or the police.

Temporarily suspend all contact, whilst seeking legal advice or guidance.

19.4.3 Withdrawing unreasonably persistent status

Once classified as unreasonably persistent, this status may be withdrawn if, for example, a more reasonable approach is subsequently demonstrated or if they submit a further complaint for which the normal complaints procedures would be appropriate.

Colleagues should use careful judgement and discretion in recommending or confirming that unreasonably persistent status should be withdrawn. Discussions should be held with the chairman and chief executive (or their delegated deputies or representatives) and, subject to their approval, normal contact and procedures will be resumed.

19.4.4 Colleague guidance for handling habitual or unreasonably persistent complainants

The following form of words or a very close approximation should be used by any colleague who intends to withdraw from a telephone conversation with a complainant. Grounds for doing so could be that the complainant has become unreasonably aggressive, abusive, insulting, or threatening to the individual dealing with the call or in respect of other NHS personnel. It should not be used to avoid dealing with a complainant’s legitimate questions or concerns which can sometimes be expressed extremely strongly. Careful judgement and discretion must be used in determining whether a complainant’s approach has become unreasonable.

19.4.4.1 Form of words

“I am afraid that we have reached the point where your approach has become unreasonable, and I have no alternative but to discontinue this conversation. Your complaint(s) will still be dealt with by the trust in accordance with the NHS complaints procedure. I am now going to put the telephone down but wish to assure you that the situation will shortly be confirmed in writing to you.”

19.4.4.2 Follow-up action

The incident should immediately be reported to the patient safety and investigation team and agreement reached on future means of communication with the complainant, together with any further action deemed necessary.

19.5 Appendix E Joint complaint between agencies Rotherham and Doncaster

19.5.1 Introduction

This protocol has been developed by representatives from the agencies mentioned below. This initial version will apply to Rotherham and Doncaster.

19.5.2 Aim

To provide a framework for dealing with complaints involving more than one of the participating agencies and, where possible, to result in a single reply.

19.5.3 Agencies

• Rotherham Doncaster and South Humber NHS Foundation Trust.
• Doncaster and Bassetlaw Hospitals NHS Foundation Trust.
• Doncaster Metropolitan Borough Council.
• Rotherham NHS Foundation Trust.
• Rotherham Metropolitan Borough Council Yorkshire Ambulance Service NHS Trust.

19.5.4 Background

Guidance (SI 2006 No. 2084 Supporting colleagues, Improving Services, Guidance supports the implementation of the NHS (Complaints) Amendment Regulations (2006)), and emphasises the need for joint working or coordinated handling, to facilitate effective complaints handling, between health and social care organisations. This inter-agency protocol has therefore been developed for handling complaints, which cross boundaries between the responsibilities of both health and social services.

19.5.5 Framework

Complaints will be acknowledged by the receiving agency within two working days.

The receiving agency will, as soon as possible make contact with the complainant within five working days to:

• introduce themselves
• clarify the complaint
• determine the salient points within the complaint
• reiterate the importance of consent with the complainant

Seek the written consent of the patient or their representative to allow the receiving agency to send a copy of the complaint to other agencies involved. Confidential information should not be shared without such consent. If written consent is not possible, verbal consent should be recorded and a copy sent to the complainant.

Offer a single reply, on behalf of all the agencies involved, from the agency against whom the bulk of the complaint has been made (lead agency); however, if the complainant chooses and or in extreme circumstances, where this is not possible, a separate response should be sent from all the agencies involved in the complaint, with the receiving agency monitoring the process of each response.

Upon receipt of the patient or their representative’s consent, a copy of the complaint letter and the receiving agency’s responses will be sent immediately, but in any event no later than within 48 hours, to the other agencies involved in the complaint.

The lead will be taken by agreement between the respective complaints managers but will usually be the agency against whom the bulk of the complaint is made. Irrespective of lead responsibility, however, each body retains its duty of care to the complainant and must handle its part of the complaint in accordance with its own regulated procedures. Where agreement to identify the lead is not possible, the relevant directors should seek to reach agreement. The responsibilities of the lead agency are detailed later on.

If the complainant does not want the complaint forwarded to other involved agencies, the receiving agency will inform the complainant of a named person, address, and telephone number for each part of the complaint should they wish to pursue it. The respective agencies will then investigate the complaint via their respective complaints’ procedures.

19.5.6 If the complainant does want a co-ordinated response

• The lead agency will obtain responses from all the organisations involved and prepare a final response to the complainant.
• The complaints managers for each agency will co-ordinate any requests for responses or information to the lead agency, ensuring that agreed deadlines are met.
• The local authority will deal with its part of the complaint under the Social Services Regulations and cooperate with the NHS body that received the complaint with the aim of providing a co-ordinated response and resolving the entire complaint.
• The agencies should consider a joint meeting with the complainant if this will facilitate a more effective outcome. Joint conciliation may be considered.
• The complainant must be kept informed of any delays. If difficulties arise with meeting the relevant timescales, the complainant should be consulted at the earliest opportunity and agreement sought in writing, or, if not possible, verbal agreement should be recorded, to any extension of the timescales.
• The final reply must identify which issues relate to which agency, state the complainant’s right to refer the matter to a named regulatory body should they wish to pursue the complaint further and be approved by the other agencies involved before being sent.
• The chief executive of the lead NHS agency, or the responsible manager of the local authority, must sign the response.
• Should the second stage of the NHS and or social services complaints procedure be requested, the agencies will liaise and separate if necessary, keeping the complainant informed.

19.5.7 Summary of responsibilities of the lead agency

• Identify the responsible agency for each aspect of the complaint.
• Consider whether a single response on behalf of involved agencies would be feasible.
• Discuss and agree methods of effective communication between the respective complaints managers throughout the process.
• Agree timescales with the complainant and other agencies. Joint handling of a case should not affect the need to meet statutory deadlines for providing a response to the complainant, and both agencies should seek to avoid any unnecessary delay.
• If difficulties arise with meeting the timescale, the complainant should be consulted at the earliest opportunity, and agreement sought in writing regarding how to proceed.
• Keep the complainant updated on action being taken.
• Answer any queries during the process.
• Ensure a co-ordinated and comprehensive response is received by the complainant following investigation(s).
• Identify any learning points that arise from the complaint and how these might be shared between the complainant and the other agencies.

19.5.8 Compliance

There is an expectation that the organisations and or agencies highlighted in point 2 of this document will comply with the agreed protocol, and or national directives.

19.5.9 Review of protocol

The respective heads of complaints will review this protocol every twelve months.

Chief executive sign-off (individual respective organisations)

19.5.10 How joint complaints are handled between organisations

19.5.10.1 Inter-agency complaints procedure

1. Complaint made to agency.
2. Agree lead and identify responsibility for each aspect of complaint.
3. Obtain consent (to be request within five days of receiving) to share complaint with other agencies.
4. Consent obtained?
   • No, advise complainant unable to respond to all aspects of the complaint, investigate aspects of complaint within restrictions and respond to complainant with agreed timescale (refer to individual complaint plan)

1. Yes, share complaint with other agencies.
2. Agree if response will be joint or separate.
3. All agencies to investigate within timescales.
4. Respond to complainant with agreed timescale (refer to individual complaint plan).

• Appendix E1 Complaint letter (staff access only) (opens in new window)

19.6 Appendix F Joint complaint between agencies North Lincolnshire

Protocol for the handling of complaints or comments or concerns or compliments that involve more than one organisation Humber Making Experience Count (MEC) Group.

19.6.1 Introduction

This protocol applies to feedback (complaints, comments, concerns and compliments) that require coordinated handling across organisations. It is approved of and agreed to by the organisations named below. The protocol is to be used by these organisations to address all issues falling under the making experiences count procedure that involve two or more of them.

19.6.2 Principles

The provision of health and social care services is an increasingly complex arrangement of inter-agency responsibility. Patients, their careers, friends, and relatives cannot be expected to have a detailed understanding of these relative responsibilities and should not have to navigate their way through them in order to have their feedback addressed. This protocol is intended to ensure that any feedback about a jointly provided service or that involves services provided by more than one organisation is dealt with seamlessly, promptly, and clearly through a single coordinated process. Complainants will be given the advice and assistance they need to make the experience as straightforward as it can be.

The protocol aims to promote open and honest communication with patients and their carers as soon as possible following an incident and will follow the principles identified in each NHS organisation’s “being open” policies and procedures. It also should enable a fair, rapid, open and sensitive response to feedback that respects people’s human rights and diversity.

This protocol will require:

• openness and co-operation between agencies at each stage of the process
• a designated lead and contact for the complainant
• clarity about the way in which each issue will be addressed
• single response
• shared learning

19.6.3 Process

19.6.3.1 Receiving the complaint

• Feedback can be made verbally or in person or in writing at any organisation. Front line colleagues should be aware that they can take issues relating to other organisations and that representatives should not be asked to make their feedback in another form or at another
• Any feedback that involves more than one organisation should be passed to the person within the organisation designated to deal with these issues (referred to in this document as the complaints
• The patient safety, carer and communities lead will be responsible for co-ordination of the complaint along with their counterpart in the other organisation(s).
• The representative should be made aware of any relevant advocacy

19.6.3.2 Establishing the lead

For each feedback it will be necessary to establish the lead organisation. The complaints manager for the lead organisation will take responsibility for managing the feedback handling, providing the response, and keeping the representative informed.

The lead organisation will be that which:

• is responsible for an integrated service
• has responsibility for most issues in the feedback
• is accountable for the most significant issues
• the representative requests
• received the feedback, should the issues be evenly divided
• is determined by the respective Lead Investigators

In addition, the representative’s wishes can be considered.

If feedback is received by one organisation, which they have no authority to investigate, the lead investigator will contact the representative within 2 working days and advise them that the feedback will have to be forwarded to the relevant organisation and seeking their consent for this.

19.6.3.3 Grading

A feature of the making experiences count process is the initial impact or risk assessment. This assessment looks at the potential significance of the issues raised by the feedback. It begins to determine the means by which the feedback will be addressed by allocating a grading. This process of grading the feedback cannot be carried out by one organisation on behalf of another and therefore must be conducted by each of the organisations concerned in co-operation. It will be the responsibility of the lead organisation to coordinate the process, but each organisation is accountable for the grading of issues relating to its own services. Where it is necessary to contact the representative for the purpose of grading the complaint agreement will be reached between complaints’ managers about how this is best done to avoid repeated contact.

19.6.3.4 Planning for resolution

Clarity will be agreed for addressing the issues raised. This will:

• set out each element of the feedback
• state how each element will be addressed and by whom
• establish timescales
• record the preference for method of contact, for example, in person, in writing
• agree advocacy involvement where appropriate
• establish the relevant consents (consent should be sought only once and should apply to all organisations involved)

In addition, clear agreement should be reached about the process of adjudication, arrangements for the response and organisational sign off.

It is the responsibility of the complaints manager in each organisation to ensure that the necessary people, records, procedures are available to the complaint investigator, without separate requests having to be made, and check that appropriate consent(s) have been received.

19.6.4 Response

It should always be the aim to have a single response to inter-organisation feedback. In some circumstances this may not be possible, for example if one issue is going to take significantly longer to deal with than others. Representatives should always be advised of this as soon as possible.

If the feedback requires adjudication or management meeting again this should be a joint process to facilitate the single response. If adjudication cannot be held jointly, they should take place within a timescale that would not prolong the response. The appropriate managers in each organisation must agree or sign off the responses before they are sent.

19.6.5 Findings

If there has been no formal adjudication then the lead manager should seek to identify, with the officer or officers who handled the feedback, whether there are any identified learning issues or actions. The manager will forward to the relevant organisation. Learning from feedback is a vital feature of the process and inter-organisation feedback handling offers an opportunity for organisations to learn from each other. The process of adjudication should ensure that issues requiring action or service improvements are identified. If the lead complaints manager is involved in the adjudication process, they should ensure that any learning points or identified actions are forwarded to their counterpart in the relevant organisation.

The lead complaint manager will follow up with user feedback or satisfaction surveys to the representative.

19.6.6 Consent to information sharing

In order to deal with feedback effectively it will be necessary for organisations to make information that they hold on to individual patients available to investigators from other organisations. Similarly, they will be required to give access to internal policies or procedures.

In respect of personal information this must be handled in line with the principles of the Data Protection Act, Caldicott and any confidentiality policies the respective organisations may have. Investigators should also be aware of their responsibilities in respect of confidentiality.

Consent to share information must be sought from the representative and, if different, from the patient. If the patient is deemed not to have capacity in this respect, then consent can be sought from their representative.

Wherever possible consent should be given in writing, if this is not possible consent should be recorded carefully on file. Consent should be sought only once for each investigation and should apply to each organisation involved.

If consent is not given to share information, then it should be explained to the representative that they can:

• take the issues direct to the organisation concerned
• pursue their issues through the joint route but with the understanding that the investigation will be compromised through lack of access to information
• withdraw feedback that cannot be effectively looked into without access to some records

Once consent to access to information is given organisations should make every effort to ensure the requested information is readily available to the investigation. This includes verbal information from the colleague of the organisation.

Information that is made available to the investigation of a complaint must only be used for the purpose for which it was obtained. Only information that is relevant to the feedback and its investigation should be shared.

19.7 Appendix G Standard operating procedure: complaint relating to medical colleagues

• All letters of complaint are emailed to the chief medical officer, by the patient safety, carer and communities administrator; copied to the director of postgraduate medical education within 3 working days of receipt within the patient safety, carer and communities administrator.
• The chief medical officer or director of post graduate medical education will identify any further circulation for example, to the director of postgraduate medical education
• The chief medical officer will assess if there has been any medical involvement which relates to the complaint and advise the patient safety, carer and communities team within 10 working days.
• Where there has been medical involvement, the chief medical officer will nominate a medical investigating officer.
• The patient safety, carer and communities administrator will email the patient safety, carer and communities investigator the complaint letter, draft response letter template, and action plan template and advise the patient safety, carer and communities investigator, when a draft response is required by.
• The patient safety, carer and communities investigator will also be informed that staff statement must also be returned with the draft response and action plan. This will be copied to the care group director for information.
• On completion of the complaint, the patient safety, carer and communities administrator will email the final response letter to the lead investigator and will chase for the action plan and or statements if these have not yet been received.
• On completion of the complaint, the patient safety, carer and communities administrator will email the final response letter to chief medical officer and executive medical director for use at doctor annual appraisals as indicated.

19.8 Appendix H Risk matrix

19.9 Appendix I Guidelines for writing a report of event

Colleagues who have been involved in an event which results in a complaint, may be asked to write a statement in order that facts about events are made clear.

The following is intended as practical guidance for anyone asked to write a factual statement:

Essential details to be included:

• write in black ink or 12-point Ariel typescript on A4 paper
• name of person (in block capitals) making the report, position, pay band, and area of work
• date and time of event or incident
• full name of any other individuals involved, for example, patient, visitor, and other colleagues, or any person in the vicinity at the time
• detailed account of events and time that they occurred
• signature
• date of making statement

Detail a factual account of your personal involvement. How, why, and when were you involved?

All detail should be in chronological (date or time) order. Refer to any records made. Are there any inconsistencies between the records in question and the content of your statement? Identify other people involved.

Only record information involving others, that you saw and or heard personally. Comment on each point in the complaint regarding your own involvement. State the facts and avoid opinions. Always attach any supporting documentation.

If you require assistance, seek advice from your colleagues side organisation, or if you deem it to be appropriate, your immediate line manager.

If you keep a copy of your statement, please ensure that you respect guidelines (Caldicott) regarding the use or retention of confidential patient information.

19.10 Appendix J Definitions

19.11 Appendix K Diversity monitoring form

• Appendix K Diversity monitoring form (staff access only) (opens in new window)

19.12 Appendix L Guide for writing a letter of apology

19.12.1 Guidelines for writing a letter of apology to a complainant

Occasionally, colleagues who have been involved in a complaint and are named in the complaint may be asked to write a letter of apology to the complainant. It is sometimes appropriate to do so and can help to reach a resolution with the complainant. When such letters have been written previously, they have been recognised by the Parliamentary and Health Services Ombudsman as not only good practice, but over and above what they would expect from a trust.

The following is intended as a practical guidance for anyone asked to write such a letter and for their manager. Whilst these may all seem obvious; they can be easy to overlook when you may be feeling anxious about writing such a letter.

19.12.2 Guidelines for colleagues writing the letter

Remember that saying sorry is not an admission of liability but an expression of your empathy with the recipient.

You may feel that you have done nothing wrong; you may in fact have done everything to the best of your ability and according to policy and procedures. Nevertheless, something in your actions or behaviour has caused this person distress, anxiety, or added to their bereavement, for example:

• consider how you would feel if your roles had been reversed
• think carefully about your response and you may wish to write out a draft version first
• consider if you were the one receiving the letter:
  • how would it come across?
  • would it sound defensive?
  • would it sound sincere?
• make sure that you include the “niceties” of letter writing; address it to “Dear Mrs Smith” for example and sign off “Yours sincerely”
• check your spelling, in particular, check that you have spelled the recipient’s name correctly
• check the grammar of the letter, spelling and grammar may not seem important, but errors in these will make the letter seem rushed and therefore insincere

19.13 Appendix M Guide for investigators completing complaint responses

19.13.1 The complaint format

Brief letter:

• address needs to be added even though it is going via email
• pulling out the salient points
• providing reflections on findings
• standard phrases
• easy read language
• consider the audience
• not repeating the details of the investigation
• should not be more than 2 pages long

Layout:

• 5 spacing
• Ariel 12 unless the person has specific needs
• short paragraphs

Appendix A:

• investigation always goes into the appendix
• refer or provide brief detail of to the questions being asked or comments being made by the complainant
• subject heading

Appendix B:

• always include a care plan if action or learning identified

19.13.2 Care plan example

Ref number:

19.13.3 Beginning

• Thank you for raising your concerns with us.
• I write further to my letter dated 22 February 2023, regarding your concern that.
• Please accept my sincere condolences following the death of your father. We want to provide the very best care for all, and it is clear that we have lessons to learn from our support for your family.
• I am writing to you further to my letter dated 13 March 2023. I understand that your concerns are.
• I am writing to you following the complaint made about the service and care you have received from (insert).
• I am writing to you following your complaint regarding the care and treatment received by you between (insert) and (insert) from (insert).
• I am writing to you following your complaint about the service and responses that both you and your daughter (insert) have received from (insert).
• The information below is about your letter dated (insert) and includes responses to the additional information you shared during telephone discussions on (insert).

19.13.3.1 Consent (to complain on behalf of others)

Thank you for sending signed consent from (insert), which confirms that you may pursue a complaint on her behalf and in so doing may receive information, some of which may be confidential to (insert).

19.13.3.2 Advocacy

I understand that you are being supported with your complaint by (insert) from (insert) advocacy and that you have signed a consent form, confirming that (insert) may pursue the complaint on your behalf, hence this reply is copied to (him or her).

19.13.4 Content

19.13.4.1 First section

• As part of the investigation undertaken, we have reviewed the healthcare records and spoken with the relevant colleagues involved with you (insert) during (insert).
• I am advised by the team who have reviewed the record.
• The appendix seeks to provide information tackling each issue you raise.
• The context to your complaint would appear to be (insert).

19.13.4.2 Main content

• We want to provide the very best care for all, and it is clear that we have lessons to learn from our support for your family.
• In places it is clear that whatever the intention of action by our colleagues, we fell short of our own standards. For example (insert).
• At other times our communication did not meet my expectations, specifically (insert).
• The issues you raise suggest serious failings on our part. We will be making immediate changes as a result.
• We would like to apologise for the inaccuracies in the outcome letter.
• Discharge planning is an important part of providing care to our patients. It supports families and carers at a difficult time, and we should have communicated it a way that you and your family felt was appropriate and included you. I apologise that we got this wrong.
• I should be clear from the outset that we do not agree with your view of your experiences. I understand that this may be distressing for you, and my intention is solely to be clear with you with what our enquiries have concluded.
• We apologise for your experience of this. We have included below information from the assessments and decisions made regarding the equipment provision.
• I quite understand that you are concerned by (insert).
• In so far as you had cause to complain about our teams, our investigation finds that they acted in line with good practice and in your best interests. Specifically (insert).
• In essence our investigation has concluded that the actions taken at the time were consistent with local and national safeguarding practice.
• The expectations of how colleagues should respond and act upon information such as you had discussed at the time with the practitioner about (insert), should have been (insert).
• The investigation has found that decision-making around medication was based on research and NICE (National Institute for Health and Care Excellence).
• In places it is clear that we again fell short of our own standards.
• Communication around (insert) care was both delayed and at times poor.
• This is not the level of communication I would want to see from our services.

19.13.5 Learning

• We have already implemented changes to effect improvement by (insert).
• We have also addressed this in one-to-one supervision with the colleagues involved and will be regularly monitoring improvement through auditing.
• As a result of your feedback, we are looking at how we can improve the communication process of (insert).

19.13.6 Summary

• I would hope that the candour and detail of our response reflects our concern to improve. I have discussed how we learn from complaints with the unit’s service manager (insert).
• I am confident that we have looked with appropriate seriousness into your concerns. I understand that you may disagree with the findings of our investigation.
• Your complaint and the concern you voice on behalf of your family, have been taken extremely seriously. My letter describes changes made and to be made as a result.
• The investigation has been as thorough as possible and has focused upon the relevant health records.
• Information and advice have been sought from the trust’s safeguarding colleagues and the current head of service within (insert).

19.13.7 End

• If you wish to discuss this further and, or arrange a meeting with the appropriate trust representatives, please do not hesitate to contact Amanda Scott, Patient Safety, and Investigation Complaint’s Secretary, in the first instance. Amanda will do her best to help and discuss the options available for resolving your complaint. You can contact her by telephoning the Patient Safety and Investigation team on 07967 793306.
• If you feel that there is nothing more that we can do to answer your complaint, but you still do not feel satisfied, then you may also contact the Parliamentary and Health Service Ombudsman (PHSO) to ask for a review of your complaint and I have enclosed a leaflet for your information. For further information or guidance about the process available, please do not hesitate to contact the Patient Safety and Investigation team, on the telephone number detailed above.

19.13.8 Additional areas

19.13.8.1 Apologies

Apologising is not an admission of liability nor is it disbelieving our colleague who says (insert) never happened.  It is simply owning the distress someone describes.  We never intend that distress so are happy to apologise.

• I apologise that we made a mistake.
• We regret that this occurred.
• We apologise for your experience of this.
• We would like to apologise for the inaccuracies.

19.13.8.2 Other bodies, GPs, hospitals, and commissioners

We should always be balanced in our comments about others.  It is not our place and not helpful in implying it is someone else’s fault.

19.13.8.3 The so what

Learning is key and sharing the learning even more important, people raising concerns often want confidence that we have heard them and that something will be done to stop a mistake reoccurring.

We need to look for ways to offer that assurance in closing letters without it being formulaic.

Action plans must be meaningful and clear. Written in a way patients and families or carers will understand.

19.13.9 Ending the complaint

19.13.9.1 Sign off

Name and signature should always be framed as mostly lower case:

Yours sincerely
Toby Lewis
Chief Executive

19.13.10 Appendix M1 to M6 Complaint examples

• Appendix M1 to M6 Complaint examples (staff access only) (opens in new window)

19.14 Appendix N Member of parliament enquiries flow chart

19.14.1 Day one

• The letter will be received into the chief executive’s office from the MP.

19.14.2 Day 3

• The letter will be triaged by the chief executive.
• If the letter is identified as a compliant it will be sent to the complaints administration team where the letter will follow the formal complaints procedure.
• If the letter is identified as a non-complex response see the steps below.

19.14.3 Day 3 to 10

• The executive assistant prepares draft response for chief executive. The chief executive reviews and amends letter as required. Letter is sent to member of parliament.

19.14.4 Day 10

• Copy of letter sent to care group(s) for information.

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Document control

• Version: 19.
• Unique Reference number: 314.
• Approved by: Clinical policy review and approval group.
• Date approved: 1 October 2024.
• Name of originator or author: Head of patient safety.
• Name of responsible individual: Chief nurse.
• Date issued: 9 October 2024.
• Review date: 31 October 2027.
• Target Audience: All colleagues (including temporary colleagues).
• Description of change: In line with local review process based on recovery plan and complaints annual report, including internal audit recommendations and action.

Page last reviewed: December 10, 2024
Next review due: December 10, 2025

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