North Lanarkshire and South Lanarkshire CHPs Feedback, Comments, Concerns and Complaints Annual Report 2012/13

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1 North Lanarkshire and South Lanarkshire CHPs Feedback, Comments, Concerns and Complaints Annual Report 2012/13 1 Executive Summary The Patient Rights (Scotland) Act 2011 gave users of the NHS the legal right to give feedback, make a comment, raise a concern or make a complaint. In the past, this Annual Report has focused on reviewing performance in managing complaints received by the CHPs, comparing this with the experience of previous years. Selected data have also been provided on concerns raised with the Patient Affairs Manager. A range of mechanisms is available to service users and their carers to offer feedback or make a suggestion or comment about services. Much of this is unrecorded, for example thank you cards given to ward staff; other feedback can form part of a discussion directly with staff or be given in writing. There is currently no mechanism for recording all of such feedback. During 2012/13, there were 209 Hospital and Community Health Service (HCHS) complaints compared with 117 in 2011/12, an increase of 79%. It is not possible at present to compare this with trends in other Boards as national data is not made available until the autumn. However, this figure should be taken within the context of the many thousands of contacts between staff and service users and carers. The main issues raised in HCHS complaints continued to reflect historical local and national experience: clinical treatment (34% of issues raised) and staff attitude, behaviour or communication, both oral and written (29%). The national target for responding to complaints is 20 working days. This was achieved in 88% of cases, an improvement from 76% in 2011/12, and compares favourably to the national average of 65% in 2011/12 (latest available data). When the response is sent to a complaint an offer is generally made to the complainant to meet with senior staff if they have any outstanding concerns. However, complainants have the right to raise the issue with the Scottish Public Services Ombudsman (SPSO). During 2012/13, the SPSO issued 7 decision letters related to HCHS complaints. No reports were laid before Parliament. A review of complaints management across NHS Lanarkshire was concluded in March, resulting in the implementation from April of revised arrangements for senior clinical input to HCHS complaints and the introduction of six-monthly stocktakes. These stocktakes will consider the performance in the management of complaints; trends in issues and their association with staff groups, locations and directorates; the extent to which the management of the complaints process ensures that investigations are carried out which are fair, thorough and the findings are in a language that a lay person can 1

2 understand; and the extent to which the management of the complaints process and learning from it can provide evidence that it leads to changes in systems and practice The Patient Rights (Scotland) Act 2011 also introduced a responsibility on Family Health Service providers to provide NHS Boards with, and on NHS Boards to collect, data on feedback, comments and concerns about the services they deliver. The focus during 2012/13 was on developing and implementing processes to collect data on complaints. At the time of writing this report 79% of practices had submitted data. The SPSO routinely provides NHS Boards with copies of decision letter and reports on complaints they have received about FHS providers. During 2012/13 NHS Lanarkshire received 16 decision letters relating to GPs and Dentists. Where the complaint was upheld and/or recommendations made, NHS Lanarkshire liaised with the practices to ensure that the recommendations were implemented. 2 Hospital and Community Health Services (HCHS) 2.1 Complaints Complaints Received During 2012/13, 209 HCHS complaints were received (North 119 and South 90). This represented an increase from 117 (North 77 and South 40) the previous year. 10 of these were not acknowledged within the national target of 3 working days. All Units have been reminded of the need to forward all complaints to the Patient Affairs department for acknowledgement without delay. The breakdown of these complaints is set out in the table below. The figures in brackets are for 2011/12. Included in the 2012/13 figures for South West Unit are 22 complaints received from prisoners at HMP Shotts about their healthcare, the responsibility for which was assumed by NHS Lanarkshrie in November The issues raised in these complaints are discussed at Hospital & Community Health Services North Lanarkshire CHP South Lanarkshire CHP North West Unit 17 (12) South West Unit 55 (30) North East Unit 48 (39) South East Unit 35 (10) MH & LD 54 (26) Total 119 (77) Total 90 (40)

3 2.1.2 Complaints Correspondents The graph below illustrates the source of complaints by correspondent, the majority of which came from the patient themselves: this differed significantly from last year. Where a complaint was received from someone other than the patient, consent was sought from the patient or (where they had died or was incapable of giving consent) their next of kin before the complaint was investigated. Approximately a fifth of all formal complaints (21% for 2012/13; 23% 2011/12) were received via Issues Raised in Complaints For national statistical purposes a maximum of three issues may be recorded for each complaint received. A detailed breakdown can be found in Appendix I. Overall the number of issues recorded rose from 181 in 2011/12 to 350 in 2012/13. The main issues continued to relate to: Staff attitude, behaviour and communication, which accounted for 29% of the total; and Clinical treatment, 34% of the total. National Education Scotland and the Scottish Public Services Ombudsman has recently developed an e-learning tool to support staff in handling feedback, comments, concerns and complaints, launched in May. The tool is being assessed to identify how it might be used to positively enhance staff interaction with patients and their carers. Other themes identified by the Units were: The products supplied through the Continence Service: a new contract and changes to the ordering process have since been introduced. Difficulties with the telephone system for the Sexual Health Service which have since been addressed. The withdrawal of the toe-nail cutting service. The waiting time for an appointment with the Lanarkshire Autism Diagnostic Service. Disagreement with the treatment / care plan by patients using the Mental Health service. 3

4 Complaints by prisoners at HMP Shotts about access to dental services, which have been addressed. Delivery of the Out-of-Hours Service following public holidays. The appointment system introduced as part of the treatment room review Responses Sent to HCHS Complaints The national target of replying within 20 working days was achieved in 88 % of HCHS complaints. This compares to 76 % in 2011/12. Response 2012/13 Total in days North Lanarkshire CHP South Lanarkshire CHP (85%) 84 (93%) Total sent Outcomes to HCHS Complaints National arrangements require that a judgement be taken as to whether or not a complaint was justified. This can be a subjective decision but is one that is taken as objectively as possible by the Patient Affairs Manager. The percentage of complaints fully upheld decreased from 22% in 2011/12 to 20% in 2012/13. Details of actions taken on specific complaints can be found in Appendix II. Outcomes 2012/ 20% 56% 24% upheld upheld in part not upheld Any areas for improvement and learning points arising from complaints are highlighted and the Unit General Manager is required to report on actions taken. When a complainant is unhappy with the response they receive a meeting is offered with senior staff to attempt to fully resolve the complaint. An indication of actions taken in light of complaints can be found in Appendix II. 4

5 2.1.6 Alternative Dispute Resolution Alternative Dispute Resolution (ADR - also known as mediation or conciliation) was introduced into the complaints procedure as a result of the Patient Rights (Scotland) Act It is currently funded nationally by the Scottish Government and provided by the Scottish Mediation Network. The Patient Affairs Managers participated in an awareness raising event on ADR in July 2012 delivered by the Scottish Mediation Network. There were no complaints about HCHS services in which alternative dispute resolution was used. However, senior staff of NHS Lanarkshire are available to meet with complainants in an effort to resolve their complaints. Independent advice and support is also available to complainants through the Patient Advice and Support Service, PASS (see paragraph 4 below) Scottish Public Services Ombudsman Complainants have the right to appeal directly to the SPSO should they be dissatisfied after the conclusion of local resolution. In not all cases does the SPSO advise the Board that a complaint put to him is not to be investigated. The information in this report includes only those cases that the Board has been made aware of. During 2012/13 the SPSO issued no reports relating to HCHS services. However, in accordance with his revised way of working, he issued 7 decision letters, 2 of which were upheld and contained recommendations. Details of these decision letters are set out in Appendix V. 2.2 Concerns Concerns Received Individuals may have concerns but not wish to pursue them through the formal complaints procedure. The majority of these will be resolved directly with ward staff. However, in order to gain a broader picture of patient opinion, concerns raised with and resolved through the Patient Affairs Manager are also recorded. The breakdown of these concerns is set out in the table below. The figures in brackets are for 2011/12. The significant year-on-year increase is felt to relate to improved recording practices. Hospital & Community Health Services North Lanarkshire CHP South Lanarkshire CHP North West Unit 13 (2) South West Unit 7 (4) North East Unit 16 (1) South East Unit 13 (2) MH & LD 14 (5) Total 43 (8) Total 20 (6) 5

6 2.2.2 Issues Raised in Concerns Using the same ISD categories for formal complaints, the principal issues raised in concerns can be found in Appendix I. As can be seen the numbers in each category are small. In addition to these were a reported 438 concerns raised in relation to prisoner healthcare. These have largely been related to dental service waiting times (which have been addressed) and medication and pain management issues. There is a proactive strategy in place designed to find frontline solutions to concerns, using face-to-face interventions wherever possible. A separate report is submitted to CHP South by the Healthcare Manager for HMP Shotts. 2.3 Feedback and Comments As previously indicated, there is a range of mechanisms available to patients and their carers to offer feedback or make a suggestion or comment about services. These include: Providing verbal feedback both positive and negative - directly to the staff caring for them. This should generate an immediate response to any issue that needs to be addressed there and then. Depending on the issue raised this may be recorded in the patient s casenotes and / or on Datix. Contacting the Patient Affairs Manager. Again, if an immediate response about clinical care is needed, the matter is referred to the relevant senior member of staff, for example the Consultant or Senior Charge Nurse. The Patient Affairs Manager will follow this up to ensure that the matter has been concluded and records this on Datix. Sending letters or cards directly to staff expressing gratitude for the care received. With the exception of those brought to the attention of the Patient Affairs Manager (who records these on Datix) there is no central record of such letters or cards. Completing a Comments, Compliments and Suggestions leaflet which is widely available in wards and departments and can be downloaded from the NHS Lanarkshire website. The leaflet has a Freepost return address to Board Headquarters where the recording on Datix and response to completed forms is managed by the Patient Affairs staff. A response is given where contact details have been provided. Calling the General Enquiry Line which acts as a source of general information and sign-posts callers. The General Enquiry Line also receives calls from patients and relatives who wish to provide feedback on services they have received. In the latter case the call handler either arranges for the most appropriate member of staff to call them back or provides details so that the caller can make direct contact. Data on the type of calls being received now being analysed with a view to identifying any changes that need to be made to services. Contacting NHS Lanarkshire via the Contact Us pages on the NHS Lanarkshire website. A range of enquiries and comments is received via this format, including positive feedback and complaints. The e-form is automatically sent to the General 6

7 Enquiry Line caller handler s inbox who acknowledges the enquiry and passes it to the most appropriate member of staff to respond to. Participating in the use of the Scottish Recovery Indicator (sri2) within Mental Health Services to gather service user and carer experience to formulate future work plans for service change and development. Providing comments via social media. Moving into /14 NHS Lanarkshire will participate in the nationally-funded pilot to assess the use of Patient Opinion website. Given the variety of ways in which feedback and comments can be received there is currently no single mechanism for collating them and the actions that arise from them. This will, however, be explored in the coming year to identify what can be achieved. Examples of actions taken in response to patient feedback include: New integrated community support team introduced giving access to the district nursing service 24/7. A patient who had a positive experience of their stay in an acute mental health ward agreed to share her story with the staff who had supported her. Funding was put in place for additional staffing and equipment to provide insulin pump therapy. Changes have been made to the way in which assessments are carried out by Paediatric Occupational Therapy staff so that children and their parents are more involved in the process. 3 Family Health Services (FHS) 3.1 FHS Complaints Rate of Return of Data The Patient Rights (Scotland) Act placed an obligation on FHS practices to provide NHS Boards with specific data on complaints about their services on a quarterly basis. In order to facilitate this process NHS Lanarkshire developed and piloted an electronic tool (survey monkey). Collection of the first quarter s data was piloted using this means on November 2012 and full year data was sought in May. At the time of writing 79% of FHS practices had returned data. The return rate by practitioner group is set out in the table below. GDP GMP Pharmacy Optometry No of practices No of returns % returned 67% 83% 92% 73% Further work and follow-up will be undertaken with FHS contractors during /14 to ensure that data is received from all practices. 7

8 3.1.2 Complaints Received FHS practices from which data was received reported having received the following number of complaints: GDP GMP Pharmacy Optometry Apr Jun Jul Aug Sept Dec Jan Mar TOTAL Number of complaints where alternative dispute resolution (ADR) was used FHS practices from which data was received reported having used ADR in the following number of complaints. This service was not provided through NHS Lanarkshire. GDP GMP Pharmacy Optometry Apr Jun Jul Aug Sept Dec Jan Mar TOTAL Response Time Performance Under the Patient Rights (Scotland) Act 2011 the target response time for FHS complaints increased from 10 to 20 working days. Total number of complaints received Number of complaints replied to within 20 working days % replied to within 20 working days GDP GMP Pharmacy Optometry * (100%)* 93% 93% 100% It would appear that 3 complaints that were received by General Dental Practitioners in the latter part of 2011/12 were included in the 2012/13 return. This will be discussed with the practices concerned to ensure their understanding of the requirements. 8

9 3.1.5 Summary of key themes of complaint FHS providers are required to provide a summary of the key themes in complaints they have received. In order to facilitate this, NHS Lanarkshire developed a series of issues categories which were tested for 2012/13. The table below aggregates the data returned. Category GDP GMP Pharmacy Optometry Staff Comments/Attitudes Premises Quality of Advice Communication Treatment 3 Options/Availability Patient Confidentiality Access to Practice 6 68 Service (inc Appts) Clinical (inc diagnosis, referral) Other Quality of GOS 7 Spectacles provided Quality of GOS 2 examination Accuracy of 42 Dispensing Out of stock 26 medicines Summary of actions taken as a result of complaints FHS providers are required to give details of the actions they have taken as a result of complaints. The details given to NHS Lanarkshire are summarised in Appendix IV SPSO When the SPSO issues a report or a decision letter complaints they have received about FHS providers the Board is provided with a copy. During 2012/13 NHS Lanarkshire received 16 decision letters relating to GPs and Dentists. On those occasions when the complaint was upheld and/or recommendations made, the Board liaised with the practice to ensure that the recommendations were implemented. Details are provided in Appendix V. 3.2 Feedback and comments During 2012/13 priority was given to gathering and reporting on complaints. The collection of data relating to feedback and comments will be progressed in /14 to ensure that data is available to be included in future annual reports. 9

10 4 Patient Advice and Support Service Under the provisions of the Patient Rights (Scotland) Act 2011 Patient Advice and Support Service (PASS) replaced the Independent Advice and Support Service (IASS) on 1 April The PASS is intended to provide information and help to patients, carers and members of the public; to raise awareness of their rights and responsibilities when using health services; and to support patients to make complaints if they require it. The national contract is held by Citizens Advice Scotland and the service is delivered locally by a consortium of Citizens Advice Bureaux. The Patient Affairs staff continued to meet with the PASS Patient Advisers to consider high-level details of cases handled. Lorraine Ferguson Patient Affairs Mgr June 10

11 APPENDIX I ALL ISSUES RAISED IN FORMAL & CONCERNS HCHS COMPLAINTS (Figures in brackets relate to 2011/12) Category North Lanarkshire CHP South Lanarkshire CHP STAFFING Attitude/ Behaviour Complaint Handling Shortage/ Availability Communication - written Communication - oral Formal Concern Formal Concern 39 (20) 7 (0) 22 (12) 2 (4) 3 (4) 0 (0) 3 (1) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 4 (2) 1 (0) 3 (0) 1 (0) 21 (1) 9 (1) 14 (7) 1 (0) Competence 4 (5) 1 (0) 5 (1) 1 (0) WAITING TIMES FOR for admission/ 4 (0) 0 (0) 0 (0) 0 (0) attendance for 14 (0) 6 (0) 7 (4) 0 (1) appointment Result of tests 2 (0) 0 (0) 0 (0) 0 (0) DELAYS IN/AT Admission/transfer/ discharge procedures Out Patient and other clinics ENVIRONMENT/ DOMESTIC Premises (inc. access) Aids & appliances / equipment 0 (3) 0 (0) 2 (2) 0 (0) 8 (0) 3 (1) 9 (8) 0 (4) 9 (3) 2 (0) 6 (1) 4 (0) 2 (1) 0 (0) 1 (0) 1 (0) Catering 2 (0) 0 (0) 0 (0) 0 (0) Cleanliness/ Laundry Patient privacy/ Dignity Patient property/ Expenses 2 (0) 0 (0) 0 (0) 0 (0) 3 (2) 2 (0) 2 (1) 1 (0) 5 (1) 0 (0) 0 (0) 1 (1) 11

12 Category North Lanarkshire CHP South Lanarkshire CHP Formal Concern Formal Concern 0 (0) 0 (0) 1 (0) 0 (0) Patient status/ Discrimination Personal records 5 (6) 0 (0) 2 (1) 0 (0) Shortage of beds 0 (0) 0 (0) 0 (0) 0 (0) Mixed 0 (0) 0 (0) 0 (0) 0 (0) accommodation HAI (MRSA) 1 (0) 0 (0) 0 (0) 0 (0) PROCEDURAL ISSUES Failure to follow agreed procedure Policy & commercial decisions (NHS Board) NHS Board Purchasing Mortuary/Post Mortem arrangements TREATMENT 1 (0) 0 (0) 0 (0) 0 (0) 11 (5) 9 (0) 6 (5) 2 (0) 0 (0) 1 (0) 3 (0) 1 (0) 0 (0) 0 (0) 0 (0) 0 (0) Clinical Treatment 69 (48) 16 (6) 49 (24) 8 (0) Consent to Treatment TRANSPORT ARRANGEMENTS 0 (2) 0 (0) 0 (0) 0 (0) 2 (0) 0 (0) 3 (1) 0 (0) OTHER 0 (0) 0 (0) 0 (0) 0 (0) TOTALS 211 (112) 57 (8) 139 (69) 23 (6) 12

13 ACTIONS FOLLOWING COMPLAINT INVESTIGATIONS (April June 2012) North Lanarkshire CHP APPENDIX II Ref / Lead MHLD MHLD Issue Action Review On two occasions Depot Injection was administered wrongly. Disagreement with what has been recorded in his notes Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Outcome Further Action / Comments - including sharing with others Issue raised investigated. Response letter sent to complainant acknowledging issues, upholding one part of complaint where an apology was given by member of staff. Secondly, explanation given that depot injection was not administered wrongly, however apology for change in treatment plan not being fully explained to patient and any distress that this caused. Complaint completed Issue raised investigated. Response letter written to patient via CAB caseworker acknowledging issues raised, giving explanation that patient s subjective experience did not correspond with the objective findings of Psychiatrist which were summarised in medical records. Appointment with alternative Psychiatrist offered. Complaint completed Corrective action has been instigated locally within the team. 26/6/12 None required 9/5/12 1

14 Ref / Lead MHLD MHLD MHLD Issue Action Review Patient clothes going missing and requires a loss form and patient been without his teeth for 7/8 weeks Pain control/over sedation; clothes and jewellery missing; laundry issues and issue with staff member in ward 2 Unhappy with care and other issues in Ward 3 WGH Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Apology for the management of laundry. Brought to attention of staff, will ensure regular checks made. Loss form sent for completion and return Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this Outcome Further Action / Comments - including sharing with others Issue investigated. Response letter sent to wife confirming fitment of new false teeth and reimbursement for the loss of clothing. Reassurance given of replacement personal lockers, apologising for distress caused. Complaint completed Letter sent to family on 13/7/12 apologising for the delay in replying due to the range of issues investigated and staff unavailable as on annual leave Issue investigated. Response letter sent to complainants apologising for inconvenience caused with telephone, issues with patient s dietary intake and the privacy & dignity concerns within the ward environment; outlining action taken to resolve concern of complainant. Complaint completed None required 12/6/12 Better management of laundry requirements brought to the attention of staff Local group taking forward initiatives with the ward environment that will provide alternative meal options for elderly patients and options for supporting privacy & dignity and a safe, clean environment. 13/7/12 25/7/12. 14

15 Ref / Lead Issue Action Review Attitude of staff and delays and diagnosis of condition and delay in operation. An explanation has been provided to address the issues raised in original complaint letter. This explanation acknowledges delays in the assessment of this child, explains the diagnostic process undertaken and advises that the outcome would have been similar even if the procedure had been undertaken sooner. Outcome Further Action / Comments - including sharing with others Staff involved agreed to reflect on their practice, actions and communications with patients relatives and modify their interactions in light of this complaint All staff will be invited to undertake a reflective practice sessions in the light of this complaint Oct 2012 As such the complaint was partially upheld Unhappy with the way spoken to by reception staff at Motherwell Health Centre. Staff involved in incident have been spoken to and reminded of the need to demonstrate courtesy and respect at all times. We have also instigated further customer care training for these staff to ensure that they have the standards required reinforced. Aug 2012 Customer Care training arranged and staff are either attending or scheduled to attend this training over the next few months. The individuals involved in this complaint have been spoken to about their attitude and have been prioritised for training. Customer Care Training to be rolled out to all staff within the Unit involved in reception and other frontline interfaces with the public. March 15

16 Ref / Lead Issue Action Review Child: Unhappy with treatment received at CAMHS. In regards to investigation into your treatment by named staff, I would advise that I have initiated a review and I will contact you again when this is concluded Aug 2012 Outcome Further Action / Comments - including sharing with others Review of care, treatment and interventions completed and all interfaces with the child and mother found to be in line with standard approaches utilised within CAMHS. Similarly a review of case notes reflected good record keeping and notes found to be in good order. An appointment with an alternative CAMHS Team (Hamilton) was arranged which the mother and child failed to attend; despite this being set up to meet the mother s expressed wishes. Communication with mother and with the MSP is ongoing. Meeting between mother and senior management and clinical staff being established Not known NWU Patient unhappy with difficulty experienced in using Centralised line ( ) - Sexual Health line. - wait of 15 minutes on one occasion and 20mins on another - inadequate phone times and long delay for appointments I understand that an average wait time of this magnitude (six minutes and thirty seven seconds) on this particular date may not be ideal and we recognise this. Let me please inform you that we have recently invested additional dedicated resource into the appointment line Patient seemed to be happy with the response. We review all data for the phone line and monitor the longest wait. Ongoing monitoring through the Sexual Health Clinical Governance group

17 ACTIONS FOLLOWING COMPLAINT INVESTIGATIONS (July - Sept 2012) North Lanarkshire CHP Ref / Lead MHLD MHLD MHLD Issue Action Review Transfer and sedation at Udston/poor communication regarding fall. Appointments that were arranged and no honoured/clothes going missing/delayed diagnosis of fractured hip Complaint regarding mother who committed suicide while under the care of Ward 24 Monklands Poor patient care, wrong dose of medication supplied and delay in supplying medication Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Telephone call and letter sent to family on 11/10/12 to inform that Critical Incident Review being undertaken and concluded on 30/10/12 Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. 17 Outcome Further Action / Comments - including sharing with others Issue raised investigated. Meeting held on 3/10/12 with complainant to discuss actions taken to address issues raised. Response letter sent to complainant acknowledging poor communication & giving a full apology for concerns raised & distress caused. Complaint completed. Outcome of CIR and feedback to family initially satisfactory, however subsequent complaint raised by them covering original issues and additional questions. This is dealt with as a new complaint to be concluded March Issue raised investigated. Response letter sent to complainant acknowledging a time delay in patient receiving prescribed drugs & apologising for concerns raised & distress caused. None required 19/10/12 Investigation into staff 30/10/12 actions regarding noncompliance with ECT. Observation Protocol. Introduction of observation form and awareness training regarding enhanced observation following ECT and ensure imbedded in practice. Include ECT observation within MHLD Observation policy Improve staff knowledge and effective use of risk assessment documentation None required 3/10/12

18 Ref / Lead MHLD Issue Action Review Unhappy with Doctor following CIR. Son discharged prior to death Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Outcome Further Action / Comments - including sharing with others Issue raised investigated. Response letter sent to complainant acknowledging issues, giving explanation of doctors management of patient on discharge & apologising for distress caused. Complaint completed. No further action required 31/7/ Attitude of receptionist at Viewpark Health Centre Reception staff in all Health Centres are attending the delivering a perfect service training to ensure that staff attitudes are appropriate and all callers at our facilities are greeted with respect dignity and in relevant timeframes Decem ber 2012 The Unit OSM met with the complainant and explained the action which had been instigated to prevent any repetition. A personal apology was also given to the complainant in respect of the part of the complaint which related to the Health Centre Reception staff Training rolled out to all A&C staff within the Unit. Jan Treatment of daughter re anorexia complaint made back in 2006 to Paed GM and meeting with staff to discuss strategy not taking place. Also information in regards to service provision for young people with eating disorders Contact made with the father of this girl and as a result he has been invited on to a group looking at CAMHS responses to eating Disorders, to provide a parental perspective N/A The inclusion of Mr C on this group has ensured that all issues are resolved. Mr C s input is ongoing ongoing Unhappy with attitude and professionalism of Receptionist for treatment room 18

19 Ref / Lead Issue Action Review Unhappy with treatment of feet. Staff attitude and being interrupted during treatment for staff lunch orders Complaint about car parking at Harthill Health Centre Issue re treatment room processes and pain and bruising following taking of blood Problems experienced with dietician/care and treatment of father relating to treatment and poor communication Unhappy that no records available when attending for MMR booster/appointment cancelled and no notification given An explanation was provided in relation to the assessment of risk levels for Diabetic patients. Staff have been reminded that treatments should only be interrupted in urgent situations which arise for professional reasons. Such interruptions should be kept to a minimum. Estates dept have been in contact with NLC Roads to discuss the practicality of creating a further 7 car parking places at Harthill HC. The Treatment Room processes have been reinforced with all practices to ensure that long delays in accessing Treatment Rooms are avoided. An explanation was provided by the GP that the pain and bruising was not a direct consequence of the actions of the individual Treatment Room Nurse. Dietetic staff reminded of the Power of Attorney authority and the need to take cognisance of this. Explanation provided in relation to the weighing of patients in Care Homes Explanation provided in relation to the policy requirement for records to be available for immunisation. Also explained why delay in accessing records had arisen Dec 2012 Sep 2012 Dec 2012 Dec 2012 Nov 2012 Outcome Further Action / Comments - including sharing with others In relation to risk levels national guidance and systems were being utilised. Estates will follow up with a formal application to obtain the necessary planning and roads authority to proceed. Treatment Room processes were reinforced Explanation of Power of Attorney provided to all Dieticians. Apology Given and arrangements made for a suitable replacement time when LM s immunisation could proceed. All staff across the Podiatry service have been reminded of the need to minimize interruptions to treatment. All practices were reminded of the need to comply with Treatment Room processes. In new paperwork a specific question has been introduced to establish whether a Power of Attorney is in place. Dietetics are appointing a Dementia Champion and Dementia training is being provided to all Dietetic staff. Oct 2012 Mar Oct 2012 Mar Nov

20 Ref / Lead NWU NWU Issue Action Review Waiting time for LADS Delivery of continence pads Inappropriate change to continence pads, questioning if cost saving exercise Explanation for prolonged wait for Autism Diagnostic Assessment provided as was an outline of the measures which are being implemented to bring these waits back to an acceptable level Complainant noted issue with orders had twice activated her order but didn t arrive. Action: contact SCA to ascertain why products weren t delivered. Complainant found new Tena product too small and when changed to a larger one, the new delivery was twice activated but didn t arrive. Dec 2012 Sept 2012 Sept 2012 Outcome Further Action / Comments - including sharing with others Estimated timescale for assessment given. Delivery of pads had already taken place before letter received. System error was resolved by SCA. New product was acceptable to the patient. System error was resolved by SCA. Work is ongoing to deploy additional resources to bring this waiting time back into line. Issue raised at regular meeting with SCA to ensure better communication when issues arise Issue raised at regular meeting with SCA to ensure better communication when issues arise Mar 21/09/12 21/09/12 Action: Contact SCA to ascertain why products weren t delivered. Continue dialogue with complainant to ensure new product is acceptable. 20

21 ACTIONS FOLLOWING COMPLAINT INVESTIGATIONS (Oct - Dec 2012) North Lanarkshire CHP Ref / Lead MHLD MHLD MHLD Issue Action Review Delay in referral being made see consultant in Hamilton. Waiting time for clinic resulting in delayed diagnosis Staff making advances and Dr not being present at review as advised Wait for Psychiatric appointment and concern re mental health deterioration. Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Outcome Further Action / Comments - including sharing with others Issue raised investigated. Response letter sent to complainant acknowledging a time delay in patient s referral from Psychologist to Consultant Psychiatrist. Apology given for concerns raised & distress caused. Complaint completed Issue raised investigated. Response letter sent to complainant acknowledging issues, giving explanation that Dr s can at times be prevented from attending reviews as planned and not upholding the claim that staff member made advances. Complaint completed. Issue raised investigated. Response letter sent to MSP acknowledging issues and giving details of arrangements for appointment with Psychiatrist. Complaint completed. None required 7/01/13 None required 14/12/12 None required 6/12/12 21

22 Ref / Lead Issue Action Review Treatment by GP - lack of test/treatment. Delayed diagnosis and incompetence and medical negligence Unhappy with care and treatment Cancellation of appointments/lack of training in issue of Epipen/attitude and manner of Paediatrician/communication at meeting Error in giving immunisation - wrong jag administered Complaint in relation to CAMHS not upheld Response not receive yet so not clear yet if upheld or not please complete response asap to allow report to be finalised Response not receive yet so not clear yet if upheld or not please complete response asap to allow report to be finalised. Clinic arrangements to be reviewed and amended to avoid this situation being repeated in future. Feb March March Jan Outcome Further Action / Comments - including sharing with others Response to CAMHS issues provided to complainant. This reinforced that good communion, assessment and treatment had been provided to the complainant, other agencies and his mother during the course of his treatment. Complaint not upheld. Additional information and explanation provided for actions of medical staff involved in this potential Child protection situation. Complaint was partially upheld and explanation was provided to the complainant. The system and procedures employed at the clinics were to be reviewed. Complaint upheld and apology provided to complainant. Clinical arrangements reviewed and amended to minimize future risk of repetition. No further action required for CAMHS Findings will be shared with Medical staff in Acute Pediatrics and the Medical Child Protection team to ensure that lessons are learned and that the approach to parents and grandparents involved is sensitive and proportionate Consultant to reflect on operation of the clinic and methods utilized. Hope expressed that the complainant will return to clinic to review improvements in clinic operation. Details of the review of the clinic have been shared throughout the Unit to minimize the possibility for these circumstances to reoccur. Feb June June April 22

23 Ref / Lead Issue Action Review Cancellation of appointment resulting in 38 week wait. Process of decision on who cancelled whether children who have waited under 38 weeks to be seen before patient. Explanation provided to complainant on reasons for cancellation. Complaint upheld. Return appointment was delayed as the case had been deprioritised in light that both parent and child are well aware of allergies and action which should be instigated in emergency situations Feb Outcome Further Action / Comments - including sharing with others Consideration to be given to changing the appointment system to make better use of cancelled appointments and avoid any repetition of these circumstances. Findings to be shared across all Paediatric clinics. May Lack of pain relief administration and communication No notes for patient despite attending clinic. Addicts congregating at entrance to clinic and problems arranging appointment. Complaint responded to and subsequent meetings held with complainant. Further investigation of issues agreed and arrangements initiated. Complaint investigated and appointment organised with records being available. Feb Feb Agreed to provide a comprehensive report on the communication, understanding and compliance with the pain relief regimen in place. Complaint upheld and remedial action initiated. Appointment provided for 13 November where devices were fitted. Review appointment given for 13 January to ensure that devices are functional and resolving the presenting condition. When report is completed this will be circulated to all podiatry Teams to ensure that all relevant lessons are shared across Podiatry Service. Presenting situation and resolution learning shared across Podiatry service June April 23

24 ACTIONS FOLLOWING COMPLAINT INVESTIGATIONS (Jan - Mar ) North Lanarkshire CHP Ref / Lead Issue Action Review MHLD MHLD MHLD Injuries sustained while in Mental Health Ward Physical and medical treatment ignored in Ward 19 MH Burns sustained while inpatient in Ward 19 Disagreement with treatment/care plan; lack of communication Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Outcome Further Action / Comments - including sharing with others Issue raised investigated. Response letter sent to complainant acknowledging issues, giving apologies for deficiencies in record keeping, risk assessments, communication between staff members and failure to engage with the family. Complaint completed Issue raised investigated. Response letter sent to complainant acknowledging issues, giving explanations for appropriateness for patient s transfer to Ward 19 however apologising for deficiencies in the management of medical health needs, assessment, management plans and communication. Complaint completed Issue raised investigated. Response letter sent to complainant acknowledging issues, giving apology that a letter summarizing feedback and outlining arrangements to see another therapist was not done. Complaint completed Review of current practice of observations of patients, recording of information within patient notes and how this written information is then used to support person centred care. Discussion with doctor re building on assessments and ensure that junior doctors know the importance of discharge letters and appropriate communication. 27/2/13 4/4/13 21/1/13 24

25 Ref / Lead Issue Action Review MHLD MHLD Linked to not happy with outcome from previous investigation around death of mother. This complaint is about treatment by CPN and Monklands MH ward of mother - questions regarding lack of support from CPN; Risk management of ECT; mother being left alone; and around escort to and from WGH (i.e. additional issues not dealt with as part of first complaint) Care and treatment affected by refurbishment going on while Patients are still within Ward 19 HM Dignity and response of patient; personal information not relayed in a sensitive and confidential manner Attitude and behaviour of CAMHS staff working in Crisis Team/Disagreement with Treatment care plan Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Investigate issues raised. Reply in writing to complainant giving findings of investigation & explanation outlining any actions taken at time or since & apology for circumstances requiring this. Reception interface with patients reviewed and staff advised to respect patient dignity and confidentiality at all times. Changes made to information imparted to patients at main reception in Health Centre Apology given for staff attitude and inaccurate information conveyed. At initial meeting. May June Outcome Further Action / Comments - including sharing with others Issue investigated. Response letter sent to family acknowledging issues, giving explanations to questions raised and apologising if CIR panel s view that family were happy with level of support was misinterpreted. Complaint completed Issue investigated. Response letter sent to complainants apologising for inconvenience caused with refurbishment of the ward. Complaint completed Complaint upheld and procedural changes made. Sincere apology conveyed to patient. Complaint upheld in part and member of staff counseled about his interface with patients and families Staff advised on frequency of risk assessments. Experience shared with all reception staff across Unit and reminder given that confidentiality and dignity should be respected at all times. Lessons shared across all CAMHS Teams Completi on 2/4/13 2/4/13 April May 25

26 Ref / Lead Issue Action Review Lack of facilities at MacInnes Medical Centre. - treatment room services being dealt with at Bellshill which causes travel problems for those relying on public transport Lack of response received by CAMHS re complaint raised directly with them; assessment and treatment of son by CAMHS service; lack of support and diagnosis / treatment. Infection control measure in Ward 20. Blame for contact and infection of "Staphylococcal Scalded Skin Syndrome" Food and facilities available at WGH on Christmas Eve. CHILD - Unhappy with treatment for son. Delay in diagnosis, disagreement treatment / care plan. Non sufficient pain relief. Explanation provided to complainant about the facilities available in the practice accommodation both now and historically. Also advised regarding areas of service delivery which are currently under consideration. Full explanation of the diagnostic, treatment and care plans provided to Mother. Apology given for oversight in appointing child earlier. Case now closed but should mother wish this can be reopened in future. Explanation of the working diagnosis, potential causes and Treatment plan provided. Reassurance given in regard to isolation and barrier nursing. Availability of catering services available over the festive period also provided. The management of the child s multiple presentations was explained and the amended processes were described. Although there were frequent presentations the blood results on each occasion were normal and a diagnostic outcome was not straight forward. May June March May 26 Outcome Further Action / Comments - including sharing with others Completi on Complaint not upheld Nil March Complaint partially upheld for failure to arrange earlier appointment after telephone contact with Service. Nil. May Complaint not upheld Nil March Complaint was partially upheld. On each presentation the child was seen by a different Jnr Doc, although the medical clerking on each occasion was approp. The instruction to Jnrs that where a child presents on 2 or more occasions with similar symptoms consideration should be given to admission was reinforced. At each medical staff intake the consideration of admission for children who have repeat presentations with the same symptoms will be highlighted. Ongoing

27 Ref / Lead Issue Action Revie w NWU No sedation for scan Lack of explanation and diagnosis Disagreement care/treatment plan Verbal abuse and foul language by NHS driver who was parked in disabled parking place Waiting time for an outpatient podiatry appointment No privacy to speak to Health Visitor. Professionalism of Health Visitor Parents provided with an explanation of the treatment and care provided in Paediatrics. Closer working with Ophthalmology now in place for this type of case. Explanation given that sedation would not routinely be provided for scan. Met with complainants to discuss these issues. Incident investigated language and abuse denied and no witnesses to collaborate. Admission of parking in disabled bay Delay arose due to referral being logged on Waiting list that Podiatry could not see. Waiting list management system reviewed and altered to prevent repetition of this situation. Met with Complainant to explain how this situation arose. Further biomechanics appointment arranged. Team Leader has discussed and counselled the practitioner in relation to her behaviour and professionalism. May Feb April Mar Outcome Further Action / Comments - including sharing with others Complaint partially upheld in relation to the discharge plan and links with Ophthalmology. Complaint partly upheld as drivers admitted parking in disabled space but denied verbal abuse or foul language Complaint upheld. RMS Systems amended to avoid repetition of these circumstances The Review of this case has led to improved communication between Paediatrics and Ophthalmology for this type of presentation. In future Ophthalmology will attend Paeds to allow and expert examination of the eyes to be undertaken. This has been reinforced with all medical staff Staff have been reminded of the need to avoid parking in or obstructing disabled bays in the course of their work and the need to be polite and courteous to members of the public at all times whilst carrying out their duties Nil Completi on May Feb April No further action required Nil