Revised Complaints Policy OP08 Director of Nursing and Midwifery Complaints Management Co-ordinator

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1 RROYAL WOLVERHAMPTON HOSPITALS NHS TRUST AGENDA ITEM NO: 10a Report to: Trust Board Date: 22 nd June 2009 Subject Report By Author Revised Complaints Policy OP08 Director of Nursing and Midwifery Complaints Management Co-ordinator Purpose of Report To inform Trust Board of the revised Complaints Policy OP08 in response to the new Complaints guidance. Implications Financial Human Resources Healthcare Relevant Policy Standards for Better Health A financial impact assessment has been undertaken which has revealed that financial resources will be required for publicity i.e. posters, leaflets and translation of leaflets Nil The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 OP08 Core standard C14 a b c. Review Committee Approval Quality and Safety Committee Date May 2009 Recommendation(s) That the Board approve the revised complaints policy. 1.0 Detail From 1 st April 2009, the Department of Health introduced a single complaints system across health and adult social care, that will focus on resolving complaints locally with a more personal and comprehensive approach to handling complaints. The fundamental objectives are to facilitate effective handling at local level and to encourage organizational learning. The framework for handling complaints will be a two stage process: Resolving complaints locally, getting it right first time Review from the Parliamentary and Health Service Ombudsman The Care Quality Commission who succeeds the Healthcare Commission will have no role in reviewing complaints about the NHS. T:/ Committees/ 1

2 R ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST It is proposed that the Trust introduces a triage system for complaints handling. This is attached as appendix 1 to the policy. 2.0 Healthcare Commission Spotlight on complaints (February 2009). The Healthcare Commission in its third and final annual report makes 12 key recommendations to help all NHS Trust to improve the way they resolve complaints locally: 1. Acknowledge the person s right to complain 2. Ensure that the complaint is assessed upon receipt, so that any concerns about a risk to the safe care of other patients can be identified promptly 3. Clarify what the person s concerns are and manage expectations about possible outcomes to the investigation of the complaint. 4. Consider the various options for resolving the complaint e.g. a meeting or reimbursement of costs. 5. Ensure that the person is kept informed of progress throughout the life of the complaint. 6. Confirm to the person what support is available to assist in making a complaint e.g. the Independent Complaints Advocacy Service (ICAS). 7. Take statements from, and interview if necessary, those staff involved in the events leading up to the complaint, as soon as possible. 8. Where necessary, obtain independent clinical advice on the matters raised e.g. from the trust s medical director or from a clinician at another trust. 9. Ensure that any response letters are written in plain English and free from clinical or technical terminology. 10. Offer an apology if appropriate. 11. Ensure that general learning is taken from specific complaints and is embedded into the system of care for the future. 12. Ensure that Trust boards satisfy themselves that all the above are happening. 3.0 During 2007/08 the Healthcare Commission upheld 30% (2,655) of the complaints received, making recommendations to organisation to help resolve the complaint or improve services such as: Provide an apology to the complainant Hold meetings with relevant staff Offer a clear explanation of the events leading to the complaint Make improvements to a service to assure the complainant that lessons had been learned to prevent a recurrence of the problem for other patients Provide redress, e.g. expenses incurred by the complainant where it is apparent that administrative failings within the trust have unnecessarily prolonged the process of complaining. T:/ Committees/ 2

3 R ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST In 17% (1,545) of cases the Healthcare Commission negotiated with the complainant and the healthcare organisation to return the complaint to a local level with specific action such as: Holding a meeting between the complainant and relevant staff Mediation between the complainant and provider Providing clinical advice from a source independent of the trust. 4.0 The revised Complaints policy emphasises all of these recommendations. T:/ Committees/ 3

4 The Royal Wolverhampton Hospitals NHS Trust Policy Ref: OP 08 Policy Title: Complaints Management Procedure Date of Implementation: January 2001[approved by TB ] Version Date of next review: Director sponsor: Author s Title Policy location: 1.0 Policy Statement April 2009 v April 2012 [or at such time as there is a revision of national regulations] Director of Nursing and Midwifery Complaints Management Coordinator Trust Organisational Policy Folder and Trust Intranet The Royal Wolverhampton Hospitals NHS Trust (RWHT) welcomes feedback from users of their services. Complaints are just one of the many ways in which the Trust receives feedback and should be used to inform us about our patients experiences, to learn from them and improve our services. The purpose of the Complaints Procedure is to enable users of our services, their relatives or representatives, to raise issues of concern related to their care and treatment. The aim of the Complaints Procedure is to satisfy complainants by providing a sensitive, positive and detailed response to matters of concern. A complaint handled well will often restore the public s confidence in our services. At no time will patient s care or treatment be compromised as a result of them raising their concerns. 2.0 Definitions Used Complaint a complaint is an expression of discontent or dissatisfaction requiring a response. Responsible body means a Local Authority, NHS body, primary care provider or independent provider. Local Resolution The first stage of the NHS Complaints Procedure which gives the Trust the opportunity to resolve issues of discontent or dissatisfaction no matter how they are raised. Independent Review This is the second stage of the complaints process and is managed by the Parliamentary and Health Service Ombudsman Mediation independent impartial outsider acting as a go between who seeks to achieve agreement between disputing parties (i.e. The Trust and the complainant) Working Day any day except Saturday, Sunday or a bank holiday. Triage system of determining how complaints should be investigated and by whom Risk Assessment how the Trust assesses the severity of incidents/complaints Page 1 of 50

5 3.0 Accountabilities Following approval the Governance department is responsible for ensuring the policy is made available on the intranet policies page. The Chief Executive is responsible to the Trust Board for ensuring a comprehensive complaints system is in place throughout the Trust. The Director of Nursing and Midwifery is responsible for ensuring compliance with the arrangements made under the Department of Health Guidance. The Medical Director and Director of Nursing and Midwifery are responsible for providing expert clinical and nursing advice/guidance where appropriate and for ensuring action is taken following the outcome of independent reviews by the Parliamentary and Health Service Ombudsman. The Legal Services Manager is responsible for providing advice in accordance with Standing Orders of the Trust including the management of litigation and claims. The Complaints Management Co-ordinator is responsible to the Director of Nursing and Midwifery and Patient Experience Lead for the: day to day co-ordination, monitoring and review of the complaints procedure Quality control of DATIX Initial triage and planning of a complaint for managing the Conciliation / Mediation process in conjunction with the appropriate Mediation Service for co-ordinating investigations by the Health Service Ombudsman. Divisional Managers / Heads of Service are responsible for ensuring that: the policy is implemented within their areas of responsibility complaints are dealt with in line with the Trust s Complaints Management Procedure there are nominated members of staff to investigate complaints Divisional Management Team sign off of responses before they are sent out any recommendations identified as a result of complaints received by their Division are implemented and monitored. any recommendations made following independent reviews by the Ombudsman are actioned appropriately and that they are discussed at Divisional Governance meetings in order that lessons might be learned. Directorate Managers/ Matrons/Head of Department will be responsible for: investigating complaints in their areas of responsibility, preparing responses for the Chief Executive s signature, ensuring complaints are dealt with in line with national/local timescales, ensuring complaints are risk assessed on receipt of a complaint and at the completion of an investigation identifying areas of change, Page 2 of 50

6 making recommendations for change, developing action plans and monitoring outcomes, Ensuring complaints are discussed at directorate Governance meetings in order that lessons learned might be shared and disseminated across the Trust. Ensuring that lessons learned are noted on DATIX All Complaints, concerns comments and compliments received by the Trust will be entered onto the complaints module of the DATIX database system. Each Division/Directorate will have a nominated member of staff who will be trained to undertake the inputting of this data. Front line staff - The prime responsibility of any member of staff is to attend to the patient s immediate health care needs before dealing with the complaint. Front line staff are the most likely to receive complaints from dissatisfied patients or relatives at the time they occur. Many matters that trouble patients can be dealt with as they arise, by front line staff empowered to deal with a complaint on the spot. In such cases the Line Manager should be informed of the action taken. Junior medical staff should advise the Ward Sister or Consultant in charge of the patient, as appropriate, of the action they have taken. Where the front line member of staff is unable to deal with the complaint because it is serious, complex, or warrants a fuller investigation, the matter should be referred to the appropriate Senior Manager / Matron / Head of Department for the service concerned, who may seek the advice of their Clinical Director, Divisional Director or Divisional Manager in the first instance. The Divisional Manager may seek advice from an Executive Director if necessary. Guidelines for staff are available on the intranet or by contacting the Complaints Management Co-ordinator on extension Policy Detail The Department of Health (April 2009) introduced a single complaints system across health and adult social care, which focuses on resolving complaints locally with a more personal and comprehensive approach to handling complaints. NHS and social care organisations are required to deal efficiently with all complaints and to investigate them properly and appropriately, providing complainants with an explanation of the outcome of any investigation into the complaint. The fundamental objectives are to facilitate effective handling at local level and to encourage organizational learning. The framework for handling complaints will be a two stage process: Local resolution Ombudsman The Parliamentary and Health Service Ombudsman view good complaint handling as meeting the following principles: Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement Page 3 of 50

7 4.1 Duty to Co-operate All health and social care organisations must work together to ensure co-ordinated handling of complaints and provide the complainant with a single response that represents each organisations final response. This includes providing information to another responsible body as required or to attend, or ensure it is represented, at any meeting. To aid this co-operation a Protocol for Co-ordinated Complaints Handling Across Health and Social Care Boundaries has been produced (see appendix 4) Complaints that effect more than one division / department In such cases, the investigating officer will be the person responsible for the directorate / department having the major involvement in the complaint. An investigation will be undertaken by the managers of other named directorates / departments, who will forward their response to the investigating officer with responsibility for the overall co-ordination for inclusion in the response to the complainant. That person will be responsible for formulating the overall response to the Chief Executive. 4.2 Time Limit for making a complaint A complaint must be made not later than 12 months after the date on which the matter which is the subject of the complaint occurred, or if later, the date on which the matter which is the subject of the complaint came to the notice of the complainant. The Complaints Management Co-ordinator will have the discretion to waive the above if he/she feels that the complainant had good reasons for not making the complaint within that time limit and, notwithstanding the delay, feels it is still possible to investigate the complaint effectively and fairly. 4.3 Time Limit for responding to a complaint For the purpose of this procedure complaints will be subject to a triage process (see appendix 1) by the Complaints Management Co-ordinator and, depending on the triage rating, the Trust will respond to complaints in the following time frames:- Option A Minor complaints (those of a minor nature traditionally Known as informal complaints) 2-10 days Option B complaints requiring investigation and response 25 working days Option C Complex and/or serious complaints maximum of three months 4.4 Risk Assessment All complaints will be risk assessed in line with the Risk Management Reporting Policy [OP 10] using the Trust s categorisation matrix. The initial grading applied at the time the complaint is received must be reviewed once the investigation is complete. This will be the responsibility of the investigating officer. All significant residual risks must be recorded on the relevant Department s Risk Register. Page 4 of 50

8 4.5 Procedure before investigation acknowledgement and planning A complaint may be made orally, in writing or electronically. Any communication to a complainant may be sent electronically as long as they have consented in writing or electronically for us to do so. If a complaint is made orally the member of staff receiving the complaint will make a written record of the complaint and provide a copy to the complainant. Triage All complaints received by the Trust will be subject to a triage system by the Complaints Management Co-ordinator (or a member of the Patient Experience Team in his/her absence). The Complaints Management Co-ordinator will make contact with the complainant within three days of receipt of the complaint to clarify the issues to be investigated, to discuss a timescale for response and to develop a plan in conjunction with the complainant about how the complaint will be dealt with. Thereafter, the complaint will be passed to the appropriate Divisional/Directorate Team for investigation and response. (appendix 1 & 2) 4.6 Investigation and response All complaints must be investigated thoroughly, fairly, objectively and consistently (i.e. similar circumstances are handled in a similar way). Complaints will be investigated in proportion to the circumstances and seriousness of the issues raised. However, it is important that those investigating a complaint take into account the differing needs and requirements of the complainant and avoid a one size fits all approach. The Trust should act fairly towards staff as well as complainants. This means ensuring members of staff know they have been complained about and where appropriate have an opportunity to respond. (see appendix 3 for process on investigating complaints and 3a for protocol for final response). There are a number of options that can be employed when trying to resolve complaints. This list is not meant to be exhaustive or prescriptive and more than one activity can be used:- Meeting with complainant and any staff involved Involvement of PALS/ICAS Commissioning of an independent mediator Involvement of more senior staff (i.e. Divisional Manager/Head Nurse/Divisional Director Commissioning of independent specialists to undertake a review (i.e. Consultants from other Trusts reciprocal arrangement) Involvement of someone not involved in the department where the incident occurred (i.e. Peer review) Review of records/documentation Providing fair and proportionate remedies is an integral part of good complaints handling. In many cases a prompt explanation and an apology will be sufficient and will prevent the complaint going further. The majority of complainants want to know that we have listened to their concerns, taken action to put things right and have learned lessons from the situation. Page 5 of 50

9 Occasionally however (e.g. when the Trust has got it wrong) we will need to take steps to put things right. This means, if possible, returning complainants to the position they were in before this took place. In cases where it becomes apparent that complaints may lead to clinical negligence claims and these must be discussed with the legal services department. (Appendix 3a gives further detail on responding to complaints) 4.7 Lessons Learned & action plans Where a final response to a complainant identifies the need for changes to practice or other action and contains recommendations, the Divisional Manager responsible for the area in question must ensure that an action plan is produced and the recommendations are implemented within agreed timescales. 4.8 Confidentiality and Consent Confidentiality of patient information is paramount in the handling of complaints. The disclosure of information from complaints should only be made available to:- the complainant the complainant, with the express permission of the patient, where the complainant is not the patient [usually the next of kin or main carer]. the patient s representative where the patient is unable to act for themselves the investigating officer dealing with the complaint those referred to in the complaint the Consultant, where the complaint concerns treatment and / or care No documentation or correspondence about complaints is to be filed in the patient s medical notes. Complaints may be made on behalf of a patient where the patient has given express permission for the complainant to act in their interests. In order for the patient to give consent he / she has to have explicit knowledge that the complainant is acting on their behalf. Exceptions to this rule apply to patients incapable of representing themselves. A child may make a complaint in their own right. If, however, someone else makes a complaint on behalf of a child, the permission of the parents or those with parental responsibility must be sought to the disclosure of information. If a relative or friend is acting on behalf of the patient, the patient must complete a form consenting to the release of information [see attached]. Under no circumstances must confidential information relating to the patient be released to a third party without the patient s express consent. Where a patient is not capable of giving their consent because they are too ill, or they have a mental or physical impairment which prevents them from giving their consent, a suitable representative of the patient can act on their behalf. However, it is important to establish whether the complainant is the most suitable person to represent the patient. The patient may have expressly stated prior to being unable to give their consent that they do not wish any information to be divulged to a named person or persons. Such intentions of the patient must be recorded in the patient s medical records. In such cases, the wishes of the patient must be strictly observed. Page 6 of 50

10 In cases where it is considered that the complainant is not the most suitable person to represent a patient who is unable to act for them advice must be sought from the Complaints Management Co-ordinator or Legal Services Manager. Complaints may be received from visitors about issues they have seen on the ward which do not relate to the patient they are visiting. In such cases the complaint should still be investigated and recorded in the usual way. However, when responding to the complaint it is important that no personal details about the patient are released and the complaint is responded to in general terms only. Further advice can be sought from the Complaints Management Co-ordinator or Legal Services Manager. 4.9 Litigation Cases Where a complainant states an intention to take legal action or has requested compensation, the investigating officer must inform the Legal Services Department. However, unless otherwise advised the complaint will continue to be dealt with under this policy. It should not be assumed that, because a complainant has communicated their complaint through a solicitor, the complainant s intention is to take legal action, unless there is an express intention from the solicitor to this effect. The advice of the legal services department should be sought in any case of difficulty or doubt Disciplinary Cases Where it becomes apparent that disciplinary action is indicated the investigating officer must inform the Human Resources Department. However, the investigation of the complaint should continue to be dealt with under this policy. It will be necessary for the investigating officer to discuss the matter with the complainant and agree a relevant timescale for response. During the investigation, the investigating officer must keep the complainant informed of progress on a monthly basis. The final response to the complainant must be mindful of patient and staff confidentiality at all times. The Complainant should be informed of what has happened, why it happened and that the Trust will do its utmost to prevent a recurrence Administration and Documentation An integral part of good complaints handling is the need for excellent record keeping. Staff should be aware that if a complaint escalates to the second stage it is imperative that the Trust is able to show that we have followed this procedure, have done what we have said we will do and have the evidence to prove this. Further information about the case file and recording complaints on the database is given at appendix Patient Support Patient Advice and Liaison Service [PALS] This service provides patients, their carers and families with on the spot help and information. They will provide advice, help and support to anyone wishing to raise concerns or requesting information. The relationship between the PALS service and the Complaints Management Coordinator should be seamless. However the PALS service will not be involved in the investigation of formal complaints. Page 7 of 50

11 Independent Complaints Advocacy Services (ICAS) This is a service totally independent of the NHS. It offers complainants experienced advocates and caseworkers to help them make a complaint about services provided by the NHS. [Further information can be obtained from Staff support Members of staff who become involved in allegations of negligence or even in investigations of complaints can find it both stressful and traumatic. It is important that we support our staff during these times. Appendix 6 provides further information Vexatious & Habitual Complainers A minority of complainants can be unreasonably persistent or their behaviour is unacceptable. Arrangements for dealing with these types of complainants can be found in appendix The role of the Ombudsman The Ombudsman may investigate a complaint on behalf of a patient if they have suffered hardship or injustice owing to a failure to provide a service, a failure of service, maladministration, or where the complaint relates to clinical judgment. The Ombudsman will not be able to investigate complaints until the NHS complaints procedure has been invoked and exhausted, unless in the circumstances of a particular case he judges that these conditions would be unreasonable. Further information about the role of the Ombudsman and how the Trust will deal with reviews by the Ombudsman can be found in appendix Publicity The Trust will:- display posters at the entrances to the hospital welcoming comments, concerns, complaints and compliments have available a leaflet explaining the process and who they can approach for further information information Folders by Patient Bedsides. Hospital website patient page 4.17 Annual Reports and reporting An annual report on complaints will be compiled which will include:- the number of complaints received the number of complaints well founded the number of complaints referred to the Parliamentary and Health Service Ombudsman a summary of the subject matter of complaints any matters of general importance arising out of those complaints (i.e. how they were handled) actions taken and improvements to services as a consequence of the complaints This report will be made available to any person on request; the PCT who commissions the services as soon as is reasonably practicable after the end of the year to which the report relates. Page 8 of 50

12 In addition, quarterly Patient Experience reports will be presented to:- Quality and Safety Committee Patient Experience Steering Group/Council of Members Monthly Performance report 4.18 Exclusions from this Policy Complaints received which are not required to be dealt with under this policy are as follows:- Complaints from a responsible body (i.e. LA, NHS body, primary care provider or independent provider. A complaint by an employee of a LA or NHS body about any matter relating to that employment *A complaint which is made orally and is resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made A complaint the subject matter of which is the same as that of a complaint that has previously been made and resolved in accordance with the above point. A complaint the subject matter of which has previously been investigated under these regulations, the 2004 regulations, the 2006 regulations or any other previous relevant regulations. A complaint the subject matter of which is being or has been investigated by a Health Service Commission under the 1993 Act A complaint arising out of the alleged failure by a responsible body to comply with a request for information under the Freedom of Information Act 200 (b) A complaint which relates to any scheme established under section 10 (superannuation of persons engaged in health services, etc) or section 24 (compensation for loss of office, etc) of the Superannuation Act 1972 or to the administration of those schemes. Where the Trust decides that a complaint falls under any of the above criteria it is not required to consider the complaint or consider it further under these regulations. However, the investigating officer must notify the complainant in writing as soon as possible of its decision and the reasons for that decision. (*Will not apply in this case) Furthermore, if any complaint under the above criteria is connected or part of another complaint which does not fall under this criteria the investigating officer must handle that part of the complaint under these regulations. 5.0 Financial Risk Assessment A financial impact assessment has been undertaken which has revealed that financial resources will be required for publicity i.e. posters and translation of leaflets. 6.0 Equality and Diversity Impact assessment It is recognized that the Complaints Procedure should apply to all groups of patients. However, it is also recognized that some groups will have to be dealt with differently. Therefore an impact assessment has been undertaken and an action plan developed. This is attached as appendix 9. Page 9 of 50

13 7.0 Maintenance The Complaints Management Co-ordinator will be responsible for ensuring that the policy is regularly reviewed to ensure the policy reflects up to date practice. Amended versions of the policy will go to the Quality and Safety Committee and Trust Management Team for approval. 8.0 Communication and training There is a mandatory requirement for all staff to undertake training in the handling of complaints and this will be provided within the Trust s Induction Programme and the Trust s Mandatory Training Programme. This will include raising the level of awareness of the importance of responding in a satisfactory way and to ensure that staff acquire the appropriate skills to equip them for this purpose For senior members of staff who are required to undertake the investigation of complaints as part of their role, including where appropriate using Root Cause Analysis, more in-depth training will be provided by the Complaints Management Co-ordinator Where staff training is highlighted as part of any investigation by the Healthcare Commission or Health Service Ombudsman the Governance Director for Education will be required to ensure these requirements are brought to the notice of the Board of Education and Training for inclusion in future Trust Training Programmes. The Complaints Management Policy will be available on the Trust internet site. An will be sent out to advise staff of this and an article written for Monday Briefing. Posters and leaflets are also available throughout the Trust. 9.0 Monitoring of Audit Requirements Compliance of the Trust s complaints procedures is reported and monitored monthly as part of the Chief Operating Officers Performance Report to Trust Management Team and Trust Board and quarterly as part of the Patient Experience Report to Quality and Safety Committee in accordance with The Local Authority Social Services and National Health Service Complaints (England) Regulations References Statutory Instruments 2009 No 309 The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 Department of Health Listening Responding Improving A guide to better customer care 2009 Parliamentary & Health Service Ombudsman Principles of Good Complaints Handling, Principles of Good Administration and Principles for Remedy Statutory Instrument 2004 No 1769 the National Health Service [Complaints] Regulations 2004 Department of Health Guidance to support implementation of the National Health Service Complaints Regulations 2004 Statutory Instrument 2006 No 2084 the National Service [Complaints] Amendment Regulations 2006 Page 10 of 50

14 Department of Health: Supporting Staff, Improving Services Guidance to support implementation of the: National Health Service [Complaints] Amendment Regulations 2006 [SI 2006 No 2084] Better Standards for Health / NHSLA Standards Healthcare Commission Complaints Toolkit March 2008 Page 11 of 50

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16 COMPLAINTS & CONCERNS PROCESS FLOWCHART Appendix 1 Action: all levels and disciplines of staff Contact at time of event or issue raised directly with staff and dealt with by next working day -falls outside of complaints process Action: Complaints Management Team Triage and Planning Complaints Manager to acknowledge (verbally or in writing 3 working days of receipt) Advocacy support arranged if appropriate/ required Pass to relevant member of staff (investigating officer) with the agreed way forward with the complainant Disciplinary/ Legal cases to run in conjunction with Human Resources or Legal Services Department Option A Minor ( informal ) Complaints dealt with on the spot or max 10 days Action: All staff, PALS/CMC/ Investigation Manager Telephone call/meeting Advocacy support if required Any member of staff/pic Apology/Explanation Prompt remedy Action Points Written or verbal feedback No outstanding actions Service user unhappy renegotiate plan if appropriate Option B Complaints requiring more details investigation and response resolved in 25 working days Action: Directorate Managers/ Matrons Appoint investigating officer Advocacy support Meeting/local mediation Statement and interviews Action Planning Report writing/feedback Divisional Manager sign off If Service user unhappy renegotiate plan if appropriate or refer to Ombudsman after sign off Option C Complex/Serious complaints Resolved max 3 months Action: Div/Directorate/matron Advocacy support Appoint investigating officer (independent of provider??) Full RCA Action Planning Meeting with complainant Report with covering letter from Chief Executive Service user unhappy re-negotiate plan if appropriate or refer to Ombudsman after sign off ABILITY TO REGRADE DURING PROCESS Action: Division/Directorate Team QA Action: Directorate Team DATIX completed Discussed at Directorate Governance Meeting Reported to Q & S as part of quarterly report/trends identified for services improvements QA Action: Div/Dir Team DATIX completed Discussed at Directorate/Div Governance meeting Reported to Q & S as part of quarterly report/trends identified for service improvements Update to complainant QA Action: Div/Dir Team DATIX completed Discussed at Divisional Governance meeting Action Plans Reviewed Update to complainant 3 months Reported to Q & S /TMT/Trust Board/trends identified for service improvements Update to complainant Action: Complaints Management Team Satisfaction Survey issued, Organisational learning through Governance, Reporting and service improvement identified and monitored by Divisions Page 13 of 50

17 Action: Complaints Management Ream/Divisional Team Further correspondence from complainant following completion of the above previous activity to be assessed to decided whether further work required or close file and advise complainant of next stage Action: CMC/Div Ombudsman Page 14 of 50

18 Appendix 2 THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST Initial Contact Proforma The following proforma should be completed during the initial contact with the complainant. Once the issues have been discussed and the plan for addressing those issues agreed an action plan should be completed and sent to the complainant for review. Complainant s name, address, telephone number Mr/Mrs/Dr/Miss/Ms Patients name, address, telephone number Mr/Mrs/Dr/Miss/Ms etc Patients Hospital No or Date of Birth Preferred method of contact and time:- (i.e. telephone, writing, ) Name of member of staff who contacted the complainant: Date of contact: Third Party Complaints: Consent required: YES/NO LETTER SENT REQUESTING THIS YES/NO Summary of discussion Page 15 of 50

19 It was agreed that the following issues would be investigated: Outcome the complainant is seeking (i.e. apology, explanation) Agreed plan for addressing the issue: Agreed timescale for response: Agreed feedback following investigation (meeting, phone call, letter agree who will send the letter i.e. Directorate Manager/Divisional Manager etc) Complainant informed about ICAS or other support agencies Page 16 of 50

20 Appendix 3 Investigating a complaint (Source: Advice sheet issued by the Department of Health) When something has gone wrong, it is vital to establish the facts about what happened in a systematic way. Although for serious complaints, it may be necessary to involve an independent investigator, most complaints will be looked into by someone from the specialty concerned i.e. the appointed investigating officer. In order to clarify the issues of concern the Complaints Management Co-ordinator, or a member of the team, will initially contact the complainant to clarify the issues to be investigated, to discuss a timescale for response and to develop a plan in conjunction with the complainant about how the complaint will be dealt and what they hope the outcome of making a complaint will be. Thereafter the complainant will be passed to the appropriate Divisional/ Directorate team for investigation and response. All further contact with the complainant will be made by the Directorate Team. The purpose of an investigation is to identify what happened, the sequence of events and identify all those involved who may be able to assist in responding. During the investigation it will be necessary for the investigating officer to obtain comments from those involved in the incident. Attached is a proforma to be used when obtaining statements from members of staff The investigation may identify problems with working practices or procedures and will provide an opportunity to take action to improve the quality of our services. The investigating officer should therefore complete an action plan which should be monitored and reviewed appropriately. When considering how best to resolve a complaint, a number of options can be considered (this list is not exhaustive or prescription and more than one activity can be used): Meeting with complainant and any staff involved Involvement of PALS/ICAS Commissioning of an independent mediator Involvement of more senior staff (i.e. Divisional Manager/Head Nurse/Divisional Director Commissioning of independent specialists to undertake a review (i.e. Consultants from other Trusts reciprocal arrangement) Involvement of someone not involved in the department where the incident occurred (i.e. Peer review) Review of records/documentation When meetings take place, whether with the complainant or with members of staff who are assisting in responding to a complaint, notes must be taken. A proforma for recording these notes is attached. Complaints identified as red risks will be investigated in accordance with the Trust s Root Cause Analysis policy [see Governance Strategy]. Page 17 of 50

21 Proforma for writing statements Two copies of the statement should be made; one to be retained by the author and one to be sent to the manager requesting the statement. Name [of the author of the statement] Status [Job title i.e. Staff Nurse / Ward Manager / Clerical Officer / SHO etc] Contact address [i.e. Ward / Department] Contact number [telephone extension] Name of patient / complaint involved in the complaint. Explain what your involvement with the patient / complaint was:- [Wherever possible itemise the points raised] 1 Attitude 2 Waiting time in clinic 3 Treatment received 4 Etc It is important to include dates and times and wherever possible the names of anyone else who may be able to assist with responding to the complaint. I confirm this is a true record of my complaint Name: Title: Date: STATEMENT MUST BE SIGNED AND DATED Page 18 of 50

22 PROFORMA MINUTES OF MEETINGS WITH COMPLAINANTS [or members of staff] Names and titles of all those present: [i.e.] Mr F Bloggs Complainant / Patient Mrs A N Other Consultant / Clinical Director Mr Facilitator Divisional Manager / Specialty General Manager Mr S Ward Chief Officer, Wolverhampton Community Health Council Agenda / List of Issues to be discussed [Examples as follows] 1. Attitude of member of staff 2. Communication by member of staff to relatives 3. Treatment provided to patient 4. Missed fracture Etc 1. Attitude of member of staff 1a Details of discussion 1b Any action agreed [i.e. further training required] 2. Communication by member of staff to relatives 2a Details of discussion 2b Any action agreed Etc Signed by all those present as a true record of the meeting and dated. Page 19 of 50

23 Appendix 3 a PROTOCOL FOR FINAL RESPONSE LETTERS Reference should be made to the Complaints & Concerns Process Flowchart to establish who will sign off the complaint before sending to the Chief Executive for signature. Please note that the following suggestions are a guide only and you may need to adjust the wording to suit the circumstances. Before writing the final response ensure that all the issues have been identified and investigated. The tone of your letter should be sympathetic, clear and accurate, avoid technical terminology and include apologies as appropriate. All responses should be shared with those complained about and those who have provided information to assist in resolving the complaint. Private and Confidential Dear * Thank you for your letter/telephone call dated (date of original complaint letter). (Name and title of person investigating the complaint) has, on my behalf, investigated the issues you raised in your letter and I do hope you will find our comments helpful. The investigation has included (i.e. discussions with/obtaining statements from etc). For ease of reference I have used your concerns as sub headings. (List those issues of concern which have been identified from the original letter of complaint for example) 1. The care and treatment of your mother Mrs Smith, whilst an inpatient on Ward X Response to include conclusions reached and any actions taken 2. Missing Medical Records 3. Lack of car parking space The following two paragraphs are mandatory for inclusion in your final response and the final response for FORMAL (Option B & C on the Process Flowchart) complaints must be signed off by the Chief Executive. Page 20 of 50

24 I am sorry that you have needed to bring your concerns to my attention and I sincerely hope that my letter has addressed the issues raised to your satisfaction. However, if you feel there are any outstanding issues or you feel it would be helpful to discuss your complaint further, please do not hesitate to contact (name of investigating officer) on (telephone number) who would be happy to help you. If this is the case we would ask that you contact us within four weeks. If you remain dissatisfied with the response to your complaint, you have the right to ask the Parliamentary & Health Service Ombudsman to review your case and they can be contacted on or by writing to them at: The Parliamentary & Health Services Ombudsman, Millbank Tower, Millbank, London, SW1P 4QPor by at Yours sincerely David Loughton CHIEF EXECUTIVE WHERE A COMPLAINT INVOLVES A BEREAVEMENT THE OPENING PARAGRAPH SHOULD ALSO EXPRESS OUR CONDOLENCES WHERE THERE HAS BEEN A DELAY IN RESPONDING TO THE COMPLAINANT, APOLOGIES SHOULD BE GIVEN TOGETHER WITH THE REASON FOR THE DELAY. NB Reasons for delay in responding to a complaint should not be stated as being due to a member of staff being on annual leave. In such cases appropriate arrangements need to be made for the complaint to be delegated to the next most suitable person to provide the response. Page 21 of 50

25 Appendix 4 Wolverhampton City Council Adult Social Care, Wolverhampton City Primary Care Trust and The Royal Wolverhampton Hospital Trust Protocol for Co-ordinated Complaints Handling Across Health and Social Care Boundaries Adults Reviewed to reflect new regulations date March 2009 Co-ordinated Handling Arrangements for the management of complaints between Wolverhampton City Primary Care Trust, Page 22 of 50

26 The Royal Wolverhampton Hospital Trust and Wolverhampton City Council Social Care Directorate 1. Purpose To provide a framework for the co-ordinated handling of cross boundary complaints received in the NHS and adult social care arena, involving the Local Authority, the Primary Care Trust (PCT) and the Royal Wolverhampton Hospital Trust (RWHT) New Cross. To ensure service users, carers and representatives have accessible information about how complaints that span health and social care services will be handled, with the focus being on swift local resolution by looking closely at desired outcomes. To ensure effective communication between agencies and establish a method for disseminating any joint organisational learning, to facilitate a developmental approach to inter agency complaints work. To provide a simple, consistent unified approach across Health and Social Care. 2. Desired Outcomes 2.1 Complainants can have a single, co-ordinated response to complaints. 2.2 To provide a system in which the complainant feels fully engaged. 2.3 The involved agencies to have greater opportunities to identify and share joint organisational learning. 2.4 To optimise joint working arrangements between Complaints Managers to ensure their obligations under the complaints regulations are met. 3. Process 3.1 The Complaints manager of the receiving agency will engage with the complainant to advise them of the cross-boundary issue, explain who will co-ordinate the response, confirm the issues to be addressed and agree the most appropriate way forward. 3.2 The ownership of the complaint will normally be with the organisation which is legally responsible for the main element of the service which the complaint concerns. In the unlikely event that Complaints Managers are unable to reach agreement about any matter covered by this protocol, they should each refer the matter promptly to the relevant Directors/Senior Managers in their respective organisations for resolution. 3.3 Once an investigation is commenced the need for a change of ownership may become apparent. Any such change of ownership will be agreed and recorded by each organisation s Complaints Manager. 3.4 The complainant is to remain fully informed throughout the shared agreed process and the Complaints Managers will agree how the responses of the involved agencies will be delivered to the complainant. Page 23 of 50

27 3.4.1 The Complaints Manager for each organisation involved in a complaint will ensure that relevant members of staff are engaged in the process In line with national guidance, the expected timescale for responding to a complaint will be determined in line with the lead organisation s locally set timescales, taking into account the nature of the complaint, how the case is to be investigated and following discussion with the complainant at the outset of the complaint handling. 4. Organisational Responsibilities Each organisation s complaints process is governed by the general legal framework laid down by the new Health and Social Care complaints regulations that come into force on 1 st April Each organisation will have in place its own resources and operational arrangements for handling complaints. Information will be shared in line with the requirement of the Data Protection Act, Caldicott principles and in accordance with Wolverhampton City Health and Well-Being Partnership s Information Sharing Protocol It is the responsibility of the lead agency Complaints Manager to ensure that all necessary and appropriate communication takes place with the complainant regarding access to records and consent. The lead agency will notify the other complaints service upon completion of an investigation and the date that a report has been issued awaiting a departmental response. Each Agency will need to align their complaints policies. The involved agencies are to remain fully informed throughout the process at all stages through their Complaints Managers (Appendix 1) 5 Safeguarding Vulnerable Adults 5.1 In line with the Department of Health s guidance published 26 th February 2009 Listening, Responding, Improving a guide to better customer care Advice sheet 2, the only circumstances in which a complainant s lack of consent can be overridden is if the complaint includes information that needs to be passed on in accordance with Safeguarding Children or Protection of Vulnerable Adults procedures or other service user safety issues. In such cases, the complaint is entitled to a full written explanation about the organisation s Duty of Care and its obligation to pass on the information. Information about protecting vulnerable adults can be accessed on An example form that records the consent of complainants for their case records to be disclosed for the purpose of complaint investigations is attached (Appendix 2). Close co-operation between complaints managers is crucial to ensure that confidential case file information is shared appropriately and that the necessary safeguards are put in place. 5.3 Information exchanged under this protocol can be used only for the purpose for which it was obtained. 6. Support for Complainants 6.1 Details of available support are provided in each of the involved agencies respective policies and complaints literature. For example advocates, interpreters, PALS and ICAS. Page 24 of 50

28 6.2 It will be the responsibility of the lead agency to ensure complainants are notified of support services that can be accessed to facilitate the process. 7 Risk Assessment 7.1 All involved agencies will undertake an assessment of any risk factors and ensure effective inter-departmental communication in respect of risk. For example, any increased risk to vulnerable adults whose care arrangements are complicated by cross-boundary considerations 7.2 Risk assessment may require communication with involved agencies. Contact is to be made via the relevant Complaints Manager. 7.3 The individual professional remains accountable within his/her relevant agency for the information pertaining to risk that is disclosed. 7.4 In the event direct contact is to be made with a complainant, it is the responsibility of the individual undertaking the investigation to be satisfied that necessary arrangements integral to risk are identified. 7.5 A Risk Assessment form is to be completed by the lead organisation to grade the complaint. The individual professional remains accountable within their relevant organization for the grading information that is disclosed. This will be necessary prior to any direct contact with complainants. All individuals are to be aware of the relevant procedures on risk assessment and risk for lone workers. 8. Learning from complaints 8.1 Each involved agency is fully committed to facilitating organisational learning and development through complaints resolution. An action plan will be produced to demonstrate learning and organization improvement where appropriate and this should be shared across the organizations concerned. There is currently no joint governance arrangements for learning from complaints that include the RWHT. The identification of appropriate arrangements will be explored. 8.2 Taking positive steps to identify communication, procedural, operational or strategic issues, within and across each agency is a vital component in ensuring a relevant and positive complaint s service. 8.3 The complaints services will continue to develop processes to capture service user feedback. 8.4 Involved agencies will use the process of annual reporting to support effective communication between agencies. These will include any findings and recommendations that have an inter-agency impact. 8.5 Complaints activity will be reported separately by involved agencies in accordance with local procedures. 9. Evaluation of Joint Protocol. 9.1 The protocol will be reviewed annually to appraise the effectiveness of the joint working arrangements and identify any problems and solutions. Page 25 of 50