POLICY FOR THE MANAGEMENT OF COMPLAINTS

Transcription

1 UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST POLICY FOR THE MANAGEMENT OF COMPLAINTS APPROVED BY: POLICY & GUIDELINES COMMITTEE TRUST REF: A10/2002 MOST RECENT REVIEW: NOVEMBER 2008 ORIGINATOR: SENIOR SAFETY MANAGER (CLINICAL RISK & COMPLAINTS) REVIEW DATE: NOVEMBER 2010

2 CONTENTS Page Number 1. Introduction, Background and scope 3 2. Associated Policies 3 3. Complaints Involving Other Agencies 4 4. Regulation 3B Made to a NHS Body Relating Only to a Local Authority 5 5. Other Mixed Sector Complaints 6 6. Consent and Patient Confidentiality 6 7. Exclusions to the Formal Complaints Procedure 7 8. Concerns by GP s/primary Care 7 9. Being Open Responsibilities of Staff Confidentiality PALS Complaints Management Directorate Management Responsibilities Management of Response Letters Learning Lessons from Complaints Re-opened/Un-resolved Complaints Complaint Handling when there is an Inquest Second Stage Complaint (Healthcare Commission) Disciplinary Matters Vexatious Complainants Analysing Information and Monitoring Complaints Retention of Documents Audit/Monitoring 21 Policy For The Management Of Complaints 2 of 21

3 1. Introduction, Background and Scope 1.1 The University Hospitals of Leicester NHS Trust is committed to providing high quality patient services to all of its users. Robust and clearly understood systems must therefore be in place to inform people of the following: - That suggestions, comments or complaints are welcomed. How to make suggestions, comments or complaints, either in person or in writing. This will be available in other languages upon request. How to get help to make a complaint. (Appendix 1 complaints leaflet) (Appendix 2 PALS leaflet) 1.2 The Trust is committed to the concept of learning from events that occur in its hospitals and that feedback from its service users will enable it to: - Improve aspects of its services. Identify what people need from its services. Source possible problems before they become complaints. Identify areas for immediate actions to reduce the risk of a reoccurrence of the issues. 1.3 It is a requirement for the Trust to comply fully with The National Health Service (Complaints) Regulations 2004 and The National Health Service (Complaints) Amendment Regulations These documents are available from the Department of Health website. 1.4 This document sets out the standards and expectations of this Trust in relation to the management of complaints to ensure full compliance with the above regulations. 1.5 The Trust is committed to improving its complaint management to ensure concerns are resolved locally, first time and to reduce the number of re-opened complaints and/or Healthcare Commission Independent Reviews. 1.6 The Trust is committed to ensuring that access to the complaints process is fair and equitable. 2. Associated Policies 2.1 All staff should be familiar with and refer to as appropriate: - Policy for the Management of Patient and Staff Safety Risk Management Strategy Claims Handling Policy Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults from Abuse Policy For The Management Of Complaints 3 of 21

4 Equal Opportunities Policy Service Equality Strategy Policy for the support of staff involved in incidents, inquests, complaints and claims. The above list is not exhaustive. All are available on the Document Management System. 3. Complaints Involving Other Agencies 3.1 Where complaints are about both NHS and Local Authority Services, where the complainant so wishes, the organisations involved must co-operate to deal with the part of the complaint that relates to them and provide a co-ordinated response to the complaint. 3.2 On receipt of a complaint, the Complaints Office will check whether it appears also to raise issues around local authority handling of the case. If so, within 10 working days of receiving the complaint, it must seek to obtain the consent of the complainant to sending details of the complaint to the local authority. Where the complainant does not want the details to be shared, the Trust is required to advise them on the part of the complaint it is able to deal with, adding that if the complainant wants to pursue the Social Services pert of the complaint, they should approach the relevant local authority. 3.3 Where the complainant wants the details to be shared, the local authority just deal with its part of the complaint under the Social Services Regulations and cooperate with the Trust to resolve the entire complaint and provide a co-ordinated response. 3.4 The Trust is bound by a duty to co-operate with the local authority in resolving the complaint. The duty to co-operate for all parties includes the duty to: - share relevant information, and attend joint meetings reasonably arranged to consider the complaint. 3.5 Additionally, the two bodies are required to agree, which organisation should take the lead in co-ordinating the handling of the complaint and dealing with the complainant. The lead body s Complaint Manager must: co-ordinate the handling of the complaint by working closely with all those involved ensure a comprehensive and appropriate response is sent, and ensure that they keep the complainant informed and, where possible, coordinate a single reply. 3.6 The protocols for determining the lead agency are best worked out locally (see paragraph 3.15). However, regulation 13(2) of the Principal Regulations provide that the Chief Executive of the NHS body should sign the response, so it is best if the Trust assumes the lead role. Irrespective of lead responsibility, each body retains its duty of care to the complainant and must handle its part of the complaint in accordance with its own regulated procedures. The Social Services Policy For The Management Of Complaints 4 of 21

5 Regulations have a provision that mirrors the new regulation 3A to ensure that this can occur. 3.7 Joint handling of a case should not affect the need to meet statutory deadlines for providing a response to the complainant and both agencies should seek to avoid any unnecessary delay. The Trust and the Local Authority should consider a joint meeting with the complainant if this will facilitate a more effective outcome. 3.8 Close co-operation between Complaints Managers should help identify which issues should be referred to the appropriate Body, should the complainant which to go forward to independent review. The co-ordinated response must identify which parts relate to the relevant aspects of the complaint letter. This will be of great assistance to an independent body that might subsequently have to review the complaint. The response should advise the complainant of their right to pursue the complaint further and provide details of which regulatory organisation would deal with each aspect of the complaint. 3.9 Where services are provided in a package, but delivered by separate bodies (e.g. some by NHS and some by a Local Authority), the lead Complaints Manager should still ensure that all aspects of the complaint are investigated by the appropriate body, and that the complainant is kept informed of the progress of the complaint. 4. Regulation 3B Complaints Made to a NHS Body Relating only to a Local Authority 4.1 There are occasions where the Trust will receive a complaint about the actions of a Local Authority. This can happen where the complainant does not understand which organisation is responsible for which service. However, in some cases, it might be an important issue of trust someone might, for example, speak to a Social Worker they trust about his concerns over NHS treatment, or approach a District Nurse about a carer employed by the Local Authority. Regulation 3B applies where the Trust receives a complaint that is solely concerned with Local Authority Services, or NHS Services provided under arrangement, by a Local Authority. However, a complaint under regulation 6 of the Principal Regulations may still be made to a NHS body about the actual making of the arrangements for the provision of health care or other services with an independent provider. A complaint about the making of these arrangements would fail to be dealt with by the NHS body. 4.2 Regulation 3B enables the Trust to refer the Complaint to the appropriate Local Authority if the complainant so wishes. The Complaints Manager must then within 5 working days, ask the complainant whether he or she wants the complaints referred to the relevant Local Authority. If the complaint so wishes the Complaints Manager must forward the complaint to the correct Local Authority. 4.3 Where the complainant does not want the complaint forwarded to the relevant Local Authority, the complainant should be advised that the Trust is unable to deal with the complaint and that if they wish to pursue it further, that they must contact the relevant Local Authority. 4.4 The action taken by the Trust should be recorded in writing. Policy For The Management Of Complaints 5 of 21

6 5. Other Mixed Sector Complaints 5.1 There are occasions where complaints received by an NHS body may also involve services provided by another body, for example, a matter relating to detention under the Mental Health Act. Where this happens, people who use such services should not have to worry about whom to approach with the complaints about different aspects of their care and the service that they receive. The Trust should advise complainants which matters fall under which procedure. 5.2 For example, where complaints are made that might relate in part to a matter for the Mental Health Act Commission (MHAC) procedures, the Trust should advise the complainant of the ability to complain to the MHAC. 5.3 Where a complaint involves more than one NHS provider, NHS bodies should seek to resolve the complaint through each body s local complaints procedure in a co-operative manner. 5.4 It is important to note that the procedures in the new regulation 3A apply only to complaints involving NHS bodies and Local Authorities. However, it is good practice that all bodies involved in delivering health and social care should work together to respond to complaints and comments about their services. 5.5 NHS bodies may receive written complaints that are solely concerned with areas properly dealt with by another health body or by a body outside the NHS although those involving a Local Authority should be dealt with as set out above. In these cases, the Complaints Manager should resolve any doubts or disagreements over which body is responsible for handling the complaint. The Complaints Manager should then ask the complainant whether they wish the complaint to be forwarded directly to the relevant body. The name of this body should be included in the letter. If the complainant agrees, the complaint should be forwarded as soon as possible. This decision, and the action taken, should be recorded. 6. Consent and Patient Confidentiality 6.1 In transferring complaints between agencies (including Healthcare Commission), it is particularly important to ensure that patient confidentiality is maintained at all times. Every effort should be made to obtain the patient s (or their representative s) consent before sharing confidential information with another body or organisation. This should, whenever possible, be done at the time the complaint is received, whatever its format. This will best ensure that the complaints process is not held up whilst waiting for consent. Consent should be obtained in writing wherever possible. If this is not possible, verbal consent should be logged and a copy sent to the complainant. 6.2 Where a Member of Parliament (MP) acts on behalf of a patient who is a constituent, who has, whether in writing, by telephone or in person perhaps by attending a constituency surgery sought that MP s assistance, it is accepted that the MP has obtained a form of consent. 6.3 When concerns are received from a MP, the Corporate Team will acknowledge receipt in the normal way, but will also inform the constituent that, unless they advise us otherwise, we will be responding to their concerns via their MP. Policy For The Management Of Complaints 6 of 21

7 7. Exclusions to the Formal Complaints Procedure 7.1 Regulation 7 of the National Health Service (Complaints) Regulations 2004 deals with those circumstances whereby the formal complaints procedure should not apply or should cease, these include: - Where the complainant has stated in writing that he/she intends to take legal proceedings. Arising out of the Trust s alleged failure to comply with a data subject s request under the Data Protection Act 1988, or request for information under the Freedom of Information Act Where the Trust is taking or proposing to take disciplinary proceeding against the person who is subject of the complaint insofar as the complaint refers to such matters (See 16.1) A complaint made by an employee or the Trust about any matter relating to his contract of employment. A complaint which is being or has been investigated by the Healthcare Commissioner. 8. Concerns Raised by GP S/Primary Care Where concerns are raised by Primary Care staff because they feel UHL performance has fallen below an expected standard/target, those cases should be forwarded to the Medical Director s office for investigation and response. Further guidance/details can be obtained from the GP/Primary Care Concern Management Procedures available on the DMS, or by contacting the Acting Director of Clinical Governance on extension Being Open 9.1 Being open simply means apologising and explaining what happened to patients and / or their relatives / carers if any harm is caused during an episode of care or treatment, or following identification of concerns, either formally or informally, regarding any aspect of their care whilst a patient of the University Hospitals of Leicester NHS Trust. 9.2 Communicating effectively is a vital part of the process. In doing so, the Trust can mitigate the distress and anxieties suffered by patients and potentially reduce complaints and claims for compensation. 9.3 Being Open concerns and is applicable to all staff working within the University Hospitals of Leicester NHS Trust. 9.4 Key Principles Apologising and explaining when patients have experience harm, or have expressed concerns about their care, can be difficult but they must receive an apology as soon as possible and staff must feel able to apologise on the spot Saying sorry is not an admission of liability and it is the right thing to do. Policy For The Management Of Complaints 7 of 21

8 9.4.3 Patients have a right to expect openness and honesty in their healthcare. 9.5 Procedure When an incident or concerns are raised by a patient and / or relatives the member of staff should immediately apologise The processes and procedures for the management of all Patient Safety Incidents are clearly described within the document, specifically identifying responsibilities for informing patients and relatives at point Advice, support and guidance can be obtained at all times from the Corporate Safety Team. 10. Responsibilities of Staff 10.1 Chief Executive The Chief Executive has overall responsibility for ensuring complaints are dealt with properly The Chief Executive is responsible for signing off all complaint responses, or delegating this function to an Executive Director in his/her absence The Chief Executive is responsible for assuring the Healthcare Commission that there is no further action that can be taken at local level to respond to a complaint General Managers/Clinical Directors Ensure that all their staff are appropriately trained to deal with concerns/complaints Ensure there are adequate and appropriate resources provided within the directorate to achieve and maintain the standards and expectations of the NHS Complaints Procedure and those of the Trust Ensure an adequate level and depth of investigation is undertaken into the complaint issues raised, and that the evidence to support the investigation is kept securely within the complaint file Ensure that adequate support is sourced/provided to the complainant to ensure fair access to the complaints process Responsible for assuring the Chief Executive that all actions have been taken to resolve the complaint locally and that any appropriate changes in practice, policy or procedure have been taken and will be monitored Ensure trends and themes within the directorate are recorded, monitored, analysed and acted upon. Policy For The Management Of Complaints 8 of 21

9 Ensure appropriate information is readily available within their directorate to inform patients and carers how to raise concerns All Staff Every member of staff is empowered to deal with any complaint they may receive If a member of staff encounters difficulties in finding a resolution, support should immediately be sought from a more senior member of staff, line manager, or the Corporate Complaints team Staff must attend training, appropriate to their role, in the management of complaints. Information for this can be obtained from the Corporate Complaints Team Staff must co-operate with any subsequent investigation whether initiated internally or externally and provide factual, written, dated and signed statements if requested to do so As appropriate, attend local resolution meetings Forward all formal, written complaints received directly to the Corporate Complaints team for management within the NHS Complaints Procedure Corporate Complaints Team Advise patients, carers and staff on the correct management process for complaints Advise patients, carers and staff on other agencies available, who can give independent advice or assistance in pursuing their complaint eg ICAS (Independent Complaints Advocacy Service) Provide guidance and support to staff on the investigation of complaints, including the co-ordination of complex, multi-directorate/service/agency complaints Log the complaint on the Datix System ensuring that the primary subject and other issues are captured Following the procedures for managing formal complaints as set out in Monitor the progress of the investigation within the directorate(s) to ensure compliance with the 25 working day response target. 11. Confidentiality 11.1 Patients The use of a patient s personal information to investigate a complaint is a purpose for which it is not necessary to obtain his/her expressed consent. Care must be taken at all times throughout the procedure to ensure that any information disclosed about the patient is confined to that which is relevant to the investigation of the complaint and only disclosed to those Policy For The Management Of Complaints 9 of 21

10 11.2 Third Parties 11.3 Staff individuals who have a demonstrable need to know it for the purpose of investigating the complaint The duty of confidentiality applies equally to third parties who have given information or who are referred to in the patient s records. Only information which is relevant to the complaint should be considered for disclosure and then only to those within the NHS who have a demonstrable need to know it in connection with the complaint investigation. Disclosure of information provided by a third party outside the NHS also requires express consent Extreme care shall be taken when complaints are raised by third parties acting on behalf of the patient. Wherever the patient retains mental capacity, express consent must first be sought. Such permission to be in writing other than in exceptional circumstances. Where mental capacity does not exist, the person raising the complaint must be next of kin or have designated responsibility for the patient s healthcare The Trust recognises it owes a duty to its staff to respect their rights to anonymity in written complaint responses where there is no demonstrable need for an individual to be personally named. However, it is admissible to identify an individual by their post or title, where such detail is necessary within the context of the response for purposes of clarity A demonstrable need to personally identify staff members may arise where: - An individual bears overall responsibility for the patient s healthcare (eg consultant). An individual has been identified by the complainant and the issues concerning the individual require a direct response Where a demonstrable need arises on the part of one staff member this does not automatically give rise to the need to name other staff members in the same response. Each disclosure of an individual s name must be determined on its own merits Wherever staff members are identified and wherever statements prepared by staff members are used in whole or in part in response letters, the staff members shall be made aware of this and provided with a copy of the response letter, by the Directorate Correspondence All correspondence with complainants should be marked Private and Confidential and/or Personal and first class or special delivery mail used. 12. Patient Advice & Liaison Service (PALS) 12.1 The core functions of our PALS is to: - Be identifiable and accessible to patients, their carers, friends and family Policy For The Management Of Complaints 10 of 21

11 Provide on the spot help and negotiate immediate solutions or speedy resolution of problems Act as a gateway to appropriate independent advice and advocacy support Support staff at all levels within the Trust to develop a responsive culture 12.2 Concerns and queries can be raised by: - Approaching the PALS officers on each hospital site All telephone calls to main switchboard, where the caller identifies concerns about care or queries, will be put through to the appropriate PALS officer in the first instance The PALS officer will sensitively and confidentially assess the potential to deal with the issues quickly, achieving resolution through their network or contacts without escalating to a formal complaint. If satisfactory resolution is not possible the concerns individual will be given information and guidance on the formal complaints process Information about PALS is available: - On UHL website On posters displayed around the organisation In leaflets, available in all areas of the organisation and on the website 12.4 PALS play a key role in bringing about changes in UHL by identifying themes and trends in issues raised and spotting potential serious complaints Producing quantative and qualative data and analysis for inclusion in the quarterly Trust Patient Safety Report, including information about changes made. 13. Complaints Management 13.1 Verbal Complaints All staff are empowered to deal with any verbal complaints they might receive, wherever possible Offer an immediate apology Staff must listen carefully and show empathy. Be alert to confidentiality issues and seek consent where necessary, and always be responsive to specific individual needs Staff must recognise their limitations in being able to deal with a complaint and seek support, guidance and advice when required eg interpreting/translation, another service area, a more senior manager, Patient Liaison Service (PALS), Corporate Complaints Team. Policy For The Management Of Complaints 11 of 21

12 Confirm and agree the actions to be taken and within what time frames with the complainant, identifying themselves by name and status Record the complaint using the verbal complaint record (available on the Document Management System). It is the staff s responsibility to complete the verbal complaint form and to obtain the signature of the complainant (when made in person), confirming all aspects of the issues raised have been understood and ensuring a copy is passed to their line manager and the Corporate Complaints Team Verbal complaints that are unresolved must be forwarded to the Corporate Complaints Team within one working day, so that they can be acknowledged and managed within the formal process Formal Complaints Complaint letters received anywhere other than in the Complaints Office, must be immediately faxed to the Complaints Office. Originals should then be forwarded via internal post Acknowledgements must be sent within two working days of receipt by the Complaints Office The Complaints Office will: - (i) Review the letter to determine if it should be processed as a complaint by assessing if, among other things, it is merely asking for information or seeking financial recompense, rather than seeking an explanation. If appropriate, seek advice from Claims team. (ii) If the letter is found not to be a complaint, forward it to relevant office/department (eg to Patient Advice & Liaison Service office, Litigation Department etc) (iii) Determine if confidentiality issues arise and if consent is required (eg if complaint is being raised by a third party, other than a MP, and not by the patient). (iv) Acknowledge within two working days of receipt enclosing a copy of the Trust s Complaint Leaflet. Communicate with complainant in respect of (ii) and (iii) above as necessary. Forward the complaint to the appropriate Directorate within 3 working days. (v) Determine if complaint is clear or if the Trust requires further detail. (vi) Identify key areas of complaint for which the complainant seeks a response to assist quality assurance processes and to facilitate prioritising of complaint. (vii) Identify the most appropriate lead where one or more directorates or organisations are involved, to ensure a co-ordinated approach to the investigation and response. (viii) Identify any issues of potential discrimination that my require the advice/support of the Service Equality Manager in relation to Disability Equality and information to the directorate. Policy For The Management Of Complaints 12 of 21

13 (ix) Identify any issues of potential vulnerability that may suggest concerns in relation to vulnerable adults or children and obtain the advice/support of the Trust Leads for these areas When stages (i) to (vii) in have been completed, log the complaint, which will represent the start of the 25 or 45 working day period in which a written response should be made Send complaint by most appropriate route to the complaints lead in the relevant directorate/corporate department with a copy to the Clinical Governance Manager. Information to be forwarded will include: - Copy of the complaint management form detailing response timetable, consent action, priority rating and detailing key areas of complaint to be addressed. Copy of the letter of complaint and any subsequent exchange of correspondence It should be noted that formal complaints may be received verbally. Under these circumstances, acknowledgement processes should confirm the detail of the issues to be investigated and seek agreement to this detail Liaise with the complainant if delays are anticipated in providing a response and agree an acceptable timeframe Quality assure draft responses received to ensure all issues raised have been addressed and that the format is professional, sympathetic and understandable Ensure written translation and interpreting services are provided where appropriate Maintain the complaints file in accordance with the standards as identified within the NHS (Complaints) Procedure Guidance Maintain the Datix System to include all appropriate information is readily accessible Ensure the complaints file is maintained, including all correspondence between the Trust, complainants and directorate(s), including copies of all investigation material e.g. statements, file notes, appropriate entries from medical records Facilitate complaint meetings at the request of the directorate Provide training to all staff in the organisation on complaints handling and management. 14. Directorate Management Responsibilities 14.1 Each directorate will develop its own departmental policy regarding the management of complaints and will appoint a designated lead who will facilitate contact with the Complaints Office. Policy For The Management Of Complaints 13 of 21

14 14.2 On receipt of the complaint detail, if the designated directorate lead feels they should not be the lead directorate, or they consider that input from other directorates is required, they should notify the Complaints Administrator within 24 hours On review of the complaint, the designated directorate lead should immediately consider whether an extended timeframe i.e. to 45 days, should be considered and negotiated with the complainant If an extended timeframe, as above, is considered sensible, the designated directorate lead will contact the complainant immediately to negotiate an agreed timescale, and will inform the Corporate Complaints Administrator of the outcome, so that Datix fields can be updated. NOTE: - the timescale must be agreed by the complainant, it cannot be imposed 14.5 The designated directorate lead will progress the complaint investigation within the directorate and ensure key staff are notified/involved as necessary. If a complaint is particularly complex or serious, support will be provided with the investigation by a Corporate Safety Manager, and a full root cause analysis approach taken. Where appropriate, key staff shall be asked to provide statements to assist in the investigation. These statements shall clearly include: - The name of the person making the statement. The individual s position and how long in post. The date the statement was made. The name of the complainant/patient. The individual s response to all relevant points of complaint. Signature of the individual giving the statement. (See appendix 2 for guidance). NOTE: Staff should receive appropriate support. Further information/guidance is contained within the Policy for the Support of Staff Involved in Incidents, Inquests, Complaints and Claims, available on the DMS The designated directorate lead, in conjunction with key staff, will consider at an early stage whether a meeting with the complainant will assist local resolution of the complaint. For each meeting, a chair shall be appointed (who may be the a Corporate Safety Manager) Notes of the meeting must be taken by a member of the directorate team. The notes of the meeting shall clearly identify: - Date and time of the meeting. Where the meeting was held. Those present. Purpose of the meeting. Record of the discussions. Outcome including any follow up action agreed. Meeting notes must be written up and returned to the Corporate Team for quality assuring within 10 working days. Policy For The Management Of Complaints 14 of 21

15 14.8 Copies of all statements/file notes obtained during the investigation must be forwarded to the Corporate Complaints Team for inclusion within the main complaints file, at the same time as the draft response is sent The draft response must be written by an appropriate member of staff within the directorate i.e. Complaints Co-ordinator, Service Manager, Clinical Governance Manager The draft response to the complaint shall be returned to the Complaints Office for quality assuring within the prescribed time frame. The use of for this purpose is the preferred route to help minimise delays in process The final response must be signed off by the General Manager or Clinical Director, or an appropriate designated deputy. 15. Management of Response Letters 15.1 On receipt of the draft response letter from the relevant directorate, it shall be quality assured by the Complaints Administrator, to ensure that key issues have been addressed and an approved house style is maintained. For this purpose, the following guidance must be adhered to: - Headings must be in bold detailing the name of the patient if different form the complainant. In the case of MP letters, quote MP reference if given, the name of the patient/complainant is needed, but not prefixed by Your /Constituent or the word re: or ref. (RIP) and (Deceased) are not to be used within the heading. In the case of a deceased patient, this is referred to in the main body of the letter. When responding to complaints concerning a deceased patient, the paragraph Please accept my sincere condolences... etc must be incorporated. Where staff are referred to in response letters, they must always be prefixed by title eg Mrs, Staff Nurse. No mention should be made of any staff member who has not been mentioned in the complainants letter Patients and/or complainants or staff should never be referred to by forename only. The date on the complaint letter and the Chief Executive s signing off letter must be as close as possible. When producing final directorate responses, please be aware that the date may need to be changed before signing. Response format should always be in Arial 12 font with justified margins left and right In those circumstances where a meeting has been held with the complainant, the notes of the meeting will be drafted by the directorate and forwarded to the Complaints Administrator with a covering letter for quality assuring within 10 working days of the date of the meeting The Complaints Team shall promptly quality assure the draft response, where necessary suggesting any amendments required by the use of to facilitate the production of a formal signed response letter Once the response letter/meeting notes have been agreed, and the original has been signed by the Clinical Director or General Manager, or an approved deputy, it shall be returned to the Complaints Office. The Complaints Office will prepare a Policy For The Management Of Complaints 15 of 21

16 covering letter from the Chief Executive s Office and submit the complete file to the Chief Executive for review and sign off The Complaints Office will post the complaint response The Complaints Office shall ensure the directorate(s) is provided with a copy of the final response, signed by the Chief Executive. 16. Learning lessons from Complaints 16.1 All responsible Trusts should ensure that lessons are learnt and changes are made as a result of concerns / complaints made. The University Hospitals of Leicester NHS Trust endeavour to achieve this through the following processes: LOCAL Final complaint responses will, where appropriate, have an action plan that identifies the recommendation/s, the person(s) / group responsible and the date of completion Locally, the Clinical Governance Manager or equivalent will be responsible for monitoring the action plans produced in order to ensure their completion Each directorate will produce a quarterly report identifying quantative and qualitative data in relation to complaints, lessons learnt and changes made. This report will be taken to the local governance / management group. Access must be made to this report for all staff Those changes that present the opportunity for organisational learning will be presented to the Clinical Governance Business Meeting (CGBM) which will have changes as a result of complaints as a standing agenda item ORGANISATIONAL The Safety Managers (Clinical Risk & Complaints) will monitor the production of action plans to ensure they are of the required quality, and that timeframes for actions are met Those changes that present opportunities for cross boundary / agency learning will be communicated to those organisations by the Corporate Safety Team through the Trusts quarterly Patient Safety Experience Report Issues that present significant clinical, operational, litigation or media risk, where changes cannot be executed immediately will be presented at the Trust Executive Meeting and put on the Trust Risk Register for regular monitoring by that committee The Patient Safety Team will produce a quarterly Patient Safety Report that presents qualitative and quantative information relating to all complaints and changes made as a result The above report will be presented to the Clinical Governance Business Meeting and the Clinical Governance Committee and shared with our commissioners through the Quality Schedule meetings. Policy For The Management Of Complaints 16 of 21

17 The Patient Safety Team will produce an Annual Complaints Report that will be presented at the Clinical Governance Business meeting, Trust Executive and Clinical Governance Committee. 17. Re-opened/Un-resolved Complaints 17.1 However the Trust is notified of a complainant s dissatisfaction with the Trust s response, the Corporate Complaints Team must be informed The same standards for administration, investigation and response will apply as for the initial complaint The directorate is encouraged to make direct contact with the complainant by telephone and liaise with the Complaints Team regarding the preferred management of re-opened complaints, eg a meeting or further response If a meeting has not yet been held, this should be offered. 18. Complaint Handling when there is an Inquest 18.1 The fact that a death has been referred to the Coroner does not mean that investigations into a complaint need to be suspended The Coroner recognises the importance of addressing concerns with relatives at the earliest opportunity However, the cause of death must not be discussed in any way. This is the purpose of the inquest. All other issues may be addressed The same timescales should be adhered to as far as possible. However, it is important that communication is clear and ongoing between the complaints and claims officers to reduce the risk of conflicting information being provided to the complainant. 19. Second Stage Complaint (Healthcare Commission) 19.1 The role of the Healthcare Commission (HCC) in the complaints procedure is to find out why a complaint about the NHS has not been resolved locally and to identify what action needs to be taken to achieve resolution The HCC may also choose to investigate the substance of the complaint themselves and make recommendations of how the case might be resolved The HCC can make a range of decisions at the conclusion of an independent review, including: - Referring the review back to the provider this would occur when there are still steps that can be taken locally to resolve a complaint. Deciding to investigate further themselves this would usually occur where there are doubts about the accuracy of the provider s response to the complaint, or the robustness of its investigation or learning from the incident. Policy For The Management Of Complaints 17 of 21

18 Referring to another part of the Commission this would occur when we spot a pattern of complaints suggesting that a serious failure in services is not being addressed locally and is compromising the safety of patients. Taking no further action this would usually occur when the provider has responded fully to the complaint after a thorough investigation, and has taken any necessary steps to prevent a situation from re-occurring. Referring directly to the Ombudsman there are a number of situations in which this might occur. For example, when a case raises issues which span the jurisdiction of two Ombudsmen, such as cases involving health and social care (which can be dealt with by the Health Service Ombudsman and the Local Government Ombudsman) or where issues of retrospective continuing care funding are raised. 20. Disciplinary Matters 20.1 The complaints procedure is concerned only with resolving complaints and not with investigating disciplinary matters. Inevitably, however, some complaints will throw up information about serious matters which indicate a need for disciplinary investigation Consideration as to whether or not disciplinary action is warranted is a separate matter for management, outside the complaints procedure, and must be subject to a separate process of investigation Relevant papers that have been accumulated during the investigation of the complaint may be passed to the appropriate person in the Trust who will be considering the need for a disciplinary or other form of investigation. Information gathered in the complaints process will not be privileged If any complaint received by a member or employee of a Trust/Health Authority indicates a prima facie need for referral to any of the following: - (i) an investigation under the disciplinary procedure (ii) one of the professional regulatory bodies (iii) an independent inquiry into a serious incident under Section 84 of the National Health Service Act 1977 the person in receipt of the complaint should at once pass the relevant information to the Senior Complaints Manager, who will ensure that it is passed on to a suitable person who can make a decision on whether and when to initiate such action, this reference may be made at any point during any stage of the complaints procedure Where it is decided to take action under any of (i) (iii) above (or investigation of a criminal offence), before a complaint investigation has been completed, a full report of the investigation this far should be made available to the complainant The complaints procedure will not deal with matters which are currently the subject of disciplinary investigation. If action is initiated under (i) (iii) above, the complainant should be advised accordingly so that appropriate action under the complaints procedure can be pursued where there are other matters raised in the complaint which do not relate to disciplinary investigation. Policy For The Management Of Complaints 18 of 21

19 20.7 If any action is initiated under (iii) above, or investigation of a criminal offence, the complaints procedure should be similarly modified until such action is concluded When any action, as set out above, has been concluded, the complaints procedure should only recommence where there are matters in the complaint which have not been dealt with through that action When a decision is made to embark upon a disciplinary investigation, the processing of the complaints procedure does not automatically cease. There may well be other aspects of the original complaint, not covered by the disciplinary inquiry that should continue to be investigated. The Complaints Administrator may need to make clear to the complainant that a disciplinary inquiry is now underway, particularly if the complainant is likely to be asked to take part in the process Where there are no outstanding issues from the original complaint to be investigated, the complainant should be advised that no further action will be taken, other than that through the disciplinary procedure. 21. Vexatious Complainants 21.1 All personnel dealing with vexatious complainants are reminded of the principles of good practice and the general procedures outlined in the main policy. These include the need to maintain detailed records of all communications and the need to maintain a polite and sympathetic approach wherever it is practicable to do so without compromising the Trust s position or conceding liability Vexatious complainants can fall into the following categories: - People who make frequent complaints about a variety of different things. People who persistently make the same complaint with minor differences, but never accept the outcome of any investigation into their complaint. People who are seeking an unrealistic outcome and intend to persist until such an outcome is achieved. People who make the same complaint from slightly different angles or via different routes (eg Chief Executive, Members of Parliament, Councillors) in the hope of getting a different response or applying pressure such action can happen consecutively or concurrently Vexatious complaints are also likely to include (but are not limited) some or all of the following: - Contact is frequent and often lengthy and complicated taking up excessive time and committing the Trust to an unreasonable and unrealistic commitment of resources. The complainant behaves aggressively and provocatively towards members of staff. The complainant changes aspects of the complaint or the desired outcome part way through the investigation and/or after Independent Review If having responded to the complaint, the complainant remains dissatisfied and declines to follow the procedures defined within the Trust s Policy for Handling Complaints, then the Chief Executive should indicate that the matter is now closed and that no further correspondence will be entered into unless a fresh Policy For The Management Of Complaints 19 of 21

20 complaint is being raised, which is not related to that which has been through the procedure and which could not have been raised with the original complaint In extreme cases, the Chief Executive may wish to refer the matter to the Board to consider the issues and whether the final response should be made by the Chairman with the Board s approval The decision to refer the complaint to the Chief Executive shall be made via the Complaints Team following discussion and agreement with the relevant directorate/specialty where appropriate and with the approval of the Assistant Director of Corporate and Legal Affairs Staff should not be expected to put up with verbal abuse from complainants either over the telephone or face to face. If a complainant is abusive over the telephone, staff should first identify the caller (if possible) and advise them that they are not prepared to continue with the call if the abuse continues. If the complainant continues with the abuse, staff should state I am ending this call and put the telephone down. NOTE: Further information/guidance is contained within the Management of Violence and Aggression Policy available on the DMS In the case of persistent abuse, the complainant should be advised in writing that all future communications will be in writing only All such incidents shall be fully documented If it is likely that an individual who is attempting to investigate a complaint is considered to be at risk of violence because of previous incidents then appropriate steps must be taken to create a safe environment for any face to face interviews with the complainant Wherever appropriate, the complainant shall be advised that the interview will be immediately terminated in the event of any risk of violence Under the provisions of Health and Safety legislation, the employer is under an obligation not to knowingly place an employee at risk and therefore in the last resort, the Trust could refuse to investigate the complaint. If there were to be a challenge to such a decision, the Trust would have to demonstrate that it acted reasonably. 22. Analysing Information and Monitoring Complaints 22.1 Information about complaints shall be passed regularly to the Trust Board, Trust Executive, Patient Safety Group, Clinical Directors and General Managers. Complaints reports shall where appropriate: - Record/Monitor complaints by ethnic groups. Set out clearly the number of complaints, broken down into different categories, including informal and formal complaints and discriminatory practice. Include achievement against published standards and comparison with previous periods. Include a quality analysis of the main subjects of the complaints, to explain the basic figures and highlight problem areas. Suggest action for improvement. Policy For The Management Of Complaints 20 of 21

21 22.2 The Trust Board shall: - Monitor arrangements for local complaints handling. Consider trends in complaints. Consider any lessons which can be learned from complaints particularly for service improvement The Trust will publish an annual report on complaints handling which shall be sent to the Strategic Health Authority and the Healthcare Commission and which shall include information on: - Number of complaints. Subject matter of the complaint. Nature of the investigation and outcome including any detail or recommendations made by the Healthcare Commission and whether these have been acted upon and if not, why not. 23. Retention of Documents 23.1 In accordance with the guidance in NHS Circular HSC 1999/053 dated 19 March 1999 and the Trust s Retention Policy, all complaints documents shall be retained for a period of not less than 10 years Documents may be converted to microfiche CD s, or other alternative means providing the data contained within the documents remains available for the 10 year period. 24. Audit, Monitoring and Review 24.1 It is important for the Trust to be able to demonstrate the overall effectiveness of this policy by monitoring its implementation This will be achieved by employing a variety of methods, for example: - Reviewing data for Datix and undertaking analysis of that data to monitor numbers and themes. (quarterly) Undertaken audit of completed complaints files to identify compliance/non compliance issues with complaints handling process, communication and documentation (annually). Ongoing monitoring of corporate and directorate compliance with key performance indications i.e. Acknowledgement within 2 working days 25, 35, 45 working day response targets for both initial and re-opened complaints. Meeting notes received within 10 working days. 25 working day response targets to Healthcare Commission reports. Undertake complainant satisfaction questionnaires (ongoing) 24.3 Monitoring will be undertaken by the Corporate Safety Team (Complaints) with the support of CASE and results will be submitted to Clinical Governance Committee. Policy For The Management Of Complaints 21 of 21