INCLUDING THE PROCEDURE FOR HANDLING, EVALUATING AND RESPONDING TO COMPLAINTS

St Helens & Knowsley Hospitals NHS Trust COMPLAINTS POLICY INCLUDING THE PROCEDURE FOR HANDLING, EVALUATING AND RESPONDING TO COMPLAINTS Recommending Committee: Approving Committee: Clinical Performance Council Trust Governance Board Signature: Designation: Chief Executive Date: January 2007 Version Number: Version 07 Date: January 2007 Review Date: December 2009 Responsible Officer: Head of Complaints & Claims

Contents Page 1.0 Aim of Policy 3 2.0 Principles of Policy 3 3.0 Matters Excluded 5 4.0 Roles and Responsibilities 5 5.0 Complaints Management 9 5.1 Informal Complaints 9 5.2 Formal Complaints 10 5.3 Complaint Procedure 12 5.4 Media Sensitive Complaints 14 5.5 Involvement of External Agencies 14 5.6 Treat Officials 15 5.7 Learning from Complaints/Concerns 16 6.0 Healthcare Commission 17 7.0 Parliamentary & Health Service Ombudsman 18 8.0 Monitoring of Complaints/Concerns 20 9.0 Staff Complaints 21 10.0 Publicity of the Complaints Procedure 21 Appendix 1 - Informal Complaint Record Form 22 Appendix 2 - Informal Complaint received at 23 Local Level (flow chart) Appendix 3 - Formal Complaint 24 Local Resolution (flow chart) Appendix 4 - Witness Statement Form and 25 Guidance Notes for staff Appendix 5 - Investigation Levels re Incidents, 28 Complaints and Claims Appendix 6 Analysis Principles 29 Appendix 7 Incident Trigger Codes 32 Page 2 of 35

1.0 AIM OF POLICY To have a Trust wide systematic accessible process for dealing efficiently and effectively with complaints from any area of service. Enabling information that is gained to be used in a positive way and to avoid where possible, similar situations in order to improve the quality of the service. This policy is based on the latest NHS (Complaint) Regulations provided by the Department of Health 2004, and the NHS (Complaints) Amendment Regulations 2006. 2.0 PRINCIPLES OF POLICY 2.1 All staff will be made aware of the Trusts commitment to complaints handling and good customer care at Corporate Induction. 2.2 All frontline staff will receive detailed training on the handling of complaints and will be made aware of the contents of the Complaints Procedure. 2.3 A complaint is to be made as soon as possible after the action giving rise to it. The time limit for making a complaint will be within six months of becoming aware of the problem or twelve months from the date of the event, whichever is the earliest. A formal complaint may be written, electronic or verbal and each is to be given the same consideration. Discretion may and is to be used by the Head of Complaints & Claims to extend this time limit. 2.4 The Chief Executive will retain overall responsibility for the Trusts compliance with the handling of complaints. However an Executive Director will be designated and will have lead responsibility on behalf of the Board and will ensure that action is taken in light of the outcomes of any investigation the Director of Nursing, Midwifery & Governance). 2.5 The Trust has a designated Head of Complaints & Claims who has organisational responsibility for complaints handling. 2.6 Information regarding the Trust s Complaints Procedure will be made available to service users by way of a patient information leaflet Compliments, Comments & Complaints (see also section 9.0). Advice on how to comment on the service provided by the Trust is also contained in the Patient Information Bedside Folder. 2.7 Emphasis is on complaints being dealt with quickly and effectively where possible, by the respective Care Groups. There may be occasions when a communication comments on the service or the quality of care, but is not intended as a complaint. Such comments whether critical or positive are to be recorded on a Comments and Suggestions form, which are to be made available to patients, relatives or carers by each ward and department. On completion this can either be handed to a member of staff or placed in the internal or external mailbox (freepost). Page 3 of 35

Upon receipt in the Complaints & Claims Department the form will be scanned and sent to the appropriate Assistant Director of Operations/Head of Department for their attention. Where the sender s name and address is provided the Assistant Director of Operations/Head of Department will reply and where appropriate action the comments/suggestions made. A copy of this reply will also be sent to the Head of Complaints & Claims for inclusion in activity reports submitted to the Board. 2.8 Any complaint requires action under any of the following:- An investigation under the disciplinary procedure Report to one of the professional regulatory bodies An independent inquiry into a serious incident under Section 84 of the NHS Act 1977 An investigation of a criminal offence A major Public Relations incident Subject to investigation by HM Coroner The person in receipt of the complaint is to pass the relevant information to the Head of Complaints & Claims at once who will in turn ensure it is brought to the attention of the Chief Executive as well as being passed on to the appropriate person. 2.9 Any delay in investigation of a complaint, for whatever reason is to be explained immediately to the complainant and any other person involved in the complaint. 2.10 Help in dealing with any aspect of a complaint (whether a formal complaint or an informal concern) can be sought from the Patient Advisory and Liaison Service (PALS), Head of Complaints & Claims/Assistant Director of Operations/Head of Department. 2.11 The complaints procedure will be kept separate from the disciplinary procedure; however the disciplinary procedure will not delay any aspects that can still be addressed in the complaint. The complainant must also be kept informed of the progress. 2.12 The Trust will have the discretion to decide who is a suitable representative to complain on behalf of existing or former users of the Trust s NHS Services. Under normal circumstances this will be the named next of kin who is shown in the patient s details on the Trusts Hearts database. 2.13 Investigation of a complaint does not remove the need to respect a patient s confidentiality. 2.14 Details of any complaint must be held separately from a patients health records. Where Freedom of Information applies however all details (including the complaint investigation) could be disclosed. Page 4 of 35

2.15 For advice on dealing with vexatious complainants the Complaints & Claims Department are to be contacted. 2.16 Where possible, and with the agreement of all parties, tape recordings of meetings should be undertaken. A copy of the tape will be given to the complainant following the meeting. 2.17 Notwithstanding the above the Trust fully supports and is compliant with the provisions of the Freedom of Information Act 2000 and associated legislation. 2.18 It is essential that every effort is made by all Trust staff to ensure that patients, relatives and their carers are not treated differently as a result of raising a concern. No clinician can refuse to treat a patient who has lodged a complaint unless there is a total breakdown in relations and agreement of an Executive Director has been given 3.0 MATTERS EXCLUDED 3.1 A complaint made by an NHS body which relates to the exercise of its functions by another NHS body 3.2 A complaint made by an employee of an NHS body about any matter relating to his contract of employment 3.3 A complaint which is being or has been investigated by the Parliamentary & Health Service Ombudsman 3.4 A complaint arising out of an NHS body s alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000 3.5 A complaint about which the complainant has stated in writing that he intends to take legal proceedings 3.6 A complaint about which an NHS body is taking or is proposing to take disciplinary proceedings in relation to the substance of the complaint against a person who is the subject of the complaint 3.7 A complaint about schemes established under the Superannuation Act 1972 3.8 A complaint, the subject matter of which has already been investigated as a complaint 4.0 ROLES AND RESPONSIBILITIES 4.1 Trust Board is responsible for reviewing, on a quarterly basis, the formal complaints received in the Trust and for ensuring that the Trust is strictly adhering to the agreed procedures. Page 5 of 35

4.2 Trust Chairman is responsible for ensuring that complaints sent directly to him/her are investigated and that a response goes out under his signature. 4.3 Chief Executive is responsible for: Ensuring that all complaints received by him/her are passed to the Complaints Department on the day of receipt Agreeing and signing the written response to all complainants/delegating to Deputy Chief Executive Forwarding the agreed response to the Complaint Department for recording on the complaints database and sending out to the complainant In the Chief Executive s absence, this responsibility will transfer to the Director of Nursing, Midwifery & Governance/Deputy Chief Executive or relevant person 4.4. Director of Nursing, Midwifery & Governance is the designated Executive Officer to lead on the handling of complaints and is responsible for: Overseeing the management of the Trust s complaints handling procedures. 4.5 Medical Director is responsible for investigating complaints relating to Clinical Directors and will review and monitor medical clinical aspects of complaints. 4.6 Directorate Managers are responsible for: Informing the Complaints Department of any directly received complaints and taking immediate remedial action in all cases where the complaint is of a major or catastrophic nature Ensuring that notices are displayed in all public areas advising patients, their families, friends, carers and the general public of how to raise concerns via PALS or the formal complaints system. This includes displaying information about how to raise concerns in all patient information leaflets. The investigation of complaints and the preparation of a report to the Head of Complaints & Claims, within the agreed timescales including within the reply the lessons to be learned and the action being taken to prevent a recurrence. The report is also to detail how any actions will be monitored. Providing guidance to staff on how to write a statement and supporting them through this process The progress and outcome of the complaint Ensuring that when there is an incident linked to the complaint that the Incident Reporting form (IR1) has been completed and the incident reported and investigated. Page 6 of 35

Providing the Head of Complaints & Claims with a report demonstrating the process or barriers to the implementation of any previous action plans related to a particular complaint Agreeing the implementation and timescales of the action required within their area to learn lessons from complaints to improve the quality of services for patients, their families, friends and carers Ensuring that all new staff attend the Trust s induction which includes a session on Complaints Handling. They must also take appropriate action if staff fail to attend this training. Every effort should be made to ensure that staff attend further training sessions in Customer Care and Complaints Handling, wherever possible. Providing support to staff, recognising that many staff find complaints about their performance very distressing. 4.7 Divisional Managers are responsible for identifying risks arising from complaints and PALS concerns and ensuring that these are included on the risk register where appropriate. They will also monitor the implementation of action plans developed following a complaint/concern investigation and ensure that lessons learnt are shared with other care groups/department, enlisting the help of the Governance Facilitators as appropriate. 4.8 Head of Complaints & Claims is responsible for the administration of the complaints procedure: Recording the date of receipt of the complaint. Sending the written acknowledgement of receipt of the complaint to the complainant and include the Trust s How to make a complaint leaflet which provides details of the complaints procedure. An annual review of this leaflet will be carried out by the Complaints Manager. Advising complainants of the possible assistance that can be provided by the Independent Complaints Advocacy Service (ICAS). Recording all individual complaints information on the complaints database. Forwarding the complaint to the appropriate division(s) for investigation. Quality assuring the response from the Directorate(s) before it is passed to the Chief Executive for signing. Forwarding the response to the complainant when agreed and signed by the Chief Executive. Monitoring the timescales for the receipt of the investigation reply and reminding managers if this is not received within the national timescales Page 7 of 35

Recording the age of the complainant, where this can be ascertained. Recording the ethnicity of the complainant or member of staff where this can be ascertained and relates to an individual member of staff or individual complainant. Rating the severity of the complaint and its claim potential in line with the Risk Management Strategy using the 5 x 5 risk grading matrix Checking the database to ascertain if there is a linked incident to the complaint or a concern raised with PALS and ensuring that the relevant manager is aware and that the local investigation has been completed. Liaising with Medical Director and Director of Nursing, Midwifery and Governance (whichever applicable) when advice is required on clinical issues or when the concerns raised are about serious professional issues. Informing the Chief Executive of all complaints with the potential to result in litigation. Highlighting the need for a Root Cause Analysis to be undertaken of all complaints rated as major or catastrophic Ensuring that the final paragraph of the response from the Chief Executive advises complainants that if they are not satisfied with the Trust s response, they should contact the Head of Complaints & Claims for further investigation or to arrange a meeting with staff. Compiling a quarterly complaints performance report for the Trust Board, outlining each Care Groups compliance with the timescales. Compiling a quarterly summary report for the Trust Board of all complaints received, their adherence to the specified timescales, a trend analysis and actions identified. This will also include a summary of any complaints that have been independently reviewed by the Healthcare Commission or have gone on to the Ombudsman. This information will also be shared with the PALS department (if appropriate) and the Clinical Performance Governance Council 4.9 Consultant Medical Staff are in charge of the patient s care and will be responsible for obtaining statements relating to the complainant s issues from all their relevant junior staff. Will provide a written response within the specified time requested responding directly to the issues raised in the complaint letter. 4.10 Members of staff are responsible for: Listening and responding to the concerns of users regarding the services or care provided Page 8 of 35

Actively contributing to the investigation process when requested to do so by their manager Taking personal responsibility for participating in service or care improvement action plans Making every effort to resolve complaints as they arise and involving their line manager, PALS or the complaints staff when complaints cannot be resolved locally Attending Complaints Handling, Customer Care Training/ Communication workshops to equip themselves with the appropriate skills to deal effectively with complainants 5.0 COMPLAINTS MANAGEMENT Reference are to be made to Appendix 2 when reading this section of the complaints policy + appendix 5 regarding investigation process/severity. 5.1 INFORMAL COMPLAINTS 5.1.1 Any matters that give rise for concern are to be dealt with as they arise e.g. minor criticisms about waiting times, meals or transport arrangements. 5.1.2 All comments and misgivings are to be listened to sympathetically, even those that appear trivial. The person to whom these misgivings are expressed or the person in charge of the ward or department should be able to provide an explanation that is acceptable to the complainant. Most informal complaints are dealt with this way and a brief note of them and any action taken to resolve them made on the Informal Complaint Record form (Appendix 1) is all that is necessary. This is especially important in case a complainant decides to make a formal complaint at a later date. It is also vital data which will assist in identifying trends and lessons to be learned. 5.1.3 All complaints no matter how trivial must be brought to the attention of the person in charge of the ward or department. 5.1.4 Once the informal complaint has been resolved and an informal Complaints Record form completed it is to be forwarded to the Line Manager (eg. Matron/Head of Department) as soon as possible. It is the responsibility of the line manager to ensure that the completed forms are forwarded to the Assistant Director of Operations/Head of Department on a monthly basis in order that they can review and identify trends and action as required. 5.1.5 The Assistant Director of Operations/Head of Department will forward a summary of each informal complaint to the Head of Complaints & Claims on a monthly basis for inputting on to the Trusts database (erms) in order to generate reports analysis and submission to the Board and Clinical Performance Council. Page 9 of 35

5.1.6 Where a complaint cannot be resolved in an informal manner, a record of the complaint and any action taken in an attempt to resolve it (as above) is to be recorded on the Informal Complaints Record form and the Matron/Head of Department is to be informed immediately. If an advisory role is required and only if the Matron/Head of Department has been unable to resolve the issue then PALS are to be contacted during office hours, or the Duty Manager out of hours. In addition the complainant is to be advised of the role of ICAS and how they can be contacted. NB. Complaints involving a senior member of staff i.e. Assistant Director of Operations/Head of Department does not necessarily make the complaint a formal one. If this is resolved locally it remains an informal complaint and is to be concluded as in section 4.1.4 above with completed forms forwarded to the Director of Operations. 5.1.7 Where issues have been brought to the attention of the Head of Complaints & Claims, and it is felt these can be dealt with informally, the Head of Complaints & Claims will acknowledge these and refer them to the appropriate Assistant Director of Operations/Head of Department for action. It will be for the Assistant Director of Operations/Head of Department, in consultation with or as instructed by the Head of Complaints & Claims to decide the best way to deal with the matter e.g. telephone/face to face meeting. As a matter of courtesy the Assistant Director of Operations/Head of Department will respond by letter to the person who has raised the concerns. A copy of the response together with a completed informal Complaints Record form is to be sent electronically to the Head of Complaints & Claims for analysis and inputting into the Trust database (erms). 5.1.8 If the complaint remains unresolved all details are to be delivered (not by internal post) to the Head of Complaints & Claims the same day (or next working day if at a weekend). If an individual is not satisfied with the action/explanation given by the Matron/Head of Department, he/she is to be asked if he/she wishes to make a FORMAL COMPLAINT, this is to be done in a sympathetic and polite manner. A Trust Complaint Pro-forma is to be offered to the complainant for completion. 5.1.9 Similarly where an expression of dissatisfaction is considered by the member of staff to warrant investigation as a formal complaint the procedure in the formal complaint process is to be followed (section 4.3 below refers). 5.2 FORMAL COMPLAINTS Reference is to be made to Appendix 3 when reading this section of the complaints policy. A formal complaint is one that the complainant wishes to have investigated and responded to in writing by the Chief Executive regarding the service they have received or treatment provided from the Trust. Page 10 of 35

NB. If the complaint relates to clinical treatment and the complainant is not the patient, then the patient s permission to reply to the complaint must be obtained unless: The patient is deceased (if so the permission must be sought from the next of kin who is shown in the patient s details on the Trusts Hearts database); The patient is a minor. In such cases the permission of the parent, guardian, or other adult person who has care of the child must be obtained if the complainant is none of the above; The patient has a debilitating illness that prevents them from giving permission (again permission must be sought from the next of kin who is shown on the Trusts Hearts database or as recorded on the patient s last inpatient documentation); A formal complaint may be: 5.2.1 VERBAL COMPLAINT If the complaint is made verbally (i.e. in person or by telephone) a typed record of the verbal complaint must be made by the recipient of the complaint as soon as practically possible but no later than within 2 working days. This is to be delivered the same day to the Complaints & Claims Department who in turn will send it to the complainant with the acknowledgement of the complaint. The complainant is requested to confirm that this is an accurate account of the complaint by signing and returning it, or alternatively to amend and return (see paragraph 3 below). 5.2.2 WRITTEN COMPLAINT (letter/pro-forma/email) On receipt of a written complaint the complainant is to be advised of the following:- Name and address of the Chief Executive to whom complaints is to initially be sent. The complainant is advised to contact either person as soon as possible:- Ms Ann Marr Chief Executive St Helens & Knowsley Hospitals NHS Trust Whiston Hospital Tel No. 0151 430 1242 E-mail address: ann.marr@sthk.nhs.uk Alternatively individuals can refer their complaint to the Trusts designated Complaints Manager who is:- Mrs Carol Freeman Head of Complaints & Claims St Helens & Knowsley Hospitals NHS Trust Whiston Hospital Tel No. 0151 430 1433 E-mail address: carol.freeman@sthk.nhs.uk Page 11 of 35

Where a complainant is unable to make a written statement (especially inpatients) the staff member is to arrange for a written account of the complaint to be made. They are to then sign the complaint and request that the complainant signs this. A refusal by the complainant to sign a statement is in no way a reason not to investigate the complaint fully. The complaint pro-forma can be used for this purpose if appropriate. As far as is reasonably practical a complainant must be offered a copy of any statement he/she signs. 5.3 COMPLAINTS PROCEDURE Once a complaint is received the following procedure must occur: 5.3.1 Any complaint received anywhere else within the Trust is to be delivered immediately to the Head of Complaints and Claims. Outside of normal working hours complaints is to be referred to the Duty Manager. 5.3.2 The complainant's letter is acknowledged within 2 working days by the Chief Executive, which includes details of how the complainant can contact ICAS and also gives a time frame when a response will be sent to the complainant. 5.3.3 The Complaints & Claims Department will log the complaint on the (erms) database, categorising the complaint in accordance with the Department of Health statistical returns (K041) and will grade the severity of the complaint using the National Patient Safety Agency grading criteria. 5.3.4 The relevant Assistant Director of Operations/Head of Department will investigate the complaint within the designated time limits (Appendix 3). All statements, e-mails, telephone calls, meetings etc MUST be logged on the (erms) database by the officer designated to investigate the complaint. NB. Consultant/all staff must be made aware by Assistant Director of Operations/Head of Department of any formal complaint about them which has been made by any patient in their care and given the right to reply to any allegations made. 5.3.5 Statements are to be obtained from all appropriate staff using the Trust approved form (Appendix 4) and following the guidance on the form. 5.3.6 When permission to respond to a complainant who is not the patient has been requested and this is not forthcoming, the Assistant Director of Operations/Head of Department will contact the complainant after a period of 4 weeks following the initial request advising them that permission has still not been received. Once a period of 3 months has elapsed from the date of receipt of the complaint, the Assistant Director of Operations/Head of Department will refer the complaint back to Head of Complaints & Claims who will write to the complainant advising them that the complaint will be closed unless/until permission is received. A further 2 week period will be allowed before this is completed. Page 12 of 35

5.3.7 Where the complaint relates to the clinical treatment of a patient who has died, the appropriate Assistant Director of Operations/Head of Department and clinician will offer a meeting with the deceased's family at the earliest possible opportunity. 5.3.8 If at any point within local resolution it is decided that meeting a complainant is necessary for any reason, a written account is to be sent to the complainant confirming any points raised or agreement reached at the meeting within 5 working days of the meeting being held. At an early stage in the process it is good practice to ensure that all communication is open, honest and in a timely manner throughout. To achieve this various methodologies are to be used and include the offer of meetings in serious or complicated cases and always in cases of bereavement. 5.3.9 The Head of Complaints & Claims will offer advice or assistance where necessary. All response letters will be forwarded in the first instance to the Head of Complaints & Claims for proofing and validation, with the action plan. This is to be no later than the 15 working day from receipt of the complaint. Prompts for 10 and 15 day deadlines will be given by the Complaints & Claims Department. At day 21 if it is clear that the 25 day deadline can not be met an exception report must be produced and sent to the Complaints & Claims Department for forwarding to the Executives. 5.3.10 The Chief Executive will then sign the response letter, which is then sent to the complainant by the Complaints & Claims Department within 25 working days. 5.3.11 The Assistant Director of Operations/Head of Department will be the point of contact for further queries or issues raised by the complainant following the response letter. A copy of the response letter will be available to the Assistant Director of Operations/Head of Department concerned for dissemination to staff who were involved in the complaint. A sign off sheet will be completed to confirm receipt. Any training needs identified and achieved by the manager will be incorporated within the Action Plan for that complaint. 5.3.12 If during the investigation process it is apparent that the 25 working day target cannot be met e.g. staff leave etc. then the complainant must be contacted and advised of the situation. A revised time frame is then to be agreed with the complainant and this is to be confirmed in writing. Any subsequent extensions to the time frame must be with the expressed approval of the complainant taking into account the reason why an extension is necessary. 5.3.13 The Assistant Director of Operations/Head of Department will analyse the complaint using the Trust's guidance for Root Cause Analysis and will be required to produce Action Plans to demonstrate action taken as a result of a complaint. Page 13 of 35

5.3.14 The Assistant Director of Operations/Head of Department will be responsible for developing and implementing action plans. Their outcome will be forwarded to the Head of Complaints & Claims on a monthly basis. 5.3.15 In cases of clinical incidents it will be appropriate to also record the event on a clinical incident report form. 5.3.16 On completion of the complaint investigation all working papers are to be held by the Assistant Director of Operations/Head of Department for 3 months, then it is to be sent to Complaints & Claims Department for complaint documentation to be stored centrally. The file must be sent earlier if a request is made by the Healthcare Commission or the Parliamentary & Health Service Ombudsman. 5.3.17 Activity data relating to the complaint will be collated by the Head of Complaints and Claims in order to process the quarterly reports for the Trust Board, Governance Board and Commissioners. Assistant Director of Operations/Head of Department will also be able to access reports they have requested to be generated by erms. 5.4 MEDIA SENSITIVE COMPLAINTS 5.4.1 Where a complaint (or similar incidents e.g. Inquests) generate a degree of media interest, then managers and staff are instructed to involve the Head of Complaints & Claims and Head of Media, PR & Communications who will offer guidance, instruction and support to staff. 5.4.2 Staff who are involved in Media Sensitive cases will also be given support and guidance in accordance with the Trust s policy on Supporting Staff. 5.5 INVOLVEMENT OF EXTERNAL AGENCIES 5.5.1 Every attempt is to be made to resolve complaints and this may, on occasions necessitate the involvement of external agencies in this process. This may include for example: Where it is felt that conciliation and/or mediation is required the Trust will draw upon the Strategic Health Authority s list of individuals/agencies who provide such services. The involvement of the Independent Complaints Advisory Services (ICAS) at the initial stage of the complaint process must be offered to each complainant, and this will be reflected in the Trust s acknowledgement letter sent on receipt of each formal complaint. Where there are difficulties in resolving a complaint because of clinical issues, the Trust is to be prepared to offer the complainant the option of obtaining external independent clinical advice. Where this is mutually agreeable the Trust will obtain the names of such assessors from the list retained by the Strategic Health Authority. This assessment may sometimes only entail a review of the complaint documentation and health records but may, on occasion, involve a full clinical examination of the patient. The nature and extent of this external review will depend upon the nature of the complaint. Page 14 of 35

Reports produced for this purpose are to readily be made available to the complainant and they are to be invited and encouraged to meet with senior Trust Managers to discuss the outcome of these. 5.5.2 Complaints often overlap agencies and it is important that there is an understanding between them regarding the responsibility in addressing them. For example: There may be issues in a complaint, which involve the ambulance service and family practitioner as well as the Trust. It is important that good lines of communication exist with such agencies to establish who will take the lead on such a complaint and it will not necessarily be for the receiving Authority to assume the lead. Complaints that in part relate to a Local Authority or other third party must be referred to that Local Authority or third party as soon as reasonably practicable, once permission has been given by the complainant. This permission must be requested and obtained within 5 working days. The complainant must also be notified about which part of the complaint will be dealt with by the Trust and which by the Local Authority or third party, and they will be given the name of the respective lead person to whom their complaint has been referred. In addition the Trust will look to other agencies to provide treatment on its behalf e.g. waiting list initiatives, choice etc. where appropriate. Again it is important that such agencies which are outside the NHS Complaints process, for example Private/Independent Hospitals have a complaints system that is robust and satisfies the Trust s requirement. When negotiations are taking place to provide activity on behalf of the Trust then the Head of Complaints & Claims should establish that their complaint process meets the criteria and is an integral component of this external provision. Arrangements pertaining to this section shall be co-ordinated and actioned by the Head of Complaints & Claims. 5.6 TREAT OFFICIAL 5.6.1 A small number of complaints are received via the Strategic Health Authority having been sent to Government ministers. These are referred to as Treat Official (TO) complaints. These are to be dealt with as if they are a formal complaint, however the Trust will be expected to deal with these within 10 working days. The response will be sent to the person making the complaint and a copy will be sent electronically to the Strategic Health Authority. 5.6.2 In the majority of cases a TO will have been the subject of a previous or current complaint direct to the Trust. It is therefore important that the TO response is consistent with correspondence that has already been sent to the complainant. Page 15 of 35

5.7 LEARNING FROM COMPLAINTS/CONCERNS 5.7.1 The Trust is committed to using complaints/concerns as an opportunity to learn and to improve services and care. This needs to happen at all levels of the organisation. Concerns raised through complaints and lessons learnt/actions taken will be shared with the Trust Board, Clinical Performance Council, governance newsletter and Trust team brief where appropriate. Many complaints arise from misunderstanding and may be resolved through appropriate explanation and discussion. Other complaints reveal ways in which services have been entirely appropriate but have not lived up to the patient s expectations. Again, explanations may resolve matters. Further complaints, however, will reveal ways in which the Trust services may be improved. This Policy must ensure that where possible these potential improvements are identified. Directorate Manager/Heads of Department will be responsible for formulating action plans in response to complaints made and identifying mechanisms to monitor these. They will also take responsibility for implementing agreed improvements to services and care. Where it is clear that improvements to services can be made, these are to be explained to the complainant in the response to the complaint. The Head of Complaints & Claims, Deputy Head of Complaints & Claims and Care Group Directorate Managers/Head of Governance will identify how lessons learned in one directorate/department can be shared with other directorate/department. The quarterly performance and governance meeting with the Executive Directors & Head of Governance with each of the Care Groups will discuss lessons learnt and changes in practice as a result of informal concerns and formal complaints. Sharing between Care Groups/Departments will be further communicated via the Governance Facilitators. Liaison with external stakeholders e.g. PCT; police; social services, HSE, SHA etc is essential when sharing lessons learnt especially in relation to patient safety concerns. PCT representation on the Trust Governance Board will further facilitate this process as will Trust the representation on the PCT Governance Committee 5.7.2 The Clinical Performance Committee is a subgroup of the Governance Board and monitors complaints performance. The Committee will: Review and monitor frequently occurring themes arising from complaints by directorate/department and location to ensure that concerns are being addressed Review complaints performance by directorate/department and identify barriers to timely responses Monitor the implementation of agreed actions following a complaint Page 16 of 35

Ensure that lessons learnt are disseminated throughout the organisation Promote best practice in complaints handling across the Trust Identify training needs for directorates/departments and ensure that appropriate training/support is provided in line with the Trust Learning Together Strategy Ensure all staff attend a 2 hourly complaints training update every 3 years in accordance with the training needs analysis and the Trust Learning Together Strategy 6.0 HEALTHCARE COMMISSION A complainant may request his complaint to be considered by the Healthcare Commission when:- 6.1 He still remains dissatisfied with the outcome of the investigation by the Trust into his complaint; 6.2 The investigation into the complaint has not been completed within 6 months of the date on which the complaint was made; 6.3 The Trust has refused to investigate the complaint because it was not made within the time limits (see section 2.3); Where relevant this request should normally be made within a period of 6 months from the completion of the Local Resolution process or where it is not possible, as soon as reasonably practicable after the date of response. i) INITIAL REVIEW ii) The Healthcare Commission will undertake a document review of the complaint involving the complaint correspondence and where appropriate the patient s health records. A decision will then be made as to whether the complaint is to be investigated further. INVESTIGATION If the Healthcare Commission decide that the complaint is to be the subject of further investigation they will inform the Chief Executive of their decision. They will establish Terms of Reference for the complaint and will identify the staff they wish to interview. The Head of Complaints & Claims will act as the Liaison Officer between the Trust and the Healthcare Commission and will facilitate any interviews, meetings etc as the Healthcare Commission deem appropriate. iii) PANEL If the complainant remains dissatisfied with the outcome of the Healthcare Commission s investigation they have the right to request an Independent Panel to hear their concerns. As with the investigation stage the Head of Complaints & Claims will ensure that staff involved in the complaint are advised of what this process entails Page 17 of 35

iv) REPORT As soon as is reasonably practicable the Healthcare Commission will prepare a written report of its investigation which will: a) Summarise the nature and substance of the complaint b) Describes the investigation and summarises its conclusions including any findings of fact, the Healthcare Commission s opinion of those findings and its reasons for its opinion. c) Recommends what action are to be taken and by whom to resolve the complaint as well as identifying what other action is to be taken and by whom. The report may include suggestions which it considers would improve the Trust, or which otherwise would be effective in resolving the complaint and is to be sent to: a) The complainant b) The Trust c) Strategic Health Authority Where necessary the report will be anonymised to ensure confidential information is not disclosed. v) TIMESCALE The Healthcare Commission will expect to complete its investigation within 6 months from date they decide to investigate the complaint. Should the complainant remain dissatisfied and the complaint is subsequently referred to a Panel, they will expect this to normally be completed within 4 months of the date of the request, including the distribution of the Panel report. Details of the role of the Healthcare Commission are available from the Complaints & Claims Department and at the Healthcare Commissions website, which is www.healthcarecommission.org.uk. 7.0 PARLIAMENTARY & HEALTH SERVICE (OMBUDSMAN) 7.1 The Parliamentary & Health Service Ombudsman is the final stage of the NHS Complaints procedure. They are independent of the of the NHS and derive their powers from the NHS Commissioners Act 1993. 7.2 The Ombudsman can consider complaints made: a) by a patient b) by a member of the patient s family, their spouse or partner c) by someone acting on the patient s behalf who is authorised to do so 7.3 The Ombudsman can consider complaints about: Page 18 of 35

a) Unsatisfactory care or treatment, including the exercise of clinical judgement; b) Failure to provide a service that ought to have been provided; c) Poor administration, which might include poor documentation, rudeness, misleading advice, refusal to provide information to which an individual is entitled, or clerical error; 7.4 It cannot consider matters that relate to: a) Private health care not funded by the NHS; b) NHS personnel matters such as recruitment, pay or discipline; c) Refusal to access medical records (this matter is for the Information Commissioner); d) Contractual disputes between NHS bodies and their suppliers; e) Matters about which legal action has already been taken or about which the individual intends to take legal action; 7.5 Complaints to the Ombudsman must normally have been put first to the NHS organisation concerned. However the Ombudsman does have the power to consider complaints where the first two stages of the Complaints Procedure (ie Local Resolution and Healthcare Commission) have not been exhausted and where it is considered that, in the circumstances of the particular case, it is not reasonable to expect this. 7.6 Complaints are likely to be made to the Ombudsman where: 7.6.1 Trust has refused to investigate a complaint for whatever reason and the Healthcare Commission has upheld that refusal 7.6.2 An individual is dissatisfied with the failure to resolve their complaint at Local Resolution and the Healthcare Commission has refused an Independent Review of their complaint 7.6.3 The complainant is dissatisfied with the outcome of Independent Review 7.6.4 The Trust or Healthcare Commission decides to refer a complaint direct to the Ombudsman, using their powers under section 10 of the Health Service Commissioners Act 1993 7.7 On receiving the complaint the Ombudsman will decide whether it has the legal power to consider it. It will then assess whether or not the complaint is to be referred back to the Trust or Healthcare Commission 7.8 Where it is deemed the complaint is for investigation it will request all the relevant papers and other relevant information. Any such requests made to the Trust will be co-ordinated by the Head of Complaints & Claims, who will act as the Trust s Liaison Officer for such cases 7.9 Upon completion of its investigation the Ombudsman may uphold the complaint in full, in part or not at all. In any event a report will be produced Page 19 of 35

setting out its findings. Where any aspect of the complaint is upheld, recommendations may be made to the Trust regarding appropriate redress, which might include an apology, an explanation, improvements to practice and where appropriate, financial redress 7.10 The Ombudsman also has the power to refer individual clinicians to regulatory bodies if it considers this is necessary in the interests of patient safety 7.11 The Ombudsman will expect the recommendations to be implemented and will contact the Trust to find out if/when this has been undertaken. The Strategic Health Authority will also be provided with a copy of the Ombudsman s report and will be provided with a copy of the Trust s response (including the Action Plan) in relation to the complaint 7.12 Preventing the Intervention of the Ombudsman The Ombudsman will expect that: Individuals are treated with respect and are not penalised for making a complaint The Trust can explain clearly to the complainant how their complaint has been handled and will ensure that they are aware of the appropriate advice, advocacy and support services available to them Individuals are given clear specific reasons, which are based on evidence, for decisions taken on their complaint and that these decisions address all the concerns raised by the complainant Individuals making complaints will be given accurate information about the role of the Ombudsman and are aware of their rights to take the complaint further if they remain dissatisfied with the outcome of Local Resolution 8.0 MONITORING OF COMPLAINTS/CONCERNS 8.1 The Trust Board will continue to receive quarterly reports on complaints and statistics, seeking assurance that action have been taken and risk reducing measures are in place and monitored re effectiveness 8.2 An Annual Report will also be provided to the Healthcare Commission as required. 8.3 Complaint Satisfaction Surveys will be undertaken by the Complaints & Claims Department to monitor all processes. 8.4 Lessons learned, trends, follow up action will be identified by the Assistant Director of Operations/Head of Department and co-ordinated by where such information needs to be disseminated within the Trust or included in future training needs. Page 20 of 35

9.0 STAFF COMPLAINTS These may be dealt with under other policies or procedures e.g. Raising Concerns at Work policy, Grievance procedure. 9.1 Staff concerned about the actions of other members of staff or concerned on a patient s behalf, should feel able to approach their manager or the identified contact under the Public Interest Disclosure Act 1998. 9.2 Information received in such a way will be treated with the utmost respect, however, it is unreasonable to expect that this information can remain confidential and staff may be asked to provide a statement or be called as a witness in any investigation. 9.3 Staff who are concerned that approaching their Manager is not possible, or feel this is unreasonable, can approach their Chief Executive, Medical Director or Director of Nursing, Midwifery & Governance. 9.4 Confidential helplines are available as published throughout the Trust, Internal Ext. 1777 or External 0151 430 1777. 10.0 PUBLICITY OF COMPLAINTS POLICY/PROCEDURE 10.1 All staff must be aware of the Complaints Policy/Procedure. 10.2 All members of staff are to know the name and address of the Complaints Manager, who is the Head of Complaints & Claims. 10.3 All staff are to know the role of PALS, the Independent Conciliation and Advocacy Service (ICAS), the Healthcare Commission and the Parliamentary & Health Service Ombudsman. 10.4 The address of the local ICAS is to be publicised. 10.5 Notices and information leaflets are to be made available to staff, patients, visitors and members of the public. All the above information is to be contained in handbook/leaflets produced by the Trust. Page 21 of 35

INFORMAL COMPLAINT RECORD FORM APPENDIX 1 Name of Patient: Ward: Date Reported: Completed By: Hospital Number: Print Name: Sign: Date/Time of Incident Complainant's Name/ Place of Incident Description of Incident Staff Involved Action Taken Was the Matter Resolved? What Further Action Was Taken? YES NO ON COMPLETION THIS FORM IS TO BE SENT TO YOUR LINE MANAGER AS SOON AS POSSIBLE Page 22 of 35

COMPLAINT RECEIVED AT LOCAL LEVEL APPENDIX 2 COMPLAINANT DISSATISFIED Does member of staff feel this should be treated formally? NO YES Is complainant satisfied with action taken? YES NO COMPLAINT BECOMES FORMAL No further action required unless requested. (i) Ask complainant to complete complaint pro-forma or complete this on their behalf at the time. (ii) Obtain signature from complainant (but not compulsory). Informal complaints form completed and sent to (iii) Forward to Complaints & Claims Department same/first working day. Asst Director/Head of Department via Line Manager (iv) Explain to complainant that it will be investigated and they will be contacted. (v) Collect statements and relevant documentation, forward to Assistant Director of Operations/Head of Department. SEE APPENDIX 4 FOR FURTHER GUIDANCE Page 23 of 35

FORMAL COMPLAINT - LOCAL RESOLUTION COMPLAINTS (WRITTEN OR VERBAL) APPENDIX 3. Direct to Service Record all details at location and forward both verbally and hard copy to the Complaints & Claims Department. Direct to Chief Executive Forwarded to Complaints & Claims Department. Complaint Acknowledged and email details to all involved and relevant Assistant Director/Head of Department. Relevant Assistant Director/Head of Department instigates investigation. WITHIN 2 WORKING DAYS OF RECEIPT Complaint acknowledged in writing. If complaint made verbally, summary of complaint sent for complainant to confirm content. WITHIN 2 WORKING DAYS OF ACKNOWLEDGEMENT BEING SENT Copies of complaint and request for investigation to relevant Assistant Director/Head of Department, who instigated investigation. Where a member of staff is named in a complaint they must be provided with a copy and be given the right to respond to the allegations made Relevant Assistant Director/Head of Service instigates investigation. Complaints & Claims Department will log complaint onto to Prism (erms). Allocate to Assistant Director/Head of Department. Complaint investigated and statements collected & logged onto prism (erms). WITHIN 15 WORKING DAYS REMINDER E-MAILS WILL BE SENT AT DAYS (10,15,20,25) Draft written response to complainant forwarded to Head of Complaints & Claims via e-mail. DAY 21 (OR SOONER) Should delays in response occur, apologies must be offered to the complainant and they must be informed of the reasons why and an agreement reached with a new timescale for the response to be sent. WITHIN 25 DAYS Complaint response sent to Chief Executive for signature. WITHIN 28 DAYS OF DATE OF RESPONSE LETTER If complainant remains dissatisfied, invited to contact relevant Assistant Director/Head of Department to discuss. If remain dissatisfied referred to Head of Complaints & Claims Dept. WITHIN 6 MONTHS OF DATE OF RESPONSE LETTER If still dissatisfied complainant should refer complaint to the Healthcare Commission. Page 24 of 35