HANDLING COMPLAINTS POLICY & PROCEDURE

HANDLING COMPLAINTS POLICY & PROCEDURE This policy can be made available in other formats and languages upon request to the PALS office on 01708 435454 Content includes: Principles of Complaints Management General Guidelines Stage One - Local Resolution Stage Two - Health Service Ombudsman GMC/NMC Complaints Third Party Complaints Freedom of Information Act Learning from Complaints Policy Number: 2012/CG/073 Version: 3 Ratified by: Policy Ratification Committee Date: 12th September 2012 Approved by: Quality & Safety Committee Date: 16 th October 2012 Name & Title of Originator/Author: Gary Etheridge, Deputy Director of Nursing Responsible Committee/Individual: Quality & Safety Committee Responsible Division: Corporate Nursing Date Issued: Review Date October 2014 Target Audience: All BHRUT staff Policy Template Issued 2nd November 2011 Barking, Havering & Redbridge University Hospitals NHS Trust Page 1 of 49

Contents Section Page Complaints Handling Process (Flowchart) 4 1 Introduction 5 2 Purpose 5 3 Definitions 6 4 Roles & Responsibilities 7 All Trust Staff 7 Trust Board 7 Chief Executive 8 Director of Nursing 8 Clinical Directors 8 Associate Directors (Directorates) 8 Deputy Director of Nursing 8 Complaints Manager & Complaints Co-ordinators 8 Investigating Officers 9 Matrons/General Managers/AHP Managers 9 Senior Clinicians 9 Independent Reviewers (Internal & External) 9 4.1 Principles of Complaints Management 10 4.2 General Guidelines 11 4.3 Stage One - Local Resolution 12 4.3.1 Verbal Complaints 12 4.3.2 Written Complaints 13 4.3.3 Complaint Investigation 14 4.3.4 Action to be taken when the Complainant is not Satisfied 15 4.3.5 Complaints Involving More than one Organisation 16 4.4 Stage Two - Health Service Ombudsman 16 4.5 Vexatious Complainants 16 4.5.1 Identifying a Vexatious or Unreasonably Persistent Complainant 17 4.5.2 Options for Dealing with Vexatious or Unreasonably Persistent Complainants 18 4.5.3 Withdrawing Unreasonably Persistent or Vexatious Status 19 4.6 GMC/NMC Complaints 19 Barking, Havering & Redbridge University Hospitals NHS Trust Page 2 of 49

4.7 Confidentiality 19 4.8 Third Party Complaints 20 4.9 Freedom of Information Act 20 4.10 Learning from Complaints 21 5 Development of this Policy 21 5.1 Consultation & Communication with Stakeholders 21 5.2 Equality Impact Assessment 22 5.3 Approval & Ratification 22 6 Review & Revision Arrangements 22 6.1 Review 22 6.2 Revision 22 7 Dissemination & Implementation 22 7.1 Dissemination 22 7.2 Implementation 22 8 Monitoring 23 9 References 25 10 Associated Documents 25 11 Amendments 25 Appendices A Verbal Complaints Form (taken on site) 26 B Complaints Form 27 C Trust Risk Grading Matrix 31 D Guidance on Statement Writing and Recording Interviews 35 E F Guidance for Meetings with Complainants about Formal Complaints Protocol for the Handling of Cross Agency Complaints in the NHS & Adult Social Care Services G Complaint cases taken forward by the complainant with the Parliamentary & Health Service Ombudsman (PHSO) 42 H Equality Impact Assessment Tool 43 I Checklist for the Review and Approval of Procedural Documents 38 39 45 J Plan for Dissemination of Procedural Documents 48 Barking, Havering & Redbridge University Hospitals NHS Trust Page 3 of 49

COMPLAINTS HANDLING PROCESS Verbal complaint received via PALS Verbal complaint or concern received (within ward, department, clinic) Written complaint received via Directorates Written complaint received via CEO Office/Complaints Department Issues recorded on Safeguard database Resolved by end of next working day Not resolved by end of next working day Resolved by end of next working day Not resolved by end of next working day Notify Complaints Department File opened within Safeguard database if not already logged Safeguard file updated and closed Notify complainant of progress and agree timescale for resolution within 5 working days Feedback provided in accordance with contract of agreement (verbal/meeting/ written within 5 working days Completed Verbal Complaint Form sent to Complaints Department for recording on the Safeguard database File Closed Complainant not satisfied Investigation of complaint Complaint sign off by CEO Complaint referred to Directorate on day of receipt, for investigation Complaint Manager to telephone complainant (or if not possible, write) to introduce, acknowledge receipt and to agree contract, including issues, timescales, feedback mechanism and preferred outcome Within 3 working Days Resolved within 5 working days update Safeguard file & close Not resolved within 5 working days, notify contact and offer options for PALS continuation or escalate to a formal complaint Barking, Havering & Redbridge University Hospitals NHS Trust Page 4 of 49 Outcome of investigation shared with the complainant in accordance with the contract and confirmed in writing Development and implementation of recommendations File Closed

1. INTRODUCTION This policy and procedure explains how Barking, Havering & Redbridge University Hospitals NHS Trust (BHRUT / the Trust) implements the statutory legal framework for the Local Authority and National Health Service Complaints (England) Regulations 2009, and meets the requirements of the NHS Constitution (DH, 2010). The policy and procedure reflects the Department of Health s (DH) guide Listening, Responding, Improving (2009), acknowledges the good practice outlined in the Parliamentary and Health Ombudsman s Principles of Remedy (2007) and aims to ensure compliance with the Care Quality Commission - Essential Standards of Quality and Safety, and the NHS Litigation Authority Risk Management Standards for NHS Trusts providing Acute, Community or Mental Health & Learning Disability Services. In developing this policy and procedure the Trust has taken into account lessons learnt following the inquiry into the care provided by Mid Staffordshire NHS Foundation Trust. The inquiry found that the poor experiences of patients and their families were not taken into account in the delivery of safe and effective services. The policy and procedure applies to all departments and areas within the organisation; and applies to all permanent and temporary staff working with the Trust. 2. PURPOSE The Trust views complaints positively and is committed to having effective procedures in place to handle all issues brought to the attention of staff. The organisation will take an active approach to asking for people s views, dealing with complaints more effectively and using the information received to learn and improve. Staff work hard to get the job right first time but sometimes mistakes can occur. When services respond to user feedback quickly and effectively, problems and mistakes can be prevented from happening again. Complaints arise from differences of understanding, perceptions or beliefs but they provide a valuable indication of the quality of services provided and this information can and will be used to help improve services and find a better way to meet the needs of patients. Staff will treat all complaints seriously and listen to what service users have to say, providing assistance and advice on the process which the Trust will follow to provide answers and where possible resolve concerns. It should be recognised that patients in receipt of care can at times feel vulnerable and may feel that their care will be effected if they complain, staff should do everything they can to dispel this impression, for example by actively seeking patients views on their care and by being open and responsive to patient needs. It is essential that patients and carers understand that they have a right to complaint without fear or discrimination. The Trust will always respond to a complaint in a non defensive and open manner, apologising where appropriate and any discriminatory actions identified will be dealt with according to the Trust s Disciplinary Policy, Rules and Regulations. Barking, Havering & Redbridge University Hospitals NHS Trust Page 5 of 49

The underpinning aim of the Policy and Procedure for Handling Complaints is to establish a process to effectively manage situations of perceived or actual failure or shortcomings of the services provided by the Trust. The Policy and Procedure for Handling Complaints reflects the needs of: Complainants, with regard to respect, courtesy, accessibility, timeliness, empathy, clear communication, simplicity, confidentiality, transparency, efficiency and quality of personal service given. Staff, by creating a transparent and supportive culture. The Trust, by creating an open, effective system which provides the basis for an overall culture of learning. The Local Population, by seeing that the Trust can demonstrate a positive response to complaints will hopefully increase their confidence in the services provided. 3. DEFINITIONS The following definitions apply for terms used in this policy and procedure: Patient: the person whose care and treatment is the subject of the complaint, concern or comment. Complainant: the person who is raising the complaint, concern or comment. Complaints: can be defined as an expression of discontent which requires a response. It is a generic term for any sort of complaint, raised either orally or in writing by people using health/social care services. Formal complaint: anything in writing that cannot be concluded in the next working day following receipt. Stage 1 (Local Resolution): when those providing the service are able to resolve the complaint to the complainant s satisfaction. Stage 2 (Parliamentary Health Service Ombudsman - PHSO): when the complaint is not resolved at Stage 1 and the complainant takes up the option to refer the case for review by the PHSO. The Ombudsman is independent of the NHS and the Government and derives her powers from the Health Service Commissioners Act 1993. First contact resolution of a complaint: this is defined as a complaint which is made orally and is resolved to the complainant s satisfaction no later than the next working day after the day on which the complaint was made. These complaints are not reportable externally under The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, but should be recorded electronically on the Safeguard database for monitoring purposes. Safeguard: is the organisation s risk management software which is used for the recording and reporting of adverse incidents, complaints, claims, concerns raised with the Barking, Havering & Redbridge University Hospitals NHS Trust Page 6 of 49

Trusts Patient Advice & Liaison Service (PALS), Freedom of Information requests, inquests and organisational risks. Time limit on initiating complaints: a complaint should be made as soon as possible after the action giving rise to it. The time limit for making a complaint will be within 12 months from the date the matter occurred or the matter coming to the notice of the complainant. There is discretion to investigate beyond this, if there are good reasons for a complaint not having been raised sooner, e.g. bereavement, and it is still possible for the Trust to investigate the complaint effectively and fairly. Patient Advice and Liaison Services (PALS): provides support to patients, carers and relatives, representing their view and resolving local difficulties on-the-spot by working in partnership with Trust staff. In addition to helping resolve patients concerns quickly and efficiently, and improving the outcome of care in the process, PALS provide information to patients to help make contact with the NHS as easy as possible. Information leaflets regarding the PALS service are available in clinical and non clinical areas throughout the Trust. Independent Complaints Advocacy Services (ICAS): helps individuals to pursue complaints about the NHS, ensuring that complainants have access to the support they need to articulate their concerns and navigate the complaints system, thereby maximising the chances of their complaint being resolved more quickly and effectively at a local level. ICAS will determine the level of service required according to complainant s needs. As well as providing advice the service provides advocacy in terms of writing letters and attending meetings to speak on the complainant s behalf. 4. ROLES & RESPONSIBILITIES All Trust Staff All staff have a responsibility to respond to any concern or complaint raised to them by patients or visitors, with an emphasis on early resolution. All staff have a responsibility to deal with a concern or complaint in an open, constructive and non-judgemental manner. Where possible, the staff member will resolve the matter immediately or as soon as possible or refer to a more senior member of staff on duty at the time. All staff who deal with or investigate concerns or complaints should possess the necessary skills to undertake this role. All staff have a responsibility to direct patients and carers to appropriate information regarding how to give feedback and how to raise a concern or complaint. Trust Board The Trust Board has a monitoring role: to receive regular assurance reports that the policy and procedure for handling complaints is working effectively; to monitor themes from complaints; and ensure systematic learning and appropriate actions are taken in response to concerns or complaints. Barking, Havering & Redbridge University Hospitals NHS Trust Page 7 of 49

Chief Executive The Chief Executive has overall accountability for ensuring compliance with the statutory regulations. S/he is responsible for approving and signing off all complaint response letters. Director of Nursing The Director of Nursing is strategically responsible for maintaining the Trust policy in accordance with current legislation, and is the Executive Director responsible for complaints and takes responsibility for; ensuring compliance with the Trust s Policy & Procedure for Handling Complaints; monitoring of performance; and providing assurance to the Trust Board. The Director of Nursing is also responsible for ensuring any issues of professional mismanagement arising from complaints are reported. Clinical Directors The Clinical Directors are responsible for: ensuring timely and complete investigation and response to all complaints regarding their services; achieving performance targets; overseeing the implementation of action plans arising from complaints; ensuring complaints are managed and actions completed within the Directorate s Governance Framework. Associate Directors (Directorates) Associate Directors (Directorates) are responsible for overseeing and monitoring the management of complaints within their Directorate, nominating Investigation Officers and providing support and assistance throughout investigations. Associate Directors (Directorates) are responsible for quality assuring the final draft complaint response letter prior to sending it to the Complaints Department to be processed. In addition, the Associate Directors (Directorates) should ensure if applicable that all complaints have comprehensive action plans and that these are monitored at relevant meetings. Associate Directors (Directorates) will ensure that all actions identified from a complaint are implemented and monitored. Deputy Director of Nursing The Deputy Director of Nursing has responsibility to ensure that the Trust s Complaints and PALS Policies are being implemented effectively and that the data required to facilitate performance monitoring across the organisation is functioning effectively and is able to identify trends and hotspot analysis, liaising as appropriate with the Complaint and PALS Managers. Complaints Manager & Complaints Co-ordinators The Complaints Manager and Complaints Co-ordinators have responsibility for monitoring the complaints process to ensure it is effective and in line with the Local Authority Social Services and NHS Complaints (England) Regulations (2009). They will also support the Directorate Management Teams in the administration of complaints, the investigation process and provide advice where appropriate. Specifically, they should: Receive and process complaints from a variety of sources where a complainant may complain. Barking, Havering & Redbridge University Hospitals NHS Trust Page 8 of 49

Centrally log the complaint onto the Safeguard database, and perform any other relevant administration tasks. For example, obtain third party consent where necessary. Ensure the complaint is shared with the appropriate Directorate Lead in a timely and professional manner, to allow them to consider how best to manage the complaint, including agreeing with the complainant a timescale for the response to the complaint. Where it is known that the complaint involves a vulnerable adult or child. The Named Nurse, Safeguarding Children or Named Nurse, Safeguarding Adults will be informed within 24 hours or next working day of receipt of the complaint and the most appropriate investigation agreed. Investigating Officers Investigating Officers are responsible for investigating complaints in line with the procedures outlined in this policy, ensuring that all appropriate actions are taken to achieve local resolution. Investigating Officers may be drawn from a wide range of staff groups, depending on the concerns being raised. Matrons/General Manager/AHP Managers The Matron/General Manager/AHP Manager is responsible for ensuring: Effective complaints management within their areas of responsibility, providing support to investigations. Patients are not treated differently in any way as a result of raising a concern or complaint. This also extends to their relatives and/or carers. That Nursing/Midwifery Staff/General Managers/AHP staff receive training in complaints management. That a process is in place which encourages patients to provide feedback prior to discharge from hospital. Senior Clinicians Senior clinicians have responsibility to co-operate in the investigation of a complaint relating to treatment provided by them or one of their team, including meeting with complainants, if requested. They also have a responsibility to provide their opinion on treatment provided by a clinician outside their team, if necessary. Senior Clinicians have a responsibility to ensure they, and their junior staff, attend complaint training to ensure they have the necessary skills and expertise. Independent Reviewers (Internal & External) Independent Reviewers (internal) have the responsibility of considering a complaint outside their area where the initial investigation has failed to resolve the complaint to the complainant s satisfaction. Independent reviews may be undertaken outside the Trust (external), if it is felt an internal review would not offer a true independent opinion, or if the complainant rejects an internal independent review. Barking, Havering & Redbridge University Hospitals NHS Trust Page 9 of 49

4.1 Principles of Complaints Management It is the right of every health service user (patient, in the case of a minor the person who has parental responsibility or a carer appointed through the courts, patient s carer or relative) to bring to the attention of Trust management aspects of their care and treatment about which they are unhappy. All staff must be aware of an individual s right to comment on the standards of service provided by the Trust and must therefore be familiar with the Trust s Handling Complaints Policy & Procedure. The Trust must seek authority of the patient themselves before any information personal to the patient is divulged. Any complaints system should be simple, easy to understand and as devoid of bureaucracy as possible, while ensuring that it is effective in responding to the satisfaction of complainants. Service users, regardless of their position in society, age, race, language, literacy level or physical or mental ability should be able to register a complaint. NHS staff should, at all times, treat patients, carers and visitors politely and with respect. However, violence, racial, sexual or verbal harassment of staff will not be tolerated. Neither will NHS staff be expected to tolerate language that is of a personal, abusive or threatening nature. All complaints should be taken seriously regardless of how trivial they may appear to the recipient of the complaint. Responses to complaints must address the substance of the complaint with the aim of satisfying the complainant. In the case of verbal complaints, front-line staff are empowered to resolve complaints at source on behalf of the Trust. Complainants must be involved from the outset and Investigating Officers should seek to determine what complainants are hoping to achieve from the process. The complainant should be given the opportunity to understand all possible options for pursuing the complaint and should be kept informed. Both complainant and anyone complained against must feel that any investigation carried out has been impartial and that all points of view have been listened to and judged fairly. Respondents should be willing to accept the validity of the complainant s point of view, even if they do not share it; to give an explanation of events and apologise if appropriate. No patient who has raised a concern or complaint is to be treated differently in any way as a result. All staff involved in the care of the patient, and those involved in the investigation, must ensure that their actions could in no way lead to the patient, their relatives or their carers, being treated differently as a result. Barking, Havering & Redbridge University Hospitals NHS Trust Page 10 of 49

Details of all complaints are logged on the Trust Safeguard database system. 4.2 General Guidelines All complaints, whether they are received within Directorates or centrally, must be checked on receipt for the following: To ensure that the complaint does not indicate that a service user, patient or member of staff is at immediate risk. If the service user, patient or member of staff is at risk, action must be taken without delay to ensure their safety and the Director of Nursing/designated deputy notified accordingly. If a complaint is a potential legal claim, it should be referred to the Complaints Manager without delay. The Complaints Manager should check whether a legal claim has been lodged against the Trust. If a legal claim has not been lodged the complaint should be investigated as per this policy and procedure. However, it is advised that the Complaint Manager liaises with the Claims Manager regarding whether there may be potentially a claim in the future. The Claims Manager may decide to seek guidance from the NHSLA. If a legal claim has been lodged the Claims Manager, Director of Nursing and Medical Director will decide whether responding to the complaint may be prejudicial to the outcome of the legal case. To establish whether the complaint has been made within the timescale (12 months) for making complaints. To determine whether the complaint concerns matters for which the Directorates or Trust have responsibility or jurisdiction. If this is not the case, the complaint should be sent to the Complaints Manager as soon as possible for appropriate re-direction. The principle of confidentiality must be respected throughout the process by all staff. The complained against, as well as the complainant, should be kept informed of the progress of complaint investigations, by either the Complaints Manager or Directorate Complaints Co-ordinators, and be made aware of the outcome. Complete and accurate records, including any written statements provided or copies of file notes, must be kept throughout the investigation of complaints. A complaint file has the same status as any other created by a healthcare organisation. It is a public record; its contents are confidential and should be maintained to an appropriate standard. All records/correspondence must be dated. Electronic and paper complaint records should be kept separate from the patient s health records, for 8 years after the resolution of the complaint after which they can be confidentially destroyed. If investigation of a complaint reveals a possible need for disciplinary action against staff at any point in the investigation, the matter must be referred at once by the appropriate manager to the Director of Nursing who, if appropriate, will liaise with Human Resource Department and any other relevant professional lead. If disciplinary proceedings are to be initiated, then the complaints process and the matter should be taken forward under the Trust s Disciplinary Policy, Rules & Procedures. The complainant and complained against should be advised accordingly. Relevant information gathered in investigating the complaint may be handed over for the Barking, Havering & Redbridge University Hospitals NHS Trust Page 11 of 49

purpose of the disciplinary investigation. However, if any part of the complaint is not the subject of the disciplinary proceedings, proceedings under this policy may continue for that part of the complaint. If investigation of a complaint reveals an unreported adverse incident, the matter must be referred at once by the appropriate manager to the Clinical Governance Department. For complainants that have difficulty communicating, or for whom English may not be their first language, the Trust has access to a range of services to facilitate understanding. These can be accessed by contacting the PALS Department. The fact that a death has been referred to the Coroner s Office does not mean that the Trust cannot carry out a complaint investigation. Any investigations involving the Coroner must be signed off by the Chief Executive. The Complaints Manager or designated deputy should liaise with the Coroner s Office and forward a copy of the report to the Coroner on completion of the investigation and advise the complainant of this. The Trust is committed to providing safe and effective care for patients and individual employees have a right and duty to raise any concerns. This policy and procedure should be read in conjunction with the Trust s Whistleblowing Policy which has been drawn up to provide an avenue for staff to raise issues of concern and to protect patients from harm. The Director of Nursing should be notified immediately of any concerns arising from a complaint which require referral to professional regulatory bodies, the police, the Coroner, or protection agencies (vulnerable adults and children). 4.3 Stage One - Local Resolution A complaint may be made verbally or in writing (including electronically). 4.3.1 Verbal Complaints Verbal complaints/concerns can be made face to face or by telephone. The member of staff receiving the complaint should listen courteously to what the complainant has to say and should identify the issues of concern and the outcomes expected by the complainant. These should be recorded on a verbal complaint form (Appendix A). If the complainant does not wish to discuss their concerns over the telephone they should be offered the opportunity of a face to face meeting at the earliest opportunity. The member of staff should apologise if appropriate, and seek to resolve the complaint immediately if at all possible. If the complaint is resolved at first contact (by the end of the next working day), the member of staff should update the verbal complaint form and forward this to the Complaints Department for recording on the Safeguard database. The file can then be closed. In the case of a clinical complaint, the relevant Consultant, Matron, Midwife or Allied Health Professional must be contacted without delay. The offer of a meeting with a clinician at this stage may resolve the complaint. Barking, Havering & Redbridge University Hospitals NHS Trust Page 12 of 49

If the complaint is not resolved at first contact the member of staff should escalate this to the Complaints Department who will open a file within Safeguard, using the information contained on the verbal complaint form. The Complaints Department will proceed to organise the investigation of the complaint. If the verbal concern is received by a member of the PALS team, the same process applies, however, the PALS Officer will record the information directly onto Safeguard and if resolved within timescales agreed at first contact, will update and close the Safeguard file. If it is not possible for the PALS Officer to feedback to the complainant by the end of the next working day, for example, because the member of staff has to obtain information from another source which cannot be provided immediately, the PALS Officer will agree a timescale and respond as agreed. Where possible, this will be no longer than 5 working days. On working day 5, the PALS Officer will contact the enquirer and discuss options for continuation of the enquiry. The PALS Officer will update the Safeguard file and close the concern. Follow up on implementation of any recommended actions will be undertaken by the Directorate in which the complaint occurred. 4.3.2 Written complaints Written complaints can be received by letter, fax or electronically. If complainants require guidance on what they need to include in their complaint, the Complaints Department will send them a Complaints Form (Appendix B) to complete. All written complaints should be forwarded to the Complaints Department who will open a file on Safeguard with individual complaints given a unique reference number. All formal complaints will be acknowledged in writing by the Complaints Department within 3 working days. The Complaints Team will have a conversation with the complainant to negotiate and agree the following issues: The manner in which the complaint is to be handled: a telephone call from the manager in charge of the service may resolve the problems, or the complainant may require a meeting to talk about their concerns, or they may require a full investigation and a written response may be required. The period of time in which the investigation into the complaint is likely to be completed. The Trust will agree a reasonable timescale which allows a thorough investigation to the carried out. A copy of the Trust s Complaints Leaflet will be enclosed with the formal letter of acknowledgement and information will also be provided on the Independent Complaints Advocacy Service (ICAS). The Complaints Manager will determine the process of investigation for the complaint in accordance with the Trust s Risk Matrix (Appendix C). Barking, Havering & Redbridge University Hospitals NHS Trust Page 13 of 49

The Complaints Team will refer the complaint to the Associate Director (Directorate) and will identify the deadline when the draft complaint response is required. The Associate Director (Directorate) will review the complaint and allocate an Investigating Officer who will proceed to investigate the complaint. If the issues raised in the complaint involve more than one Directorate, the Complaints Manager will consider the complaint and decide which Directorate should lead the investigation. The complaint will be referred to each individual Associate Director (Directorate) or Deputy who will allocate the complaint to relevant Investigating Officers in the Directorates. Where a complaint is related to a Coroner s Inquest, a clinical negligence claim, an adverse incident or serious incident, or a staff disciplinary matter, so far as possible the Complaints Manager will work with the other responsible managers to ensure that one single investigation is established. Complaints, inquests, clinical claims and adverse incidents are all entered onto the Trust database, allowing cases involving more than one category of investigation to be identified. The Complaints Manager is responsible for ensuring that complainants receive a written response to their complaint within an agreed timeframe, and documented on the complaint file. If for whatever reason the investigation is not completed within the agreed timescale a revised timescale will be agreed with the complainant and documented accordingly. 4.3.3 Complaint Investigation The investigation should be managed discreetly and confidentially in a manner appropriate to resolve it speedily and effectively. Any meetings with staff should be in private, written notes of the discussion should be taken, agreed by all parties and a copy retained in the electronic complaint file and the paper complaint file. Telephone conversations should not take place in public places, and records concerning complaints should be stored in such a way that only those with a need to know have access. Correspondence should be conveyed electronically, where possible. If correspondence is being sent externally, this should be either password protected or via the secure NHS Mail system. In cases where this is not possible correspondence should be in sealed envelopes marked Private and Confidential. The Investigating Officer should write to the Ward/Department Manager and to any other relevant parties enclosing a copy of the complaint or extract, as appropriate, asking for the individuals comments. The Investigating Officer may consider it more appropriate to meet with the staff concerned to obtain a statement (Appendix D) to clarify events. It is also useful to make it clear to those members of staff being asked to make a statement, exactly which elements of the complaint they need to answer. Statements are filed in the paper complaints file. The Investigating Officer should ensure that staff understand the procedure to be followed and offer support and guidance, if necessary. Staff should also be made aware that they can request professional support from their line manager or staff side representative if necessary. If the Investigating Officer encounters difficulties obtaining a statement from a member of staff this should be escalated up to the Associate Director (Directorate)/Head of Department. Barking, Havering & Redbridge University Hospitals NHS Trust Page 14 of 49

If the complaint involves clinical issues, the Investigating Officer should include the Matron/Clinical Director/Head of Department or any other professional lead, as appropriate, in the investigation and also consider the benefits of contacting the complainant. As part of the investigation the Investigating Officers should review relevant Trust and national policies/guidance etc to ascertain whether the care/service complained about was in line with established standards. The Investigating Officer should telephone/write to relevant members of staff who have left the Trust, if contact details are available from the HR Department, and ask for their comments. The member of staff is not legally obliged to respond although they should be encouraged to do so under their duty of continuing care. The Investigating Officer, in liaison with the Associate Director (Directorate)/Matron and Director of Nursing may seek advice, where appropriate, from Independent Experts (clinical and otherwise) from both within and outside the Trust. When the investigation is complete and a draft complaint response letter has been approved by the Associate Director (Directorate) this should be emailed to the Complaints Department, within the agreed timeframe. The Director/Deputy of Nursing will intervene if the submission of a final response for the Chief Executive s signature is unreasonably delayed. The Associate Director (Directorate) with the support of the Investigating Officer should feedback the outcome of the investigation to the staff involved. Following the closure of a complaint the Associate Director (Directorate) where relevant should sign off a complaint s action plan to deliver any recommendations that have been identified as part of the complaints investigation process. Directorates are required to establish a system to ensure that recommendations made as a result of complaints are implemented and that resultant actions are monitored and reviewed at the Directorate Clinical Governance Meetings. A summary of lessons learnt arising from complaint investigations will be included in a quarterly Patient Experience report (see 4.10 below). 4.3.4 Action to be taken when the complainant is not satisfied In situations when complainants are not satisfied with the response made by the Trust to their complaint, the Complaints Manager should contact the complainant to identify why the complainant is dissatisfied, establish issues that remain outstanding and the expected outcomes. The Complaints Manager, in liaison with the Investigating Officer and the Director of Nursing, will then review the outstanding issues and the action taken so far to resolve the complaint and identify an appropriate course of action. The following actions may be explored in order to effect resolution: Further investigation by the Investigating Officer. Barking, Havering & Redbridge University Hospitals NHS Trust Page 15 of 49

Meeting with Trust representatives. Any meetings with complainants should be in line with Trust Guidance (Appendix E). Independent review by Internal/External Reviewer. The Investigating Officer should make every effort to resolve the complaint locally. On completion of a further investigation a written response should be sent to the complainant, signed off by the Chief Executive, which should again invite the complainant to refer back to the Complaints Manager, should they require further clarification or remain dissatisfied, and a copy retained in the paper complaint file. If the complainant does not wish the Trust to investigate the complaint further, or if the Directorate believes that all avenues for local resolution have been exhausted, the complainant should be reminded of their right to ask the Health Service Ombudsman to review their case and information should be provided concerning this process. The final decision as to whether the Directorate have exhausted local resolution will be made by the Director of Nursing, in liaison with the Associate Director (Directorate). For further details on the Principles of Good Complaint Handling please visit the Parliamentary and Health Service Ombudsman website www.ombudsman.org.uk. 4.3.5 Complaints involving more than one organisation A protocol has been developed by members of the local health and social care organisations which should be followed for complaints involving more than one organisation. A copy of the protocol is attached at Appendix F. The Complaints Manager will be responsible for co-ordinating this process. 4.4 Stage Two - Parliamentary Health Service (PHSO) If the complainant remains dissatisfied with the Trust s attempt(s) at Local Resolution, they can ask the PHSO to review their case. The complainant should be advised in the Trust s final response of their right to refer their case to the PHSO if they are not satisfied. Any correspondence received from the PHSO relating to such requests should be forwarded to the Complaints Manager for action. Refer to Appendix G for the Trust s procedure in dealing with PHSO requests. 4.5 Vexatious complainants The Trust is committed to dealing with all complainants fairly and impartially. However, people who bring prolific complaints can be difficult to deal with. Whether they are right to persist with their complaint or not, they need support to resolve the issue. It is important to remember that if a person contacts the Trust with what they believe is a complaint, then to them it is a serious concern. If the complainant raises the same or similar issues repeatedly, despite receiving a full response, there may be underlying reasons for this persistence. Regardless of the manner in which the complaint is made and pursued, its substance should be considered carefully and on its objective merits. Barking, Havering & Redbridge University Hospitals NHS Trust Page 16 of 49

Complaints about matters unrelated to previous complaints should be similarly approached objectively, and without any assumption that they are bound to be frivolous, vexatious or unjustified. If a complainant is abusive or threatening, it is reasonable to require him or her to communicate only in a particular way, i.e. in writing and not by telephone or solely with one or more designated members of staff; but it is not reasonable to refuse to accept or respond to communications about a complaint until it is absolutely clear that all practical possibilities for resolution have been exhausted, and after a full discussion with the Director of Nursing/designated deputy. 4.5.1 Identifying a vexatious or unreasonably persistent complainant Complainants (and/or anyone acting on their behalf) may be deemed to be vexatious or unreasonably persistent where previous or current contact with them shows that they meet TWO OR MORE, or are in serious breach of one, of the following criteria: Persist in pursuing a complaint where the NHS Complaints procedure has been fully and properly implemented and exhausted. Change the substance of a complaint or seek to prolong contact by continually raising further concerns or questions upon receipt of a response or whilst the complaint is being addressed. (Care must be taken not to discard new issues which are significantly different from the original complaint. These may need to be addressed as separate complaints). Are unwilling to accept documented evidence of treatment given as being factual, e.g. medical or nursing records, deny receipt of an adequate response in spite of correspondence specifically addressing their concerns or do not accept that facts can sometimes be difficult to verify. Do not clearly identify the precise issues which they wish to be investigated, despite reasonable efforts of Trust staff and/or others, e.g. Independent Complaints Advocacy Service (ICAS), to help them specify their concerns. Focus on a trivial matter to an extent which is out of proportion to its significance and continue to focus on this point. (It is recognised that determining what a trivial matter is can be subjective and careful judgement must be used in applying this criterion). Have threatened or used actual physical violence towards staff or their families or associates at any time - this will in itself cause personal contact with the complainant and/or their representatives to be discontinued and the complaint will thereafter only be pursued through written communication. (All such incidents should be documented and reported, as appropriate and if necessary to the Police). Have, in the course of pursuing a complaint, had an excessive number of contacts with the Trust placing unreasonable demands on staff. (A contact may be in person or by telephone, letter, email or fax). Staff should be instructed to keep a clear record detailing the number, type and nature of contacts. Discretion must be used in determining the precise number of excessive contacts applicable under Barking, Havering & Redbridge University Hospitals NHS Trust Page 17 of 49

this section, using judgement based on the specific circumstances of each individual case. Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. (Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this. Staff should document all incidents of harassment). Are known to have recorded meetings or face to face/telephone conversations without the prior knowledge and consent of the other parties involved. Display unreasonable demands or expectations and fail to accept that these may be unreasonable (e.g. insist on immediate responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice). Once it is clear that complainants meet any of the criteria above, it may be appropriate to inform them in writing (Chief Executive/Executive Director) that they may be classified as unreasonably persistent or vexatious complainants, make them aware of the criteria and advise them to take account of the criteria in any further dealings with the Trust. In some cases it may be appropriate at this point to suggest that complainants seek advice in processing their complaint, e.g. through ICAS. Judgement and discretion must be used in applying the criteria to identify potential vexatious or unreasonably persistent complainants and in deciding action to be taken. This should only be used as a last resort and after all reasonable measures have been taken to assist the complainant. 4.5.2 Options for dealing with vexatious or unreasonably persistent complainants Where a complainant has been identified as vexatious or unreasonably persistent in accordance with the above criteria, the Director of Nursing should liaise with the Chief Executive to determine what action to take. The Director of Nursing/Chief Executive will implement such action and will notify the complainant in writing of the reasons why they have been classified as vexatious or unreasonably persistent and the action to be taken. This notification may be copied for the information of others already involved in the complaint, e.g. Trust staff, Conciliator, ICAS, MP. A record must be kept for future reference in the paper complaint file. The Director of Nursing/Chief Executive may decide to deal with the complaint in one or more of the following ways: Try to resolve matters by drawing up a signed agreement with the complainant (and if appropriate involving the relevant practitioner in a two-way agreement) which sets out a code of behaviour for the parties involved if the Trust is to continue investigating the complaint. If these terms are contravened, consideration would then be given to implementing other action as indicated in this section. Decline contact with the complainant either in person, by telephone, fax, letter, email, or any combination of these provided that one form of contact is maintained or alternatively restrict contact to liaison through a third party. Barking, Havering & Redbridge University Hospitals NHS Trust Page 18 of 49

Notify the complainant in writing that the Chief Executive has responded fully to the points raised and has tried to resolve the complaint but there is nothing more to add and continuing contact on the matter will serve no useful purpose. The complainant should also be notified that correspondence is at an end and that further letters received will be acknowledged but not answered. The complainant should also be reminded of their right to refer their case to the PHSO, if appropriate. Inform the complainant that in extreme circumstances the Trust reserves the right to pass unreasonable or vexatious complaints to its legal advisors. Temporarily suspend all contact with the complainants or investigations of a complaint whilst seeking legal advice or guidance from the NHS London, Health Service Ombudsman or other relevant agencies. 4.5.3 Withdrawing unreasonably persistent or vexatious status Once a complainant has been identified as being unreasonably persistent or vexatious there needs to be a mechanism for withdrawing this status at a later date if, for example, the complainant subsequently demonstrates a more reasonable approach or if they submit a further complaint for which normal procedures would appear appropriate. Staff should previously have used discretion in recommending unreasonably persistent or vexatious status at the outset and discretion should similarly be used in recommending that this status be withdrawn when appropriate. Where this appears to be the case, discussion will be held with the relevant Associate Director (Directorate), Director of Nursing and Chief Executive. Subject to their agreement, normal contact with the complainant and application of the NHS Complaints Procedure will then be resumed. 4.6 GMC/NMC Complaints Complaints referred directly from the General Medical Council or Nursing & Midwifery Council should be forwarded to the Medical Director or Director of Nursing, as appropriate. If the Medical Director or Director of Nursing are aware of further issues that suggest that the GMC/NMC should undertake a full investigation into the doctor s/nurse s fitness to practice they should notify the GMC/NMC accordingly. 4.7 Confidentiality Patients entrust the NHS with, or allow the gathering of, sensitive information relating to their health and other matters as part of their treatment. They do so in confidence and they have the legitimate expectation that staff will respect their privacy and act appropriately. In some circumstances patients may lack competence or may be unconscious, but this does not diminish the duty of confidence. It is essential, if the legal requirements are to be met and the confidence of patients is to be retained, that this Trust provides a confidential service. For full guidance on the disclosure of patient identifiable information refer to the NHS Confidentiality Code of Practice or contact the Caldicott Guardian, who is the Deputy Medical Director at BHRUT. Barking, Havering & Redbridge University Hospitals NHS Trust Page 19 of 49

4.8 Third Party Complaints If a third party (e.g. Solicitor) submits a complaint on behalf of another, a thorough check must be undertaken to ensure that the complaint is being made with the knowledge and consent of the person concerned. patient-identifiable information must not be used or disclosed, for purposes other than direct healthcare, without the individual s explicit consent, some other legal basis, or where there is a robust public interest or legal justification to do so. (NHS Confidentiality Code of Practice). A complaint may be made by a representative acting on behalf of the patient who: Has died Is a child Is unable to make the complaint themselves due to: (i) Physical incapacity (ii) Lack of capacity within the meaning of the Mental Capacity Act 2005(a) Has requested the representative to act on their behalf. If there is any doubt as to whether a person complaining on behalf of another is making a complaint without the knowledge of the person concerned, the person on whose behalf the complaint is supposedly being made should be contacted to ensure that they are content for personal information concerning themselves to be released to the complainant. They should be asked to sign a form authorising release of information to the third party; this should then form part of the electronic complaint file and a copy kept in the paper complaint file. If the Director of Nursing is of the opinion that the person making a complaint on behalf of another is not a suitable person to pursue the complaint, a letter should be sent to the complainant stating the reasons for this decision. 4.9 Freedom of Information Act Many complaints contain requests for corporate information. The Freedom of Information Act 2000 (FOI) is an Act which makes legal provision and creates a legal gateway for the disclosure, to the public, of corporate information held by this Trust. If the Trust assesses that the exceptions under the FOI act apply disclosure may be declined, complainants should be informed of their right to complain directly to the Information Commissioner and should be given the Information Commissioner s contact details. If they wish to pursue their complaint through the Trust this should be processed as described in this policy. The Information Governance Manager will be responsible for the investigation of all FOIA complaints. Complainants who remain dissatisfied at the end of Local Resolution should be advised to progress their complaint via the Information Commissioner. There is a legal requirement to provide any information requested under the FOI within 20 days and for a record to be kept of all such requests. If corporate information is requested as part of a complaint this must sent to the complainant within 20 working days, irrespective of whether the complaint investigation/response Barking, Havering & Redbridge University Hospitals NHS Trust Page 20 of 49

have been completed. In such cases the relevant information should be forwarded to the Complaints Administrator who will send this to the complainant together with a holding letter explaining/apologising for the delay in the investigation. 4.10 Learning from Complaints A summary of lessons learnt arising from complaint investigations will be included in the Trust s quarterly Patient Experience report (see Monitoring below). Lessons learnt are reported at a corporate level at the Quality & Safety Committee and Learning Lessons Group, and locally within Directorate Clinical Governance meetings, thereby ensuring that lessons are shared as widely as possible. Information relating to complaints is also included in the 6-monthly Aggregated Data Report, which is produced by the Clinical Governance Directorate and presented to the Quality & Safety Committee. Within this report lessons from across many activities within the Trust are aggregated and analysed to ensure that the Trust identifies issues which need to addressed and makes improvements. 5. THE DEVELOPMENT OF THIS POLICY This policy and procedure was written using the Trust s Policy Template and gives consideration to all the elements required within the Trust Policy for the Development and Management of Trust-Wide Procedural Documents. The Deputy Director of Nursing is responsible for this policy and procedure on behalf of the Corporate Nursing Directorate. 5.1 Consultation and Communication with Stakeholders Stakeholders involved in the development of this policy are: CEO Executive Directors Clinical Governance Director Complaints Manager Directorate Management Team PALS Manager Nursing & Midwifery Staff Administrative Staff North East London & City (NELC) North East London & the City Cluster (Commissioning PCT) Local Involvement Networks Local Overview & Scrutiny Committees This policy and procedure has been written by the Trust s Deputy Director of Nursing and distributed for wider consultation with representatives of all internal and external stakeholders. Internal stakeholders have been involved in the approval of the policy as all are represented on the Improving Patient Experience Group, and the Quality & Safety Committee. External stakeholders have been involved via consultation. Barking, Havering & Redbridge University Hospitals NHS Trust Page 21 of 49

Representatives of all involved stakeholders will receive a copy of the final approved policy and procedure, and all staff will be informed that the policy and procedure is available on the Intranet. 5.2 Equality Impact Assessment This policy has been equality impact assessed to ensure that the guidance provided does not place at a disadvantage any service, population or workforce over another. A completed Equality Impact Assessment is contained in Appendix H. 5.3 Approval & Ratification A copy of the Checklist for Review and Approval of Procedural Documents (Appendix I) has been completed for this Policy and submitted with the final draft for approval and ratification. This policy was reviewed and approved by the Quality & Safety Committee on 16 th October 2012 This policy was reviewed and ratified by the Policy Ratification Committee on 12th September 2012. 6. REVIEW & REVISION ARRANGEMENTS 6.1 Review This policy will be reviewed every two years or sooner if: There are any specific changes to Government Legislation relating to complaints handling. There are any significant changes to relevant practices or services within the Trust. Monitoring identifies issues which require change to the policy. 6.2 Revision This is a completely rewritten policy and procedure. Therefore, revisions have not been included in this section. 7. DISSEMINATION & IMPLEMENTATION 7.1 Dissemination A Plan for Dissemination of Procedural Documents has been completed (Appendix J) and will be held by the nominated person (Deputy Director of Nursing) for this policy and procedure. The policy and procedure will be available to all staff via the Trust Intranet and to relevant individuals as nominated on the Plan for Dissemination of Procedural Documents. 7.2 Implementation Barking, Havering & Redbridge University Hospitals NHS Trust Page 22 of 49

This policy and procedure has been written to reflect best practice. A copy of the policy and procedure will be placed on the Trust Intranet to allow access for all staff and to alleviate the need to keep paper copies. It will be distributed via e-mail to all the key stakeholders. All staff will be made aware of the new policy and procedure via staff meetings and Team Brief. Supporting patients and relatives in making a complaint can be a challenge for staff. When staff are trained and confident in managing complaints, complainants are ably supported through the process and complaints can be resolved swiftly. Training is achieved through a comprehensive training programme for all disciplines of staff. During training emphasis is placed on the importance of resolving complaints at an early stage (local resolution) to ensure the best possible outcome for the complainant and the Trust. The Trust s training programmes, which vary in content and length, provide tailor made training packages for staff within the Trust: Corporate Induction - gives staff a brief insight into the NHS/Trust s Complaints Procedure. An introduction to Complaints Management will be provided via the Mandatory and Statutory Training Programme. Ad hoc training sessions are provided, as requested. Training can be accessed directly through the Training & Development Online Booking Service or via the Corporate Complaints Team. The purpose of this training is to ensure that: All staff who have contact with service users as part of their work within the Trust are aware of this policy and procedure and its application, including the content of the information leaflets available about how to make a complaint. Those staff who will be particularly involved in the handling of complaints have the opportunity of further training in interpersonal relationship and conciliatory skills. 8. MONITORING The Chief Executive and/or Director of Nursing may, at any time, initiate a formal review of the overall investigation, management and outcome of a complaint. The Complaints Manager will produce a bi-monthly report relating to all patient complaints, the number and type of complaints together with response times, trends, action taken, the outcome of the recommendations made by the Parliamentary and Health Service Ombudsman and patient feedback (complaints and plaudits) which highlights action taken to address any shortfalls in service identified through the complaints process. The Complaints Manager will provide reports to meet NHS requirements including: Barking, Havering & Redbridge University Hospitals NHS Trust Page 23 of 49

A Trust Annual Complaints Report An Annual NHS Executive KH041 return Barking, Havering & Redbridge University Hospitals NHS Trust Page 24 of 49

The matrix below identifies all the monitoring of this policy and procedure which will be carried out, how this will be done (e.g. audit), frequency, who is the lead person responsible for ensuring that the monitoring is carried out, where reports from monitoring are reported, who (individual/group/committee) is responsible for ensuring that any gaps or deficiencies are recorded on an action plan which is followed up and who is responsible for ensuring that implementation of any changes which follow the action plan completion are implemented and, where appropriate, information disseminated within the Trust to enable learning from the experience. What will be monitored and/or Standard To Be Achieved How/Method Frequency Lead Reported to Deficiencies/gaps recommendations and action plans followed up by Implementation of any required change responsibility of PALS Contact figures Reports from Safeguard database Weekly Bi-monthly PALS Manager Directorates Quality & Safety Committee Directorates Quality & Safety Committee PALS Manager PALS Manager Number & type of complaints received Report from Safeguard Database Weekly Directorates and Director of Nursing Directorates Directorates Bi-monthly Annual Complaints Manager Quality & Safety Committee Directorates Directorates Trust Board Director of Nursing Director of Nursing Time from receipt to acknowledgement 3 days Report Bi-monthly Complaints Manager Quality & Safety Committee Directorates Directorates Time from receipt to closure of complaint (to be agreed with complainant) Report Bi-monthly Complaints Manager Quality & Safety Committee Directorates Directorates Any deficiencies identified during monitoring will be recorded and reported to the Quality & Safety Committee. The nominated persons and, ultimately, the Quality & Safety Committee, will be responsible for ensuring that an action plan has been developed, is followed through, all required actions taken to remedy the deficiency/s identified and, where appropriate, information disseminated within the Trust to enable learning from the experience. Barking, Havering & Redbridge University Hospitals NHS Trust Page 25 of 49

9. REFERENCES Care Quality Commission - Essential Standards of Quality and Safety (2010) Data Protection Act (1998) Office of Public Sector Information, London Department of Health (2009) Listening, Responding, Improving A Guide to Better Customer Care Department of Health Making Experiences Count (February 2008) Department of Health. The NHS Constitution (2009) Freedom of Information Act (2000) Local Authority Social Services and NHS Complaints (England) Regulations (2009) Mental Capacity Act (2005) NHSLA Risk Management Standards 2012/13, NHS Litigation Authority, January 2012 Principles for Remedy - The Parliamentary and Health Service Ombudsman (2007) Statutory Instrument (2009) No. 309, the Local Authority, Social Services and National Health Service Complaints (England) Regulations 2009 10. ASSOCIATED DOCUMENTATION Confidentiality & Disclosure Policy Disciplinary Policy, Rules & Procedure Grievance Policy Incident Reporting and SUI Policy PALS Policy Open & Honest Policy Patient Involvement & Experience Strategy Whistleblowing Policy Violence & Aggression Policy 11. AMENDMENTS Page/Section All All Change Transfer to new Trust Policy Template and addition of new sections Complete re-write to reflect current procedures and practice within the Trust and the 2009 Local Authority Social Services and NHS Complaints (England) Regulations Barking, Havering & Redbridge University Hospitals NHS Trust Page 26 of 49

APPENDIX A VERBAL COMPLAINTS FORM (TAKEN ON SITE) Directorate: Ward/Department: Nature of complaint: Date and Time Complaint Received: Method of communicating e.g. face-to-face, telephone call (letters/statements to be attached if available): Name and Address of Complainant: Telephone Number of Complainant: Name of Patient (if not complainant) and Hospital Number: Relationship of Complainant to Patient: Name/Grade of Staff Receiving Complaint: Immediate Action Taken: Date: Signature: Complaint Resolved/Referred (delete as appropriate) Management Action: Date Received/Informed: Advice to Ward/Dept Staff: Signature of Senior Manager/Head of Service: Copy of form to be retained in Ward/Department and a copy of the form to be emailed to the Complaints Department Email: complaints@bhrhospitals.nhs.uk Barking, Havering & Redbridge University Hospitals NHS Trust Page 27 of 49

APPENDIX B COMPLAINTS FORM You may use this form to register a complaint about the service, care or treatment you (or a relative/friend) have received from Barking, Havering & Redbridge University Hospitals NHS Trust. The information leaflet Listening, Responding, Improving Complaints leaflet gives more detail about the hospital s complaints handling procedure. If you would like further advice or help completing this form, please contact the Complaints Team directly on Tel. No. 01708 435032. Alternatively you can email us at Complaints@bhrhospitals.nhs.uk or write to: The Complaints Team, Trust Offices, Queen s Hospital, Rom Valley Way, Romford, Essex RM7 0AG Complainant s Name: Personal Details Patient s Name: Hospital No: (if known) NHS No: (if known) Date of Birth: (if known) Address: Contact Details Address: Telephone: Telephone: Home: Home: Work: Work: Mobile: Mobile: Email: Email: Relationship to the patient/service user: Please note that if you are making a complaint on behalf of someone else, you must obtain their written consent to do so. Please see the Consent Form overleaf. Barking, Havering & Redbridge University Hospitals NHS Trust Page 28 of 49

Data Protection Please complete and sign the appropriate consent section(s) If you are making a complaint on behalf of someone else we will need their written consent to take this forward. Could you please ask the patient/service user to sign the declaration(s) below. I agree to (print name of complainant) acting on my behalf for the purpose of pursuing this complaint. Name of patient/service user (please print) Relationship to complainant (e.g. mother, partner) Signed Date: (print name of patient/service user) If your complaint concerns another organisation (for example your GP, dentist, another hospital Trust, Social Services, etc.) we require the complainant s permission to pass on the details of your concerns in order for them to be investigated and responded to. Please sign below to signify that you give your consent for us to do this. Signed Date: (Complainant) Medical/Healthcare Records We may need to access your medical records for the purpose of this investigation. Please sign below to signify that you give your consent for us to do this. Signed Date: (Patient/service user) Thank You The early completion of this form will help us by enabling us to immediately commence our investigation of your concerns so that we can respond as quickly as possible. Barking, Havering & Redbridge University Hospitals NHS Trust Page 29 of 49

Date of event: Details of your complaint Where did the event occur? (e.g. ward, clinic, department, service area) Name: Details of the person(s)/service you are complaining about Job title: Details of the event(s) being complained about Barking, Havering & Redbridge University Hospitals NHS Trust Page 30 of 49

State the areas you would like to be investigated What outcome do you wish from this complaint? What would you like us to do to make things better? Please continue on a separate sheet or enclose any other information you consider relevant to your complaint. We will acknowledge receipt of your complaint within 3 working days of receipt of this form. However, if you have any questions in the meantime, please do not hesitate to contact us at the details specified on the front of this form. Signed: Date: Barking, Havering & Redbridge University Hospitals NHS Trust Page 31 of 49

APPENDIX C Trust Risk Grading Matrix The Complaints Manager according to the Trust s grading matrix below, will grade all written complaints received by the Trust: Consequence Score (C) Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on the safety of patients, staff or public (physical/psychological harm) Minimal injury requiring no/minimal intervention or treatment. No time off work Minor injury or illness, requiring minor intervention Requiring time off work for >3 days Increase in length of hospital stay by 1-3 days Moderate injury requiring professional intervention Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident An event which impacts on a small number of patients Major injury leading to long-term incapacity/disability Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients Quality/complaints/audit Peripheral element of treatment or service suboptimal Informal complaint/inquiry Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating Critical report Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsman inquiry Gross failure to meet national standards Barking, Havering & Redbridge University Hospitals NHS Trust Page 32 of 49

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Human resources/ organisational development/staffing/ competence Short-term low staffing level that temporarily reduces service quality (< 1 day) Low staffing level that reduces the service quality Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff Statutory duty/ inspections No or minimal impact or breech of guidance/ statutory duty Breech of statutory legislation Reduced performance rating if unresolved Poor staff attendance for mandatory/key training Single breech in statutory duty Challenging external recommendations/ improvement notice Very low staff morale No staff attending mandatory/ key training Enforcement action Multiple breeches in statutory duty Improvement notices No staff attending mandatory training /key training on an ongoing basis Multiple breeches in statutory duty Prosecution Complete systems change required Low performance rating Zero performance rating Adverse publicity/ reputation Business objectives/ projects Finance including claims Service/business interruption Environmental impact Rumours Potential for public concern Insignificant cost increase/ schedule slippage Small loss Risk of claim remote Loss/interruption of >1 hour Minimal or no impact on the environment Local media coverage short-term reduction in public confidence Elements of public expectation not being met <5 per cent over project budget Schedule slippage Loss of 0.1 0.25 per cent of budget Claim less than 10,000 Loss/interruption of >8 hours Minor impact on environment Local media coverage long-term reduction in public confidence 5 10 per cent over project budget Schedule slippage Loss of 0.25 0.5 per cent of budget Claim(s) between 10,000 and 100,000 Loss/interruption of >1 day Moderate impact on environment Critical report National media coverage with <3 days service well below reasonable public expectation Non-compliance with national 10 25 per cent over project budget Schedule slippage Key objectives not met Uncertain delivery of key objective/loss of 0.5 1.0 per cent of budget Claim(s) between 100,000 and 1 million Purchasers failing to pay on time Loss/interruption of >1 week Major impact on environment Severely critical report National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence Incident leading >25 per cent over project budget Schedule slippage Key objectives not met Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) > 1 million Permanent loss of service or facility Catastrophic impact on environment Barking, Havering & Redbridge University Hospitals NHS Trust Page 33 of 49

Likelihood Score (L) Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Almost certain Frequency How often might it/does it happen This will probably never happen/recur Do not expect it to happen/recur but it is possible it may do so Might happen or recur occasionally Will probably happen/recur but it is not a persisting issue Will undoubtedly happen/recur, possibly frequently Consequence (C) x Likelihood (L) = Severity grading Likelihood Likelihood score 1 2 3 4 5 Rare Unlikely Possible Likely Almost certain 5 Catastrophic 5 10 15 20 25 4 Major 4 8 12 16 20 3 Moderate 3 6 9 12 15 2 Minor 2 4 6 8 10 1 Negligible 1 2 3 4 5 1-3 Low risk 4-6 Moderate risk 8-12 High risk 15-25 Extreme risk Instructions for use 1) Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the Incident 2) Use table 1 to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated. 3) Use table 2 to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score. 4) 4 Calculate the risk score the risk multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score) Barking, Havering & Redbridge University Hospitals NHS Trust Page 34 of 49

COMPLAINT GRADING EXTREME HIGH MODERATE LOW ACTION TO BE TAKEN Complaints graded as Extreme will be notified to those senior staff listed in the Complaints Procedure and a round table review will be held on the same basis for a Serious Incident under the Serious Untoward Incident Policy. The lead for the round table will normally be the Director/Deputyof Nursing Complaints graded as Extreme will be notified to those senior staff listed in the Complaints Procedure but a round table review will be held only if the Complaints Manager judges that the particular circumstances require it after consultation with the Complaints Clinical Lead. The lead for the round table will normally be the Complaints Clinical Lead or her nominee. If a round table review is not held, the complaints investigation will proceed under the overall responsibility of the General Manager and Associate Director (Directorates) The complaints investigation will proceed under the overall responsibility of the General Manager and Associate Director (Directorates) Formal complaints requiring formal investigation and response are all graded Moderate or above. Barking, Havering & Redbridge University Hospitals NHS Trust Page 35 of 49

APPENDIX D GUIDANCE ON STATEMENT WRITING & RECORDING INTERVIEWS Section 1: Guidance for statement writing National and local evidence indicates that the most influential factor in whether a complainant will be satisfied with the outcome of their complaint is the first response letter. Consequently, it is clear that the Trust should ensure its responses to complaints are thorough, clear and honest. This should minimise the potential for a complainant feeling they have to resort to complaining to either the Trust or the Ombudsman about the response they received. The majority of complaints will require a statement from at least one member of staff to inform the person undertaking the investigation and drafting the response letter to the complainant. Statements are important as they provide investigating staff with the recollections of staff involved and their professional opinion of the issues involved in the complaint. Statements also provide written evidence should the complaint escalate to a review by the Ombudsman or if the complaint becomes a clinical negligence claim. The following guidance should be considered whether you are providing a statement for an investigator or if you are the investigator detailing the outcome of a meeting with staff involved in a complaint, or a manager supporting staff during the investigation process. Add a preliminary to the statement stating: your name your position in the Trust currently (and at the time of incident if different) the purpose of the statement, e.g. "Statement to inform staff investigating the formal complaint raised by Mr J Bloggs" name of patient name of complainant. Avoid the use of jargon, abbreviations or medical terminology. Non-clinical staff compiling or quality-assuring the final response may not understand such terms and this may result in an inappropriate response to the complainant. Structure the statement chronologically, i.e. in order of events as they occurred. Make a note of dates and times of events wherever possible. These will allow staff to understand the timing of events and can have an important and direct impact on helping the investigator understand what happened. Be honest and impartial. It is human nature to try to justify your actions but if you review your care (or that of a colleague if asked to do so) and feel that something could have been performed better, or that a wrong decision was made, say so. Where possible back this up with written external evidence or research. Refer to any written records and quote them. These may be computer records or the patient's medical or nursing notes. When doing so, assess the facts - do not speculate or assume. You can state your professional opinion but again, where possible, back this up with written external evidence or research. Barking, Havering & Redbridge University Hospitals NHS Trust Page 36 of 49

If your statement indicates that a patient's treatment outcome was adversely affected as a direct result of their care in the Trust or that staff actions were the part or sole cause of this contact the Complaints Manager for advice. Include any actions you or your department have taken to address the concern and prevent a recurrence. This will be helpful in demonstrating to the complainant that future patients will not experience the difficulties that they encountered. Always sign and date the statement in black ink. In summary: A STATEMENT SHOULD BE: a record of what you did and why an accurate reconstruction of what happened honest, even if you have to state that practice was not of the standard you were taught to expect a full recollection of the circumstances: e.g. others on duty; workload; small details of importance e.g. a bank holiday, out of hours a record of why you did certain things rather than others IT SHOULD NOT: be written in haste be dismissive seek to blame others make statements beyond your recollection or knowledge comment on what you would have done in another's place be made up if you cannot recall the events. Section 2: Guidance for recording interviews with staff Interviews will be undertaken in private and, if at all possible, away from the immediate place of work in a relaxed setting. The purpose of the interview is to find out what happened, obtain the recollections of the staff member or to gain the staff member's clinical opinion on the issue of complaint. This will be explained at the outset of the interview. The style adopted will be supportive and understanding, and not judgmental or confrontational. If it becomes clear that a professional shortcoming has occurred, this should be allowed to emerge naturally from the conversation, and should not be extracted by 'cross-examination'. Errors and mistakes in clinical care are rarely wilful and most staff are genuinely disturbed when it becomes clear that something they have done or did not do has contributed to an incident. The staff member will normally require additional support at this point and should be allowed, through supportive discussion, to start to come to terms with what has happened. Adverse comment or judgement at this stage is unhelpful, as it leads to demoralisation and defensiveness. Barking, Havering & Redbridge University Hospitals NHS Trust Page 37 of 49

Where possible ask specific questions related to the issues raised in the letter of complaint and ensure that you gain as complete an answer as possible. Do not be afraid to probe for further information-remember this is the interviewer's opportunity to gain all the information required to respond fully to the complainant. Take notes of the interview, recording clearly and accurately what is said in response to each of the issues of complaint. Before concluding check that you have gained an appropriate response to each and every point raised in the letter of complaint and gained information on what has been/will be done to prevent a recurrence of those issues. Read back your notes to the staff member before the conclusion of the meeting to ensure that they are happy with your interpretation of their comments. Send a printed or emailed document of the interview notes to the staff member before the investigation report is sent to the Complaints Manager. Barking, Havering & Redbridge University Hospitals NHS Trust Page 38 of 49

APPENDIX E GUIDANCE FOR MEETING WITH COMPLAINANTS ABOUT FORMAL COMPLAINTS Dependent upon the circumstances of the complaint, the Trust may, at some point during local resolution, find it beneficial to hold a meeting with the complainant, indeed sometimes this may expedite the resolution of the complaint. The following points should be considered in arranging meetings with complainants. Before the meeting, the issues for discussion must be confirmed and agreed to ensure that the discussion is structured. Other than ensuring that the meeting addresses the concerns of the complainant, this gives both parties reassurance in that: The complainant can be assured that the correct staff will attend and will have the necessary information required to respond fully to their concerns. Trust staff are not faced with unexpected questions that they are not able to answer. Remember that meeting with representatives of the Trust in a formal setting can be a daunting experience for many members of the public. It can also be an emotional time, especially if the complainant's relative recently died within the Trust. The staff member leading a meeting should try to put the complainant(s) at ease. The approach should be friendly and supportive and not overly formal. Before the meeting: Ensure you are able to offer drinks at the start of a meeting and that you have tissues available. Ensure that you have all necessary documentation and paperwork before you enter the meeting, with relevant sections earmarked for ease of reference. Ensure that one member of staff understands that they are required to document the minutes of the meeting. Nominate a chair from the Trust staff. During the meeting: Allow the complainants time to express their concerns and feelings without interruption Ensure that responses to questions are free from medical jargon Ask the complainant if they are satisfied with the response to each point of concern or if they require any further explanation. If they are not satisfied try to ascertain why. It may not be possible to satisfy the complainant on each point but you should ensure that any dissatisfaction is minuted together with the information that has been given to the complainant on that point. At the close of the meeting, thank the complainants for attending and inform them that they will be sent a letter, including minutes of the meeting and their further options under the NHS complaint regulations. If amendments are forwarded to the Trust these should be noted within the complaint file. Barking, Havering & Redbridge University Hospitals NHS Trust Page 39 of 49

APPENDIX F 1. Aim PROTOCOL FOR THE HANDLING OF CROSS AGENCY COMPLAINTS IN THE NHS & ADULT SOCIAL CARE SERVICES To provide a framework for dealing with complaints involving more than one of the participating organisations named below and, where possible, to provide a joint reply. 2. Organisations Involved Whipps Cross University Hospital NHS Trust Barking, Havering and Redbridge University Hospitals NHS Trust NELFT NELC London Borough of Barking & Dagenham London Borough of Redbridge London Borough of Havering London Borough of Waltham Forest 3. Background 3.1. The purpose of this framework is to clarify and speed up the process of dealing with cross agency complaints involving the organisations named above. 3.2. The process has been agreed to provide a seamless pathway for customers who want to raise a complaint, concern or comment. The communication between the organisations should be timely to prevent delays. For each agency, the designated complaints manager is responsible for coordinating whatever actions are required or implied by this protocol. 3.3. The organisations that have signed up to this agreement are expected to communicate and cooperate with each other in a reasonable and timely manner. 4. Framework 4.1. Complaints will be acknowledged by the receiving organisation within three working days. 4.2. In the event of several organisations receiving the complaint at the same time, contact will be made with the other organisations and an agreement made as to which will be the lead organisation via an initial risk assessment being undertaken to identify the seriousness of the concerns being raised. The lead organisation will acknowledge within three working days on behalf of all organisations involved and will clarify the complaint and explain the role of the other organisations. (refer to 4.4) 4.3. In the event that the complaint is sent to only one organisation (who will be known as the receiving organisation) but involves other organisations, that receiving organisation will seek consent from the complainant and or customer to copy the complaint to the other organisations involved. The consent of the complainant /patient/client must be obtained so that records can be accessed by the teams involved. Where appropriate, the complainant will be asked to complete and return a consent form as soon as possible. Barking, Havering & Redbridge University Hospitals NHS Trust Page 40 of 49

However, in order to minimise any delay, verbal consent could also be acceptable on points that relate the Social care remit of the complaint. Written consent is however a part of the NHS process and cannot be avoided. 4.4. Once the consent is received a copy of the complaint letter will immediately be sent to the other organisations involved in the complaint. Following receipt, discussions will be undertaken to agree which organisation should be the lead. (refer to 4.2). 4.5. If a complainant declines to give consent to share the complaint, the receiving organisation will advise the complainant which part (if any) of their complaint can be investigated without consent and advise the complainant how they may pursue issues relating to other organisations directly (contact details for the relevant organisation should be included in the letter). 4.6. Where a complaint may be shared, the lead organisation will confirm to the complainant a named person, address and telephone number to identify where each part of the complaint is being investigated. 4.7. Each organisation will investigate in accordance with its own procedure, keeping the lead organisation informed of progress. Ideally, all responses should be completed simultaneously and reports delivered to the complainant together. In order to facilitate this, the organisations involved should aim to work to the shorter of their respective complaints procedure timescales. It is recognised however, that this will not always be possible. (See paragraph 4.12 below). For the purpose of this agreement and those signing up to it, the benchmark for responding to the complainant will be within 30 working days. Each organisation will carry out its own investigation and its Chief Executive or appropriate signatory will sign their response and forward it to the lead organisation within the specified timescale. There maybe occasions when this time frame cannot be achieved. On these occasions the timeframe discussion will be noted by all parties with a decision taken and duly agreed with the complainant. 4.8. The lead organisation will obtain responses from all the organisations involved and coordinate them into a final response to the complainant, unless the complainant indicates otherwise. The co-ordinated response must identify which issues relate to which organisation and the advice/step up details of the next stage for each process should be included if the complainant/s want to pursue. 4.9. It is the responsibility of each contributing organisation to identify any conflict in input with the other organisations involved and to ensure this is discussed and resolved between the organisations concerned, or with the relevant Directors if necessary. 4.10The lead organisation will not have editorial licence to alter the content of the responses from those responding without their explicit and confirmed agreement. The final response from the lead organisation to the complainant MUST be approved, within an agreed timescale, by respondent organisations before being dispatched. (See para 4.7 above). 4.11. If a comprehensive response is not possible, due to delayed information from one or more organisations, the lead organisation will complete a response with the available information, indicating that the outstanding response(s) will follow separately and directly from those organisations. Those subsequent responses will be copied to all other organisations involved. Barking, Havering & Redbridge University Hospitals NHS Trust Page 41 of 49

The complainant will be made aware of this and given the opportunity to decide on either accepting the response in two parts or waiting for the joint response. 4.12. If a delay is likely to occur, the lead organisation must be informed immediately. The lead organisation will be responsible for informing the complainant. All organisations should seek to avoid any unnecessary delay. 4.13. The Chief Executive or appropriate signatory will sign off the final response from the lead organisation to the complainant. 4.14. The final response should include contact details of all the organisations involved. However, if approached, the lead organisation will ensure that any follow up from the complainant is acknowledged and passed to the relevant organisation(s) for handling. 4.15. The response should advise the complainant of their right to pursue the complaint further and provide details of the regulatory bodies who would deal with the next step of each element of their complaint. 4.16. Each contributing organisation will ensure that reference is made to their cross agency complaints in their Complaints Annual Reports, where service developments/ improvements made as a result of the complaints received, are outlined. 4.17. We agree to share learning outcomes and to discuss any actions taken. 5. Learning Outcomes 5.1 At the point at which the complaint affecting more than one organisation is concluded to the complainant s satisfaction, or at which all procedural steps have been exhausted, the two complaints manager should collaborate in identifying the learning points which arise, both for the respective agencies individually and with regard to their future collaboration. 5.2 Joint action plans, with responsibilities ascribed and timescales set, should be recorded, along with details of how they should be monitored and of how the complainant will be kept informed of developments. 5.3 In many cases, the action plan will be based on the recommendations of the person who investigated the complaint, especially where there has been a formal investigative process. 6. The Future of the Protocol 6.1 This protocol will be kept under review and will evolve by means of agreed amendments in reflection of any future changes in the statutory or regulatory framework. 6.2 In the meantime, it is intended that the implementation of the protocol will contribute to amalgamating the present diversity of perspectives, in the interest of providing an effective complaints service for patients and service users. Barking, Havering & Redbridge University Hospitals NHS Trust Page 42 of 49

APPENDIX G COMPLAINT CASES TAKEN FORWARD BY THE COMPLAINANT WITH THE PARLIAMENTARY & HEALTH SERVICE OMBUDSMAN (PHSO) STEP 1 Trust receives Initial contact letter received from PHSO Has the Trust completed all attempts to resolve the complaint? No STEP 2 Provide copies of all relevant paperwork to the PHSO for review STEP 3 PHSO suggest further action to to be taken Investigate further and respond to the complainant PHSO close their file PHSO commence full Investigation PHSO close their file STEP 4 PHSO provide draft report detailing the outcome of their investigation and request comments from the complainant STEP 5 PHSO provide final report to the Trust and Complainant Action Plan required from Trust Action Plan implemented by Trust Complaint not upheld PHSO close their file Action Plan monitored by Trust Barking, Havering & Redbridge University Hospitals NHS Trust Page 43 of 49

APPENDIX H EQUALITY IMPACT ASSESSMENT TOOL To be completed and attached to any policy when submitted to the appropriate committee/group for consideration and approval or ratification. Policy Title Policy Number Responsible Individual/Committee Approving Committee Ratifying Committee Policy & Procedure for Complaints Handling 2012/CG/ Quality & Safety Committee Quality & Safety Committee Policy Ratification Committee 1. Does the policy affect one group less or more favourably than another on the basis of: Age Disability learning disabilities, physical disability, sensory impairment and mental health problems. Race Nationality Ethnic origin including gypsies and travellers Gender / Gender reassignment Religion Beliefs Sexual orientation including lesbian, gay and bisexual people Domestic circumstances Social and employment status Marital/partnership status HIV status Political affiliation Trade Union membership 2. What is the overall purpose of this policy area, function or activity? /No NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Comments The aim of this policy and procedure is to ensure that the Trust has a complaints handling procedure that: provides a timely service for complainants; supports complainants through the complaint process results in effective resolution of complainant's concerns; complies fully with the national NHS complaints regulations; delivers a standardised approach to complaints resolution across the Trust; supports Trust staff through what can be a stressful process; enables the organisation and local Barking, Havering & Redbridge University Hospitals NHS Trust Page 44 of 49

3. What approaches are currently used to measure progress and performance in this area? services to learn lessons about the care they provide; supports the organisation with continually improving services in response to patient/user concerns. complements informal complaints procedures to provide patients with a comprehensive complaints service Quality Assurance/Care Quality Review Meeting 4. What counts as success in this area? More complaints resolved at verbal complaint stage Increased rate of complaint responses within agreed timeframe Improved patient satisfaction with service 5. Are there opportunities within this policy to: Eliminate illegal discrimination Promote equality of opportunity Promote good relations between people of different groups? YES YES YES 6. Is the impact of the policy likely to be negative e.g. is their risk of: Illegal discrimination Reducing equality of opportunity for some groups? Harming relations between different people of different groups? 7. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 8. If so, what action could be taken to reduce adverse effects and promote or enhance positive effects? 9. Please describe the options available for incorporating equality monitoring into routine arrangements? N/A N/A N/A N/A N/A N/A If you have identified a potential discriminatory impact of this policy document, please refer the issue to the Workforce Equality Manager, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Workforce Equality Manager, HR Department, Queen s Hospital on extension 3294. Barking, Havering & Redbridge University Hospitals NHS Trust Page 45 of 49

APPENDIX I CHECKLIST FOR THE REVIEW & APPROVAL OF PROCEDURAL DOCUMENTS To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval or ratification. 1. Title Title of document being reviewed: Complaints Management Policy & Procedure Is the title clear and unambiguous? Is it clear whether the document is a policy, protocol or guideline? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? Are individuals involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are local/organisational supporting documents referenced? 6. Approval Does the document identify which committee/group will approve it? /No/ Unsure Comments, including where information is included in the document Barking, Havering & Redbridge University Hospitals NHS Trust Page 46 of 49

Title of document being reviewed: Complaints Management Policy & Procedure Does the document identify which committee/group will ratify it? If appropriate, have the joint staff side committee (or equivalent) approved the document? 7. Dissemination and Implementation Is there a completed Plan for Dissemination of Procedural Documents which identifies how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? 9. Process for Monitoring Compliance Are there measurable standards or KPIs to support monitoring compliance of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so, is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? /No/ Unsure N/A N/A Comments, including where information is included in the document Individual/Group/Committee Approval If you are happy to approve this document, please sign and date below and forward to the chair of the committee where it will receive ratification. Name Anthony Warrens, NED Date September 2012 Signature Signature retained on original form On behalf of Quality & Safety Committee Barking, Havering & Redbridge University Hospitals NHS Trust Page 47 of 49

Committee Ratification If the committee is happy to ratify this document, please sign and date below and forward copies to the person with responsibility for disseminating and implementing the document and the Quality Systems Manager. Name Signature Date On behalf of Barking, Havering & Redbridge University Hospitals NHS Trust Page 48 of 49

APPENDIX J PLAN FOR DISSEMINATION OF PROCEDURAL DOCUMENTS To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval or ratification. Title of document: Complaints Management Policy & Procedure Dissemination lead (name and contact details): Gary Etheridge Date finalised: July 2012 Date due to be reviewed: July 2014 Previous document already being used? If yes, in what format and where? On the Intranet Proposed action to retrieve out of date copies of the document: Intranet copy will be archived when replaced. Staff advised of new policy issue in The Link. Have any training needs been identified and addressed (give details): N/A To be disseminated to: How will it be disseminated, who will do it and when? Format (i.e. paper or electronic) Comments: Quality Systems Manager Originator to send after ratification at committee Electronic For numbering, logging and issue Web Manager Sent by Quality Systems Manager once numbered and logged Electronic For inclusion on Trust Intranet and, where appropriate, archiving previous version. Originator Sent by Quality Systems Manager once issued Electronic For dissemination All staff Placed on Intranet and included in The Link Electronic Complaints Staff Informed at Team Meeting Verbal Dissemination Record - to be used once document is approved, ratified and issued Disseminated to: (either directly or via meetings, etc.) Format (i.e. paper or electronic) Date disseminated: No. of copies sent: Contact details / comments: Issued November 2010 Version 1 Barking, Havering & Redbridge University Hospitals NHS Trust Page 49 of 49