Complaints Policy and Procedure

Complaints Policy and Procedure To whom this document applies: All staff Procedural Documents Approval Committee Issue Date: Before 2002 Version 1 and 2 Document reference: 029 Date(s) reviewed: July 2002 Version 3 Approved by: Procedural Documents Approval Committee July 2003 Version 4 April 2004 Version 5 Date approved: April 2014 March 2006 Version 6 Next Review date: April 2016 Version No: 12 September 2006 Version 7 September 2007 Version 8 October 2009 Version 9 Responsibility for review: Deputy Director of Nursing May 2012 Version 10 May 2013 Version 11 April 2014 Version 12 Contributors: Please See Procedural Development, Consultation Proposal Form page 2 Archiving information held by the secretary of the Procedural Documents Approval Committee Policy and Procedure: 029 Page 1 of 29

Procedural Development Consultation Proposal Form Title: Complaints Policy and Procedure Policy Procedure Guideline Protocol Standard Name of person presenting document: Angela Haigh Interim Head of PALS and Complaints Kathy French Deputy Director of Nursing Reason for document development/review: Review and updating of document. Names of development team (including a representative from all relevant disciplines): As this document has been updated the names of the original development team have been omitted. Who has been consulted? Matrons Service Managers Divisional Directors Health and Safety Sub-Committee AD Governance and Risk Manager Does this document require presentation and agreement from Health and Safety Committee or Staff Partnership Forum prior to PDAC approval? Yes No Specify groups of staff to whom the document relates: All staff. Source of supporting evidence (references etc.): See Evidence Base. Are there resource implications? Yes No If yes please detail them: Does the Procedure/Guideline meet latest NHSLA, Risk Management Standards, Essential Standards of Quality and Safety (CQC)? Yes No Does this Procedure/Guideline include children, if applicable? 1. Does this document apply to children? Yes No 2. Are there aspects of this document that differ with regard to the treatment of children? Yes No If yes, please state who has been consulted A Trust review will occur every two years unless national guidance states otherwise. Date: April 2014 Policy and Procedure: 029 Page 2 of 29

Contents Review, Updating and Archiving of the Document 1 Document Development and Consultation Process 2 Contents 3 Introduction 4 Related Documents 5 1. Definition of Terms 5 2. Roles and Responsibilities 5 3. Process 6 4. Process: Informal Resolution 10 5. Process: Formal Local Resolution 11 6. Training 21 7. Evidence Base 22 8. Monitoring Compliance and Audit 22 9. Dissemination, Implementation and Access to the Document 23 Page No. Appendices Appendix A Contact to Staff Involved 24 Appendix B Statement Request 25 Appendix C Template Final Response Letter 27 Appendix D Initial Risk Grading 29 Policy and Procedure: 029 Page 3 of 29

Introduction Policy Statement and Rationale Colchester Hospital University NHS Foundation Trust is committed to providing an effective, timely and open method for service users to make an enquiry, express their concerns or raise a complaint regarding care and treatment received from the Trust. Concerns and complaints are a valuable tool for an organisation to monitor its performance and review areas that require improvement. They contribute important information to the management of clinical governance and patient safety. This policy gives staff clear guidance on how queries, concerns and complaints will be managed to ensure an effective, timely and open approach. Context and Relevance The Francis Report (2013) highlighted the need for reform of the current complaints process within the NHS making 14 recommendations. The key themes identified within the report include: The reluctance of patients and those close to them to complain, in part because of fear of the consequences. The feedback, learning and warning signals from complaints have not been given enough priority. Further reviews of the NHS Complaints System include A Review of the NHS Hospitals Complaints System Putting patients Back in the Picture a report by The Right Honourable Ann Clwyd and Professor Tricia Hart (2013) and the Parliamentary and Health Service Ombudsman report, The NHS Hospital complaints system a case for urgent treatment? (2013), both of which highlight the need for change to current practice. The Ombudsman s report found that failings in communication and inadequate responses to expressions of concern are two of the most common causes of complaints within the NHS. The NHS Litigation Authority clearly state Saying sorry is not an admission of liability and is the right thing to do ; yet often this does not happen. The further review of the Hospital by Professor Bruce Keogh s team in 2013 highlighted the need to review the Trusts complaint process and the requirement to be more responsive to and evidence the learning form complaints. Key Principles The policy follows national guidelines in line with the principles of good practice as recommended by the Parliamentary and Health Service Ombudsman (PHSO): Ease of access to the complaints process. Complainants not treated differently as a result of raising a complaint. Staff members not treated differently as a result of being involved in a complaint. Complaints handled efficiently and fairly. Complaints investigated thoroughly and honestly. Responses clear and open. Errors or omissions actioned effectively and promptly. Staff members dealt with fairly and proportionately. A spirit of putting things right and continuous improvement. Policy and Procedure: 029 Page 4 of 29

This Policy does Not Include This policy references but does not detail: the Incident, Serious Incident, Falls, Safeguarding and Cancer Pathway processes. the claims and inquest processes. Related Documents 118 Risk Management Strategy and Policy 195 Being Open and Duty of Candour Policy and Procedure 063 Incident Reporting Procedure 211 Investigation of an Incident Procedure 213 Improvement in Practice following Aggregated Analysis of Incident 201 Stress Management Procedure 1. Definition of Terms A query is any request for information. A concern is an expression of worry or anxiety that an error or omission may have, be or be about to occur. A complaint is an expression of dissatisfaction about Trust services. A complainant is any person expressing dissatisfaction with Trust services. A suitable representative is any person identified as appropriate to and accepted as representing another person in relation to a complaint. Next of kin has no formal legal definition. Whoever the patient has identified as next of kin is entitled to be treated as such. Local resolution refers to resolution of a complaint by the Trust. External resolution refers to resolution of a complaint by the PHSO, CQC or via the claims process. Informal local resolution refers to the management of concerns and complaints by staff members and/or the Patient Advice and Liaison Service (PALS) Team without the intervention of the Complaints Team or a formal complaint investigation and response. Formal local resolution refers to the management of complaints by the Complaints Team, involving a formal complaint investigation and response. 2. Roles and Responsibilities Chief Executive The Chief Executive is the Trust Responsible Officer for complaints handling. Director of Nursing Responsibility for ensuring compliance with this policy rests with the Director of Nursing. Deputy Director of Nursing Responsibility for overall running and strategic management of Complaints and PALS service and implementation of the policy. Policy and Procedure: 029 Page 5 of 29

Head of PALS, Complaints and Litigation Services (PCLS) The Head of PCLS is responsible for implementation and day to day operational management of this policy. Clinical and Service Leads Clinical and Service Leads are responsible for dissemination and implementation of this policy. All Staff All staff have a responsibility to understand this policy and its impact on their area of work. Staff should be able to respond appropriately to a complainant and achieve immediate resolution. If this is not possible, all staff have the responsibility to escalate the concern/complaint in accordance with this policy. 3. Process: Access What a Complaint can Address A complaint can address any issue relating to NHS services; or services provided overseas or by the private sector where the NHS has paid for them. A complaint should be directed to the NHS organisation which has provided or paid for the service concerned. Colchester Hospital Complaints Department will investigate concerns about: services provided by Colchester Hospital University NHS Foundation Trust. services provided by other hospitals, out of hours services, ancillary services, general practitioners and social care where the main body of the complaint concerns CHUFT related care. Note that whilst it is not necessary to obtain a patient's express consent to the use of his/her personal information to investigate an internal concern/complaint, consent must be obtained from the complainant to liaise directly with other organisations. Matters excluded from investigation as a complaint: Complaints which solely relate to services provided to other NHS organisations. A complaint made by an NHS body which relates to the exercise of its functions by another NHS body. A complaint made by an employee of an NHS body about any matter relating to his contract of employment. A complaint which relates to any scheme established under section 10 (superannuation of persons engaged in health services, etc.) or section 24 (compensation for loss of office, etc.) of the Superannuation Act 1972, or to the administration of those schemes. A complaint which is being or has been investigated by the Health Service Commissioner under the 1993 Act or a Local Commissioner under the Local Government Act 1974. A complaint arising out of an NHS body s alleged failure to comply with a data subject request under the Data Protection Act 1998(a) or a request for information under the Freedom of Information Act 2000. A complaint about which an NHS body is taking or is proposing to take disciplinary proceedings in relation to the substance of the complaint against a person who is the subject of the complaint. A complaint the subject matter of which has already been investigated and resolved. Policy and Procedure: 029 Page 6 of 29

A complaint about services provided privately, unless the relevant private services have been provided by the Trust. The Time Limit for Making a Complaint A complaint should be raised within twelve months from the incident that caused the problem. There is discretion to extend this time limit where it would be unreasonable in the circumstances of a particular case for the complaint to have been made earlier and when it is still possible to investigate the facts of the case. This discretion will lie with the Head of PCLS and the appropriate Divisional Director. If it is not possible to investigate a complaint due to passage of time, the details of the complaint should still be logged on the Datix electronic incident reporting system in order to be able to detect any long standing and adverse patterns of activity. Who can Complain A complaint may be made by a person who is affected by or likely to be affected by the action, omission or decision of the Trust or by a person who is receiving or has received services from the Trust. Anonymous concerns/complaints will be logged on the relevant database and investigated if it is possible and desirable to do so. A complaint may be made by a person acting on behalf of a patient where that patient has died, is a child, is unable by reason of physical or mental incapacity to make the complaint themselves or has requested the representative to act on their behalf. If the patient or person affected has died or is incapable, the complainant (representative), must be in the opinion of the PCLS Manager in collaboration with the Senior Divisional Manager or Matron, someone who had or who has a sufficient interest in the individual s welfare and is a suitable person to act as representative. If a person is accepted as a representative, the PCLS Manager must be satisfied that the representative is conducting the complaint in the best interests of the person on whose behalf the complaint is made. The PCLS Manager in collaboration with the Senior Divisional Manager or Matron, may refuse to accept a person as a suitable representative and nominate another person to act on the patient s behalf. If in any case the PCLS Manager in collaboration with the Senior Divisional Manager or Matron, is of the opinion that a representative does or did not have a sufficient interest in the patient s welfare or is unsuitable to act as a representative, they must notify that person in writing, stating the reasons. A person s status as next of kin is indicative, but not conclusive of suitability to act as a representative: Note that there is no legal definition of "next of kin" ("NOK"). Additionally, although a NOK is usually a relative or a spouse of the patient, it can also equally be a friend or partner of that person. Therefore, whoever the patient has specified as NOK is entitled to be treated as such. Policy and Procedure: 029 Page 7 of 29

A person does not have to be the stated "next of kin" ("NOK") in order to make a complaint. If the patient has already died, and has nominated a personal representative to deal with their affairs, the personal representative is entitled to receive a copy of the patient's medical records and make a complaint, unless the patient expressly stated otherwise. If the patient is alive but lacks capacity, a person who is acting in that patient's best interests would also be able to bring a complaint. Again, that may be someone other than the stated NOK, for example, someone acting under a lasting power of attorney or an Independent Mental Capacity Advocate. The Regulations provide that if a Trust has previously received and dealt with a complaint, it is not required to deal with any complaint that it receives afterwards which is based upon the same subject matter. This means that if the Trust has already dealt with a complaint from one representative, for example a sibling, it would not have to deal with a subsequent complaint from one of the other siblings, where the circumstances of that complaint were the same. However, if the Trust receives separate complaints from two or more siblings which overlap in part, the Trust could only refuse to address the overlapping complaint(s) and would still need to address any remaining complaints. Proof of Identity and Consent A third party e.g. MP, family member, friend, carer, independent advocate such as the Independent Complaints Advisory Service (ICAS) or legal representative may represent the patient only if they can show relevant consent/authority (see Access to Medical Records, Data Protection Act 1998 and Mental Capacity Act 2005 Guidance for Staff). When verbal consent is obtained in the first instance, written consent will be also be obtained. Where the patient is an in-patient the PCLS Team will ask the appropriate Ward Matron to gain written consent from the patient in order for the complaint to be investigated. If consent is required, the PCLS Complaints Officer will send a consent form to the complainant requesting written authorisation from the patient or their next of kin. Proof of identity as next of kin/personal representative will be required. If the patient is unable to give consent through death or incapacity, it is good practice to ask that consent is sought from the next of kin known or listed on the Inpatient Management System. This is especially the case where a child wishes to make a complaint about a parent s care, when the spouse of the parent is still alive. Any consents (patient or next of kin) must be received before confidential or information of a sensitive nature is released to a third party. This is not just to manage the Trust s duty of confidentiality to the patient, but also to manage the duty of confidence which applies to third parties who have given information or who are referred to in the patient s records (for example a family member or Trust employee or another organisation). This also applies to information provided by, or about, a third party who is not a health professional and must not be disclosed without that person s consent. The complaint will be investigated internally whilst consents are being obtained if it is necessary to uncover any error or omission. A final response will not be sent to the complainant until consents are obtained. In the rarer event that there is no indication to investigate a complaint in the absence of consent, the complaints process will commence when consent is received. If consent is not received within two weeks, a reminder will be sent, indicating that if we Policy and Procedure: 029 Page 8 of 29

have no received authorisation within a further two-week period, then no further action will be taken by the Trust. Conflicts Concerning Rights to Complain and Consents It is recognised that tense or complicated family relationships can create difficult situations in terms of identifying suitable representation and obtaining consents. The guidelines allow a suitable officer of the Trust to act reasonably in identifying a suitable representative and allow the Trust to decline to repeat an investigation into the same circumstances more than once. However, the need to ensure that issues of concern are appropriately investigated and the desire to meet an appropriate request for information and closure may require a discretionary response. Where a complex situation arises and a senior decision or a request for legal advice is required the Deputy Director of Nursing will co-ordinate a resolution. Complaints on Behalf of a Child The regulations on which NHS complaints procedures about treatment and care are based (Local Authority and Social Services and National Health Services Complaints (England) Regulations 2009 "the Regulations") state that any complaint in respect of a child must come from a parent, guardian or other adult ("Representative") who has care of that child. Where a person raises a complaint on behalf of a child the PCLS Manager will only consider the complaint once satisfied that there are reasonable grounds for the complaint being made by a representative instead of the child. Note that if a child has been legally adopted, the natural parents will be unable to pursue a complaint against the Trust. If evidence exists to suggest a child is in the process of being adopted, that child will normally have been taken into the care of the Local Authority. In that event, the only person able to bring a claim on a child s behalf is someone who has been authorised to do so by the LA. It is technically possible to find out whether a child has been legally adopted, as LAs, courts and adoption agencies ("Authorities") are required to keep adoption records. However, this is not public information. These Authorities owe a duty of confidentiality to the people they hold information on and, excepting some narrow exceptions (e.g. the prevention and detection of crime, national security, legal proceedings et cetera) would only be able to provide this information with that person's consent. The Trust could of course write to the Authorities to explain the situation and why the information is being sought. If it does, however, it should be aware that disclosure is at the Authorities' discretion alone. Access for Complainants with Impairment or Disability Attention will be given to employees and service users for whom English is not their first language, who have a visual impairment or other disability, ensuring they understand and are able to benefit from this policy. The Concerns and Complaints Procedure can be provided in other languages, Braille and large print if required. Policy and Procedure: 029 Page 9 of 29

Access in the Out of Hours Period The Head of Service for PALS, Patient Information, Complaints and Legal Services and Complaints Team is generally available between 9.00am and 5.00pm, Monday to Friday. Service users may also speak to PALS located in the main Trust building between 9.00am and 4.00pm Monday to Friday. Issues raised outside these hours should be directed to the appropriate Ward/Departmental Manager, or to the duty Matron, via switchboard. Any immediate clinical need must be passed to the appropriate clinician. If the concerns do not require immediate action, as much detail as possible, including the person s contact details, should be obtained and forwarded to the Complaints Department by the next working day. The complainant should be informed of the action taken and given the direct telephone number for the Complaints Department. 4. Process: Informal Resolution It is important that everything is done to resolve approaches for assistance as soon as possible. The method of resolution is decided in discussion with the person concerned and should be proportionate to the complexity of the question, concern or issue raised. Often listening and responding to requests for information and/or advice is sufficient. Being available to talk openly about a problem can prevent escalation of a concern into a complaint. Wards and Services Generally, requests for information and/or advice raised directly at the point of care can be resolved immediately and should be dealt with by the Ward/Matron or an appropriate staff member acting on behalf of the Matron. Staff must address concerns that are made directly and verbally and attempt to sort the problem as soon as possible and appropriate. The complainant s concerns should be addressed privately and sensitively. If there are difficulties, a more senior member of staff should be requested to assist with the concern/complaint. Staff should not be reluctant to apologise. Giving an apology is not an admission of liability. If a member of staff is experiencing difficulty in resolving a complaint, support and advice can be obtained by contacting the appropriate Ward Sister/Charge Nurse or Matron/Senior Midwife. The PCLS Department can be contacted for advice on extension 6448 or by direct dialling outside the Trust on 01206 746448The office is open from 8.30 a.m. to 5.00 p.m. Monday to Friday. Messages can be left on voicemail at all other times. If immediate attention outside office working hours is required, please contact the on call Site Matron, via the switchboard or bleep 333. Where ward or service areas are approached about a patient currently receiving treatment, a note of the contact should be made within the patient record. This includes contacts in ward, outpatients, A&E and diagnostic areas. Any meeting, standardised literature provided and written advice or explanations given should be appropriately summarised, referenced or filed against the patient note. Where a person is dissatisfied with the response they have been given the ward or service should redirect to the PALS or Complaints Team. Policy and Procedure: 029 Page 10 of 29

The Patient Advice and Liaison Service (PALS) Queries and concerns are clearly the responsibility of the PALS Team. The most common queries are: Outpatient Appointments. Listing for procedures/in patient care. Results of clinical investigations Car parking. Access to Health Records. Lost property. The PALS Team will respond to straightforward requests for non-clinical information or to simple non-clinical issues that do not need further investigation. The PALS Team will refer other enquiries to the most appropriate person to effect resolution ensuring the person contacting the service is aware of the action taken and time scale for response. Some complaints may also be dealt with by the PALS Team if it is appropriate and proportionate to do so. PALS officers will seek confirmation that issues escalated to other Trust staff have been resolved and will attach such confirmation to the Datix electronic incident report form. A contact should be recorded within the PALS section of the Datix electronic incident reporting system where that contact is initially handled by the PALS Team. Any meeting, standardised literature provided and written advice or explanations given should be appropriately summarised, referenced or filed against the Datix electronic incident report note. Queries and immediate concerns should be resolved as quickly as possible in accordance with national guidelines and preferably within two working days. When is Informal Resolution of Complaints Appropriate Informal resolution is appropriate when a complainant specifically says they do not want to be involved in a formal process OR Informal resolution can be offered when a complaint involves a clear misunderstanding of actions or intentions, rather than a possibility of error or omission. Informal resolution can be offered when an error or omission is minor and can be resolved quickly and easily. Where a complaint involves serious harm or a significant error or omission and an individual does not wish to complain, the staff member contacted should confirm that the issue concerned has been raised internally under the relevant Falls, Safeguarding or Serious Incident procedure. 5. Process: Formal Local Resolution Receipt of Complaint A complaint may be received via email, letter, phone, voicemail, personal contact or social media; either directly from the complainant or by referral from a third party. Policy and Procedure: 029 Page 11 of 29

Contacts may be made to any department, team or person. Where a contact is not made directly to the Complaints Team, it should be appropriately redirected. Consultants often receive written enquiries where it is not clear if a complaint is being made. Heads of Departments/Senior Managers/Matrons/Consultants should consult with the Complaints Department who will contact the complainant to discuss how to proceed if necessary. Letter, email and voicemail contacts are decanted throughout the day. The complaint is acknowledged in writing within three working days of receipt. A short form on the Datix electronic incident reporting system is used to immediately log contacts so they are electronically recorded, traceable and reportable. Headline complaint details are logged and initial triage conducted to flag any of the following indicators: Query harm. Query Serious Incident. Query cancer. Query safeguarding. Query fall. Patient currently receiving treatment. Any complaint relating to a patient currently receiving treatment is immediately escalated to the Matron and Service Manager of the area concerned. Any potential Serious Incident, safeguarding or falls issue is escalated to the appropriate team for review. Confirmation of Complaint A Complaints Officer will contact the complainant to offer the opportunity to discuss their complaint further, to clarify the issues involved and identify what outcomes the complainant is seeking. This exchange commonly takes place via phone and email. Where initial contact is made by phone, the Complaint s Officer will progress immediately to clarification of complaint. The Complaints Officer must: o establish context. o differentiate the focus of each concern (clinical, care, administration or organisation, information or explanation, manner or attitude). o confirm severity (harm, possible SI, safeguarding or fall). o confirm urgency is the patient is currently receiving treatment? o help the complainant be clear o help the complainant avoid inappropriate detail or emotion. Any requirements for consents or access to health records are confirmed. A predicted timescale for answering the complaint is discussed with the complainant. The complainant is given time to review the context and wording of their complaint issues, should they need it. The complainant is advised that the complaint investigation will only proceed when they have confirmed agreement of the scope of the complaint. Policy and Procedure: 029 Page 12 of 29

If the complainant does not take up the opportunity to discuss their complaint and/or cannot be contacted: If enough information and the required consents are available the complaint will be taken forwards to ensure any error or omission is appropriately investigated If insufficient information or consents are present, the contact is filed for retrieval, should the individual make contact again. This step is important for two reasons: Each complainant is satisfied that they have been heard and understood. o Experience suggests that personal engagement at the beginning of a complaint leads to greater understanding of and confidence in the overall process. The complainant values the human contact and personal relationship which is immediately established. A small number of complainants discontinue their complaint at this stage because this positive engagement is sufficient to meet their need to make the trust aware of their issues. The complaint investigation and response is appropriately clear and focused. o Where a complainant gives a narrative and question set which is logical and clear confirmation of understanding and wording is a brief exercise. It can happen that understanding, recollection or emotion affect the presentation of a complaint and a complainant struggles to provide a coherent narrative or question set. If not addressed, an unclear or muddled complaint may result in a difficult investigation and unsatisfactory response. Engagement seeks to support the complainant in more clearly expressing their concerns. A standardised form is used to capture the complaint detail for verbal contacts. Complaint Triage and Configuration Once all relevant information has being obtained and the wording and scope of the complaint has been agreed the complaint will be further triaged to: identify the subjects and sub-subjects contained in the complaint narrative and question set. assign each subject or theme to the appropriate area. Identify the risk to the Trust using Likelihood of recurrence Initial Risk Grading (see Appendix D). identify the relevant service and clinical contacts for each element of a complaint. identify who should lead the investigation into the complaint where a complaint covers more than one area or organisation. identify who will provide the response and in what format determine whether any serious incident, falls or safeguarding investigation is being conducted in tandem. determine whether a claim for compensation is being conducted or contemplated. confirm the timeframe for answering the complaint. Timescales are suggested in accordance with the following guideline: o Simple or single issue relating to a short period of care, single speciality: 30 calendar days. o Multiple issues relating to a longer period of care, multiple specialities: 60 calendar days. o External organisation involved: 90 calendar days. o External opinion required: 180 calendar days. o Where a Serious Incident Review is also taking place, a complaint investigation may take place in tandem with the SI investigation, but the complaint response will be held until the SI investigation is complete and Policy and Procedure: 029 Page 13 of 29

reviewed in the light of the SI output to ensure that the two outputs are complementary and not contradictory. The items are further configured on the Datix electronic incident reporting system, the case is made visible to the wider Trust and the relevant contacts emailed from within Datix with a link to the case. A letter is sent to the complainant to formally confirm the scope and timescales of the complaint investigation. An information leaflet providing further information on the complaints procedure is enclosed with the acknowledgement letter. Consent is requested where necessary for third party representation or access to external records. Investigation Initiation by Lead Investigator The lead investigator in receipt of a new complaint will: review the case triage in terms of timescales and allocation of themes to ensure they are practical and appropriate. inform the PCLS complaints officer of any suggests amends to the initial triage. delegate elements of the complaint investigation were appropriate. make arrangements to obtain the case notes relating to the complaint. create a timeline of the documented elements of care or treatment. make arrangements to take statements of fact from the members of staff named or involved in the complaint. make arrangements to obtain statements of opinion where a complaint issue requires evaluation or review. Disclosing Information about a Complaint Any information disclosed about the patient must be confined to that which is relevant to the investigation of the complaint and only disclosed to those people who need to know it for the purpose of investigating the complaint. A member of staff requested to provide a statement should be given access to the relevant information as necessary to aid investigation. Complaints records must be kept separate from health records and should not be placed on EPR subject to the need to record information which is strictly relevant to the patient's healthcare. All staff must comply with the requirements of the Data Protection Act 1998. Where it is necessary to discuss relevant allegations and facts with colleagues who share responsibility for investigating complaints, care should be taken to ensure that: relevant conversations cannot be overheard. written information is not left on view. suitable steps are taken to protect stored information. Requests for information from anyone not directly involved in the internal complaints process must be referred to the PCLS Department. The consent of complainants is required if information has to be shared with other organisations in order to address a complaint. Policy and Procedure: 029 Page 14 of 29

Supporting Staff Involved in a Complaint It is acknowledged that being the subject of a complaint can be stressful and traumatic and the Trust is committed to ensuring staff are adequately supported. All staff members who are the subject of a complaint will be sent a staff support letter by the investigating officer. This letter will be generated by the Complaints Department and will advise staff to seek support and advice from their line manager, staff support counsellors or the Health and Wellbeing Team. PALS and the Complaints Department will also provide support to those involved in a complaint. Monitoring Progress Whilst a complaint is in progress, the lead investigator will work with the PCLS Department to monitor progress. The Complaints Officer will meet weekly with speciality clinical and service colleagues to review complaints progress, give a rating (red, amber or green) for the ability to respond within the timescales agreed and to identify any blocks to progress. Note, the monitoring report is not anonymised and must only be shared on a need to know basis. The Complaints Department will support services, where possible, in obtaining notes, producing timelines and facilitating statements. Any issue which will delay the production of the final response within the timescales agreed will by communicated to the complainant by a Complaints Officer when it is known. The Outputs of Investigation It is essential to ensure that each point or question is properly addressed or answered. Following the investigation, each theme or subject element of a complaint must be identified as upheld, partially upheld or not upheld. Each partially or fully upheld portion of a complaint must be risk assessed using the Trust risk, assessment guide. The action required to resolve upheld or partially upheld complaint issues should be identified. Where an action is pressing it must be effected immediately, without waiting for the composition of a response to the complainant. When a Complaint and Claim are brought at the Same Time The complaints procedure should continue even if the complainant explicitly indicates an intention to take legal action in respect of the complaint unless contrary to the advice of the Trust s legal advisors or insurers. Depending on the nature of the complaint, it may be appropriate to refer the case to the NHSLA for comment. Staff should be aware that any documentation obtained during the investigation of a complaint will not be subject to legal privilege in any future litigation and therefore can be disclosed. Policy and Procedure: 029 Page 15 of 29

Where a Complaint and a Serious Incident Investigation relate to the Same Event A combined complaint and SI investigation may be identified in one of two ways: SI already registered when complaint is received: o Risk Management Team must configure all SIs in the Datix incident reporting system to allow identification when a complaint is logged. o PCLS Team must check for a possible pre-existing SI when logging complaints. Complaint is received which may require investigation as a serious incident: o PCLS Team must flag any potential SIs by sending an email from within the Datix electronic incident reporting system to the Risk Management group email address. o The Risk Management Team must respond to the email after assessing the complaint concerned to confirm SI status. If a complaint and serious incident investigation relate to the same event: The complaint Datix electronic incident report SI flag is set to Y. The complaints officer must identify which questions within the complaint will be covered by the SI investigation, log within the Datix electronic incident reporting system and inform the complaints investigation officer. The complaints officer must contact the complainant to explain the impact on the investigation of their case. The Nominated Investigator of the SI will contact the complainant and advise on the investigation process. The Risk Management and PCLS Team members must co-operate to facilitate both investigations. The complaint response must be held for review against the outcome of the SI investigation to ensure both responses are complementary. The Nominated Investigator must contact the complainant to explain the outputs of the SI review. The PCLS will incorporate any relevant items in the SI report into the complaint response. Composition of Response The responsibility to compose a response primarily sits with the lead investigator of a complaint. It is important that complainants receive a full and open response. Where an apology is warranted, it should be openly and freely offered. All complaints correspondence should be objective and not contain personal opinions. Any actions or changes to practice identified are to be confirmed in the response. The lead investigator of a complaint will ensure that all statements, timeline, meeting notes, telephone conversation records and any other documentary evidence is attached against the complaint in the Datix electronic incident reporting system so that anyone can undertake or assist with the task, if the lead investigator is not able or available to complete it. These items are also required in case there is a need for further investigation or litigation. The PCLS Team will provide support in composing a response where it is lengthy or complicated. Policy and Procedure: 029 Page 16 of 29

The lead investigator must ensure that any response referring to matters of medical care or clinical judgement is agreed by the consultant or clinician concerned before it is sent out. Where it is possible that a complaint may result in litigation, it may be appropriate to ask the Trust insurers to review the complaint response. This option should be discussed with the PCLS Manager and the Divisional Director. Content The response should be based on the Trust pro-forma document, amended as appropriate. In particular the response must contain: the case reference number. the date SENT not the date composed. an acknowledgement of the date of receipt of complaint and any delay in responding. an acknowledgement of the value of the complaint contact. details of who performed the investigation and how. a response to each question or observation giving context, a timeline where relevant and an answer to the question asked. no service slang or technical terms without explanation. a clear acknowledgement of fault and apology where appropriate. an acknowledgement of distress or misunderstanding where relevant. the details of actions taken and lessons learned as a result of the complaint. remedies which take into account a complainant s individual circumstances. the name and telephone number of the appropriate person to contact to discuss the response. any further action the complainant can take with respect to the complaint. Response Review The PCLS Team will quality control responses prior to sign-off. The team check for: spelling and grammatical errors. layout issues. service slang or technical language. confirmation of fault and actions arising. clarity of response. sufficiency of response. have the questions been answered. if it is not possible to answer a question, has this been acknowledged and explained. The response must be approved by the appropriate Divisional Director. Sign-off A simple complaint which does not contain any assertion or finding of harm or significant error or omission can be signed by the Service Manager of the speciality concerned. All other complaints must be signed by the appropriate Divisional Director, unless signed by the Chief Executive. Policy and Procedure: 029 Page 17 of 29

The Chief Executive will sign the following responses: Re-opened complaints. Method of Transmission A final response is normally sent by second class paper post to the complainant. An e-mail response can be provided at the complainant s request and with the appropriate disclaimer. In the event that a verbal response is given and the complainant declines a formal written response, a file note detailing what has been discussed, along with any agreed actions, should be completed by lead investigator and saved within the Datix electronic incident reporting system. A copy of the final response, both in word and signed pdf format must be uploaded within the Datix electronic incident reporting system against the complaint file. Outcome Lead investigators should take a proactive approach to managing outcomes wherever possible. This may involve inviting the complainant in for a meeting with those involved in their care or the use of external conciliation services if necessary. Actions Arising It is the responsibility of each Service Manager or Matron to ensure that actions which relate to their clinical or service area are completed within the specified timeframe and that the PCLS Team are notified when this has been done. Actions which relate to partially or fully held elements of a complaint must be reviewed at Divisional Governance Committee and referenced in the meeting minutes as appropriate or complete before the action can be closed. The minutes of the DGC meeting must be uploaded against the complaint concerned to evidence oversight prior to closure. Actions arising and lessons learned are currently collated via LEAPS (Learning, Experience and Action Plan), which are attached within the complaint. Individual, complaint level action plans are caused issues in terms of repetition, practicality and visibility. It is recommended that any upheld or partially upheld element of a complaint is exported to a divisional level action plan; divisional plans to have two components: Practical actions: Person or department level actions which can be completed in a one month timescale. Strategic actions: Recurrent problems which involve multiple complaints or actions which take longer to complete / which require divisional, trust or CCG involvement to finance and resolve. Each action on the divisional plan to have a unique ID which is held in Datix against the relevant complaint element. Each action on the divisional plan to include a counter of the number of complaints to which the action relates. A complaint cannot be closed until all practical actions have been completed. Policy and Procedure: 029 Page 18 of 29

A complaint can be closed if strategic actions are ongoing. Divisional Outcome Plans are reviewed at Divisional Governance Committee. Where an action is identified as required by ten or more complaints, the action will be escalated to the Trust risk register. Meeting with the Complainant Face to face communication is often more effective in resolving the complaint than protracted written communication. It can help the complainant to understand the full circumstances and to be able to resolve the complaint, restoring their confidence in health care. Any meeting should only take place when a written response to each complaint question is on file. Financial Redress Financial redress will not be appropriate in every case but the Trust will consider proportionate remedies for those complainants who have incurred additional expenses as a result of poor service or maladministration. Remedying injustice or hardship is a key feature of the Ombudsman s Principles for Remedy suggesting that where there has been maladministration or poor service the public body restores the complainant to the position they would have been in had the maladministration or poor service not occurred. Where it is apparent from the response that a case raises a risk of litigation the Divisional Director should be alerted for referral to the NHS Litigation Authority for consideration. Feedback to Staff All staff involved in a complaint should be advised of the outcome. Either a copy of the report or written response is to be provided or appropriate feedback is to be given to staff by the relevant manager. Disciplinary Action and Professional Registration Challenges In accordance with Section 4 of "Guidance on Implementation of the NHS Complaints Procedure" the Complaints Procedure is separate from any investigation under the Disciplinary Procedure, referral to one of the professional regulatory bodies, an independent inquiry into a serious incident, under Section 84 of the National Health Service Act 1977 or an investigation of a criminal offence. Where an investigation identifies information that would indicate a need to disciplinary investigation; that issue is dealt with separately to the complaint investigation itself. Complainants do not have the right to be informed whether disciplinary action is contemplated, or its outcome, unless this information is requested in the course of disclosure in pursuance of legal proceedings. Discrimination as a Result of Raising a Concern or Complaint The Trust is committed to ensuring that a person s care or treatment will not be adversely affected as a result of raising a complaint. Any person concerned that their care or treatment has been adversely affected should raise this with PCLS Manager. Policy and Procedure: 029 Page 19 of 29

Dissatisfaction with Response/Further Local Investigation From October 2001, the Data Protection Act classified complaints and untoward incident documentation as personal data. Patients are able to request copies of complaints and risk management files in the same way as they do for their health records. All documentation generated in the course of a complaint investigation is subject to disclosure to the complainant if requested; and as evidence in the event of legal proceedings and investigations by the Ombudsman. Clarification of Response All complaints are held open for a period of 30 calendar days following production of final response to allow any clarification to take place prior to closure. Currently, the complainant must actively seek clarification by contacting the PCLS Department. The department intends to trial contacting complainants 5 working days after transmission of final response to confirm receipt and understanding/satisfaction. Any reasonable further questions or issues of understanding will be referred back to the investigating team for a further response. Re-opening a Complaint A complaint should only be formally re-opened if: the original complaint is closed, OR the complainant engages, post first response, with significantly different further concerns. In the event of an ongoing difficulty to provide a response to the satisfaction of the complainant, if all local avenues for resolution have been exhausted, the complainant be directed to the Parliamentary and Health Service Ombudsman and ask them to consider taking the complaint further. Habitual or Repetitive Complainants Complainants may be deemed to be habitual or repetitive where previous or current contact with them shows that they meet two or more of the following criteria: Persist in pursuing a complaint where the NHS Complaints Procedure has been fully and properly implemented and exhausted. Persist in pursuing actions to rectify a real or perceived problem when all that can be done has been actioned and the appropriate governance/oversight has been completed. Change the substance of the complaint or continually raise new issues or seek to prolong contact by repeatedly raising further concerns or questions upon receipt of a response whilst the complaint is being addressed. Care must be taken not to discard new issues that are significantly different from the original complaint; these might have to be addressed separately. Do not clearly identify the issues they wish to be investigated, despite reasonable efforts by Trust staff and others (i.e. POhWER ICAS) to help them specify their concerns. The complaint or issue is trivial or appears to consume an excessive amount of resources. Having in the course of pursuing their concerns had an excessive number of contacts with the Trust by telephone, letter, email, fax or in person. Staff should be instructed to keep a clear record of the number of contacts to demonstrate the excessive nature. Policy and Procedure: 029 Page 20 of 29

Display unreasonable demands or expectations and fail to accept that these may be unreasonable (i.e. insist on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice). Where a complainant exhibits behaviours which compromise the complaints handling relationship and are adversarial the following should be considered: Requesting contact in a particular format e.g. letters only. Requesting contact to only be with a named officer. Restricting when telephone calls will be accepted. Requesting the complainant to enter into an agreement about their future conduct. Requesting all contact to be made via an advocate. Situations where complainants might be considered to be habitual or repetitive should be recognised promptly and the decision to categorise a patient/complainant as such will follow discussion between Divisional Directors and the PCLS Team. Where patients/complainants have been identified as habitual or repetitive the Chief Executive will determine what action to take. The Chief Executive will implement such action and will notify complainants in writing of the reasons why they have been classified as habitual or repetitive and the actions to be taken. This notification may be copied for the information of others already involved in the complaint i.e. General Practitioners, Conciliators, POhWER ICAS and Members of Parliament. A record must be kept for future reference of the reasons why a complainant has been classified as habitual, vexatious or repetitive. The above action should only be taken as a last resort and after all reasonable measures have been taken to assist the patient/complainant. External Resolution Parliamentary and Health Service Ombudsman Any complainant unhappy with the response provided by the Trust can ask the Parliamentary and Health Service Ombudsman to review their case. The Ombudsman's role is to consider complaints that government departments, a range of other public bodies in the UK, and the NHS in England, have not acted properly or fairly or have provided a poor service. Tel: 0345 015 4033 E-mail: phso.enquiries@ombudsman.org.uk Website: www.ombudsman.org.uk 6. Training The following awareness, training and support is available to Trust staff: All Trust staff: At Our Best training and complaints awareness training on induction Senior Managers: Risk Management training. As required: Root cause analysis training Investigators: Complaints Handling training supplied by PCLS Department The PCLS Manager is responsible for providing informal training in the Concerns and Complaints Procedure to all relevant staff to ensure that staff are fully aware of their responsibilities when dealing with issues of concern raised by complainants. Policy and Procedure: 029 Page 21 of 29

Staff who have responsibility for chairing meetings with complainants should receive training as required organised by their line manager. Training in informal/local resolution is also provided on an ad hoc basis to wards and departments, and is ongoing via staff induction. The Risk Management Team provides training in Root Cause Analysis and investigation procedures. Attendance is monitored as part of the general training needs analysis within the Learning and Development Department. The Trust s training arrangements on complaints for all staff groups are as identified within the Training Needs Analysis in the Planning and Delivering Risk Management Training Procedure, document number 203. 7. Evidence Base The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the Regulations 2009) Department of Health: Listening, Improving, Responding NHS Constitution 2009 Principles of Good Complaint Handling, Parliamentary and Health Service Ombudsman (2009) Making Experiences Count A New Approach to Responding to Complaints (June 2007) Supporting Staff, Improving Services Guidance to support implementation of the National Health Service (Complaints) Amendment Regulations 2006 (1/9/06) NHSLA Risk Management Standards Regulations 2012/13 Criterion 2.3 8. Monitoring Compliance and Audit The following items are monitored to ensure complaints handling is well managed: Complaints received. Complaints acknowledged within 3 days. Complaints in progress. Complaints status: o Stage. o Blocks to progress. o RAG status. Complaint final responses sent. Complaint responses overdue. Complaint outcomes identified. Complaint actions completed. Complaints closed. Complaints re-opened. Escalation to Serious Incident Review. Escalation to PHSO. Escalation to CQC. Complainant satisfaction with process. The following items are monitored to ensure that lessons are learned from complaints Complaint themes. Complaint severity by risk rating. Percentage complaint issues upheld or partially upheld. Local actions identified as a result of complaint. Strategic actions identified as a result of complaints. Policy and Procedure: 029 Page 22 of 29

Weekly, monthly, quarterly and yearly information is made available for Division and Executive reporting as follows: Weekly line level complaints monitoring list is supplied to clinical and service leads. Weekly summary data is supplied to the assistant director of nursing and clinical and service leads. Monthly summary data is supplied to Divisional Governance meetings, the Clinical Quality Review Group (CCG) and Quality and Patient Safety Committee (Governors) and the Executive Board Monthly example of complaint response is supplied to the board. Monthly clinical area data in support of the Clinical Area Assessment Programme. Yearly report in compliance with monitoring requirements of the Local Authority Social Services and NHS Complaints (England) Regulations 2009. Yearly KO41a return. Yearly Monitor report for foundation Trusts. Ad hoc reporting as required 9. Dissemination, Implementation and Access to the Document This policy and procedure is available on the Trust intranet. All staff are notified via email, of the policy and procedure and any amendments. References: The NHS Hospital Complaints System : A case for urgent review Parliamentary and Health Service Ombudsman (2013) The report of the Mid Staffordshire NHS Foundation Trust Inquiry, chaired by Robert Francis QC (2013) A review of the NHS hospitals Complaint System Putting Patients Back in the Picture Right Honourable Ann Clwyd MP and Professor Tricia Hart (2013) Policy and Procedure: 029 Page 23 of 29

Appendix A Contact to Staff Involved As you may be aware, a complaint has recently been received which relates to you. If you have not already done so, please arrange to discuss this complaint with your manager. This letter is to supplement that discussion. The complaint is being investigated and the investigator may contact you to ask for a statement. The details are as follows: >>>>>>>>>>>>>>>>>> We do realise that it can be distressing and worrying to be the subject of a complaint. If you would find it helpful to discuss this complaint with someone unconnected with the investigation, your line manager will be able to arrange this. If your line manager is the investigator it may be possible to identify another person to support you. If you feel that stress as a result of the complaint is interfering with your ability to do your job, or is seriously affecting you in any other way, please seek advice from Occupational Health who may be able to provide direct support or refer you for further support. Please be assured that the investigation of the complaint will be undertaken in the context of the "Fair and Open" principles set out in the Complaints Policy, which is available on the intranet. We recognise that complaints can be the result of misunderstanding and that, even where there has been some error on the part of Trust staff, it is important to recognise the systems issues that can lead to errors. The key objective of investigating complaints is to allow the situation to be understood, so that we can learn from it and give the complainant assurance that we are doing this. Please feel free to contact me if there is any other information that you would like in relation to this issue. Policy and Procedure: 029 Page 24 of 29

Appendix B Statement Request The following matter is being treated as a concern/complaint and in accordance with Trust Policy and Procedure, I am formally requesting a statement from you in order to investigate this complaint. >>>>>>>>>>>>>>>>>>>>>describe complaint or attach summary You should return your signed statement to me by DATE Please follow the following guidance in composing your statement Ask for help from your line manager if you are concerned or unsure. Mark your statement clearly as draft until you are ready to sign it. You should keep a copy of your statement for your own reference. Any record that you keep should be filed in a secure place, bearing in mind requirements of confidentiality. Do NOT file a copy of your statement in the patient notes. Be aware that any documentary evidence collected as part of a complaints investigation can be disclosed as part of a Data Protection Act request, an independent review or if there is a legal claim against the Trust. Describe your period of duty and responsibilities at the time. Describe other persons present: Give names and roles. If persons were not present throughout, give details. Give factual details of any background factors you believe may have been relevant, e.g. lack of full staff complement, unusual number or dependency of patients. Give a clear account of how you were involved, including actions of others and conversations held. State the sequence of events chronologically, giving dates and times. Give reasons for your own actions, but do not speculate about other people s motives. If reporting a quote from another person use direct speech in inverted commas, e.g. Nurse Brown said I saw him fall. Avoid jargon, abbreviations or emotional language Only include factual details where you have direct knowledge. State observations, not opinions e.g. His breath smelt of alcohol rather than He was drunk. You can acknowledge that you cannot remember this incident but describe your normal practice. If you refer to your normal practice please make this clear. If you refer to documentation in the patient record please cite your source. Refer to any policies/procedures/guidelines in use. Indicate any written records made by yourself in relation to matters covered in this statement e.g. clinical notes, incident form, training notes etc. Ensure all questions have been answered and all points covered. If you are not able to comment on any point, please state why (for example this may not fall within your remit). Any other relevant information. Policy and Procedure: 029 Page 25 of 29

Full Name Position/Grade Location/Ward/Dept/Team Contact number Date and time of Incident Statement/Account Signature: Date: *Use additional sheets as necessary. Sign and date each page Policy and Procedure: 029 Page 26 of 29

Appendix C Template Final Response Letter Date: Our ref: dd Month yyyy **/**/CLS/##### Quality Centre Turner Road Colchester CO4 5JL Tel: 01206 745926 Fax: 01206 742942 Title FName LName AdLn1 AdLn2 AdLn3 AdLn4 PCode Dear Title Surname I am writing in response to your recent communication with the Complaints Department expressing your concerns regarding your treatment at Colchester General Hospital. I am very sorry to hear that you have concerns about the standards of care you experienced. I would like to thank you for taking the time to raise these matters with the Trust. We strive to deliver a high standard of care at all times and your complaint gives us the opportunity to review our current practice in order to identify where improvements and changes are required. Name, Role was asked to carry out an investigation into your complaint. Name was supported in his/her investigation by Name, Role, Name, Role and Name Role. In order to investigate your complaint we have looked at the concerns detailed in your original communication, accessed your health records and interviewed relevant members of staff. The findings of our investigation are detailed below: >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>Body of response I hope that we have addressed your concerns appropriately, however, if you are unhappy with any aspect of this response or feel that it is incomplete, we would welcome the opportunity to discuss this further. It may be that you would like us to look again at certain issues or that our response has raised further questions for you. Alternatively you may wish to meet with the team involved to talk through the response with them. You can contact the PCLS Department on 01206 745926 or via email at complaints@colchesterhospital.nhs.uk If your concerns have not been addressed to your satisfaction, you also have the right to ask the Parliamentary and Health Service Ombudsman (PHSO) to review Policy and Procedure: 029 Page 27 of 29

your case. The Parliamentary and Health Service Ombudsman carries out independent investigations into complaints about treatment provided by the NHS in England, and may be contacted at The Parliamentary and Health Service Ombudsman, Millbank Tower, Millbank, LONDON, SW1P 4QP, via their helpline on 0345 015 4033 or via email at phso.enquiries@ombudsman.org.uk Yours sincerely Title FName LName Policy and Procedure: 029 Page 28 of 29

Appendix D Initial Risk Grading Likelihood of a recurrence Severity of Incident Insignificant 1 Minor 2 Moderate 3 Major 4 Extreme 5 Remote 1 Unlikely 2 Possible 3 Likely 4 Almost Certain 5 Mark box with a for Risk Assessment. Insert date in appropriate box after action taken. Policy and Procedure: 029 Page 29 of 29