the dudley group of hospitals nhs trust complaints policy and ...

THE DUDLEY GROUP OF HOSPITALS NHS TRUSTCOMPLAINTS POLICY AND PROCEDURE “LEARNING FROMEXPERIENCE”1 INTRODUCTION1.1 IntroductionThe Trust is firmly committed to continuously improving the quality of care and theservices it provides and one of its aims is to ensure the satisfaction of itscustomers and users. The Trust is accountable for its services and is keen topromote and adhere to the values of public service. It therefore encourages theviews, comments and suggestions of its service users, their families and carers.Competent handling of complaints can assist in improving the quality of care andminimising claims by listening to the voice of service users and using this as anopportunity for the organisation to learn from patient/carer experience.It is therefore important that the Trust has a consistent and orderly process forreceiving and handling complaints appropriately and makes positive use of theinformation gained to avoid similar occurrences and to generally improve services.People should be able to complain in a variety of ways and expect a detailed,considered and prompt response. They should not have their avenues ofcomplaint restricted by rigid systems.1.2 DefinitionA complaint is an expression of dissatisfaction about any aspect of the Trust’sservices requiring a response.1.3 AimsThe Trust’s complaints procedure aims to meet the following criteria:• be well publicised and easy to access• be simple to understand and use• be fair, impartial and open• allow complaints to be dealt with promptly and as close to the point wherethey arise as possible• provide answers or explanations quickly and within established time limits• ensure that rights to confidentiality and privacy are respected1

• provide a thorough and effective mechanism for resolving complaints andalso matters of concern• enable lessons learned to be used to improve the quality of services• be regularly reviewed and amended if found to be lacking in any respect• be consistent with national guidance.• provide the essential information for complaints reporting, eg. Copy ofcomplaints procedure to complainant (containing information regardingassistance from ICAS-POhWER), details of response times, etc.• ensure complainants are treated courteously and sympathetically2 POLICY2.1 General PrinciplesIt is important that the correct procedures are followed and that the contents of thisdocument are brought to the attention of all staff who are likely to receivecomplaints and patients/carers who wish to express their dissatisfaction.Complaints will be viewed in a positive way by using them to identify what serviceimprovements should occur. Health Service Providers have a responsibility to doall that is possible to reduce the need for complaints by patients, their relatives andadvocates.The Trust will act in accordance with the legal directions of the National HealthService (Complaints) Regulations 2004 and the National Health Service(Complaints) Amendment Regulations 2006.The Business Support Manager (Complaints) is the officer responsible foradministrative co-ordination and for ensuring that complaints are actioned in linewith the guidance. He/she will investigate and respond to complaints directed tothe Chief Executive or other members of staff.2.2 Proactive Complaints ManagementStaff members must place greater emphasis on resolving complaints quickly andon the spot, wherever possible (see 2.3 and 2.4 below). This may be through animmediate informal response by a front-line member of staff or practitioner, orthrough subsequent investigation. The complaints procedure will be advertisedwidely throughout the Trust. Leaflets will be available within departments, withfurther supplies available from the Business Support Manager (Complaints).2

2.3 Communicating with the ComplainantThe following principles are to be applied in any communication with thecomplainant:• Listen to the concerns being expressed• Be open, fair, flexible and conciliatory• Be courteous and sympathetic• Be apologetic where appropriate; an apology is not an admission of liability• Be prompt and follow the established time limits for reply2.4 Roles of Staff MembersTrust Board – will receive the Complaints Annual ReportChief Executive – has a responsibility for the effective management of complaintsand is held accountable for the performance of the organisation in handlingcomplaints.Operations Director – has the responsibility for ensuring the complaints policyand procedure is in place.Associate Director (Performance Delivery) – has the responsibility for managingthe Business Support Manager and ensuring complaints are appropriatelymanaged within the Trust’s Complaints Policy.Business Support Manager (Complaints) - has the responsibility for managingthe complaints process and for co-ordinating and responding to complaints. TheBusiness Support Manager (Complaints) also has responsibility for co-ordinatingall litigation claims and for reporting each claim to the NHS Litigation Authority.Medical Services Heads/Matrons/Senior Managers – have the responsibility ofensuring that investigations are carried out in a timely fashion and for providinginformation to the Complaints Co-ordinators.Complaint Co-ordinators – will be responsible for investigating complaints, forco-ordinating response to a complaint and for providing the written response forthe Chief Executive’s signature.All staff – any member of staff who is approached by a patient or theirrepresentative with a complaint should endeavour to resolve the matter there andthen. If this is not possible, PALS (Patient Advice and Liaison Service) or theComplaints Department should be contacted.3

3 THE PALS-COMPLAINTS INTERFACEPALS (Patient Advice and Liaison Service) should not become a proxy forcomplaints. However, it should be the choice of the individual to use either PALSor the NHS Complaints Procedure; there should be no requirement for serviceusers to use the PALS first if they wish to make a formal complaint.Clearly, close collaboration between PALS and the Trust Complaints Departmentis essential to ensure a coherent and seamless approach to resolving patient’sconcerns. However, there is a clear differentiation of the roles of PALS and theComplaints Department. PALS will not investigate complaints and their role isclearly to inform and support people to access the complaints procedure whenrequested:• When patients first have a concern or issue they wish to raise, their first pointof contact will often be with a member of staff or PALS.• PALS will act as quickly and creatively as possible to support service users,their carers and families to deal with their problems, before they becomemore serious.• Concerns may be resolved by listening, providing relevant information, or bycontacting departments on behalf of the patient• A key PALS role is to help people to talk through their concerns so that theycan identify the nature of the problem and work out various options, includinguse of the formal complaints procedure, for resolving the issue, explaining thepotential consequences of each option.• PALS will provide a service for service users, which aims to improve theirsatisfaction and reduce any confusion or anxiety they may have.There may be occasions when patients, their carers or relatives contacting PALShave previously made a formal complaint, or taken other action to gain resolutionregarding an issue. Patients should not use PALS to pursue a concern once thecomplaints procedure has been exhausted. PALS staff may decide that no actionthey can take will provide an effective and speedy resolution, and that the issue isoutside their remit. PALS will provide information regarding appropriateindependent advocacy or alternative means of pursuing the matter. It is importantthat PALS are able to work in an independent way and inform people of all theiroptions and rights. Contacts with PALS may initially frame their concern in theform of a complaint but the PALS staff will seek to identify if the concern can bedealt with informally through PALS. In all cases the choice of action should beagreed with the person raising the concern or issue.Using PALS will not remove the right of patients to pursue the complaints option atany stage; however, it would not be appropriate to use PALS and the Complaints4

Department simultaneously to address the same problem. PALS will act as agateway to the complaints service in the Trust. In certain cases it will benecessary to refer an individual to the complaints procedure. For example:• The person chooses to use the complaints procedure rather than the informalprocess.• The issue cannot be resolved through the informal process.• Allegations of staff assault or incidents of similar seriousness.4 LOCAL RESOLUTION PROCESS4.1 IntroductionThe Trust has designated the Complaint Co-ordinators as investigating complaintsmanagers. As such, they will be granted access to all the relevant records, which areessential for the investigation of any complaint referred to them. The role of theComplaints Co-ordinators is to deal with complaints and to prepare a draft response forthe Chief Executive to sign. The Complaints Co-ordinators will aim to resolvecomplaints at local resolution level, offering mediation where complaints cannot beresolved.4.2 Time LimitsA complaint should normally be made within six months from the incident that causedthe problem, or within six months of the date of discovering the problem. The Trust hasdiscretion to extend this time limit where it would be unreasonable in the circumstancesof a particular case for the complaint to have been made earlier and where it is stillpossible to investigate the facts of the case.4.3 Continuing care whilst a complaint is in progress(avoidance of discrimination)It is recognised that, on rare occasions, the relationship between a patient and aclinician may break down and the patient may feel cause to complain about thatindividual. This may happen in any discipline and specialty within the services operatedby the Trust. It is Trust policy not to withdraw clinical treatment or support as a result ofa complaint.If a patient complains verbally to a doctor, nurse, midwife or other health professional, inaccordance with the local resolution procedure, the doctor, nurse, midwife or healthprofessional will try and resolve the matter to the complainant’s satisfaction at that timeor within a very short period, so as to minimize any ill effect on the patient’s continuingneed for care.5

If a patient complains in writing, the Complaint Co-ordinator will endeavour to resolvematters quickly, also having regard to the patient’s need for continuing care. If eitherside feels that the matter cannot be resolved and the complaint is impacting on therelationship between the patient and the clinician, the clinician must contact his or herMedical Service Head as a matter of urgency (i.e. within 24 hours) to discuss the mostappropriate way to resolve the matter. They will refer the matter to the AssociateMedical Director or Medical Director.As indicated in the complaints leaflet given to patients when their complaint isregistered, their care will not be affected when a complaint is made.The clinician and Medical Service Head will consider the options and agree whether it isappropriate to ask a different clinician to take over the patient’s care –a) on a temporary basis until the complaint is resolved, orb) permanently, if it is felt that it would not be in the patient’s best interests to remainunder that individual’s care.If a complaint is registered at the time the clinical treatment is completed, the clinicianhas a duty of care to ensure that the patient is advised of the situation separating theissue of treatment and any aspect relating to a complaint. In addition, anycorrespondence relating to the complaint must not be filed within the patient’s healthrecords.4.4 Types of Complaints4.4.1 Written ComplaintsWritten complaints may be received by the Chief Executive, Business SupportManager (Complaints), Complaints Co-ordinator or any member of staff workingwithin the Trust. All written complaints should be forwarded to the BusinessSupport Manager (Complaints) in the first instance to be registered and formallyacknowledged. This will not delay the commencement of the investigation.4.4.2 Verbal ComplaintsVerbal complaints are viewed as seriously as written complaints. Any member ofstaff who is approached by a patient or their representative with a complaint willendeavour to resolve the issues at the time. Any verbal complaint, which cannotbe resolved at the time, will be subject to the same timescale as a written one.If the matter remains unresolved, the member of staff receiving the complaint willprepare a clear record of the details as soon as possible and seek confirmation ofthese by the complainant. It is recommended that written records are maintainedin case further action is taken by the complainant at a later date. These should beforwarded to the Complaints Department. Records will be updated as furtherinformation becomes available. The Complaints Co-ordinator has discretion in6

determining the occasions when maintaining a written record of all criticisms,complaints etc may prove impractical.It may be appropriate for the entire process of local resolution to be conductedverbally, without any written communication. However, where the complainantindicates that they are not satisfied with the verbal response, or where the persondealing with the complaint considers that the complainant may wish to take thematter further, it is recommended that the matter be concluded with a letter to thecomplainant. Any such letters may be signed by the Business Support Manager(Complaints). A copy of the Trust’s Complaints Leaflet will be enclosed with theletter.4.4.3 Complaints via EmailComplaints received via email will be viewed as seriously as written complaintsand processed in the same manner. Any acknowledgement or response lettersshould be sent by post. Signed consent will still be obtained from the patient beforeresponding to patient specific issues.4.4.4 Complaints via a Third PartyThere are many occasions where a complaint is made indirectly through a thirdparty (e.g. Members of Parliament, GPs, parent or sibling). The process andinvestigation will normally follow the same procedure as a complaint, which ismade directly by a patient.In all cases, when a letter of complaint is received by a third party, the BusinessSupport Manager (Complaints) will acknowledge the letter and ensure that consentfrom the patient has been obtained by the third party to investigate. When draftingthe response, the Business Support Manager (Complaints) should always beaware of the confidential nature of the response. All final responses will be copiedto the patient.Exceptions will include requests from a parent of a patient under the age of 16 (if achild is considered capable of understanding the implications of their decisionsthen their wishes should be followed) and complainants who have guardianship orpower of attorney, which has been registered with the Court of Protection. In allcases the status of the complainant should be confirmed and each request will beconsidered on a case-by-case basis. If it is evident from the complaint that thepatient is unable to consent to the investigation, the Business Support Manager(Complaints) will decide whether to proceed, following discussion with thecomplainant.When a complaint is received relating to a deceased patient, a response will besent to the next of kin only.7

Occasionally, a complaint will be received where the complainant has no apparentconnections with the patient concerned. In such cases, before any investigationcommences, the following points will be clarified:• Does the patient know a complaint has been made on their behalf?• Has the patient authorised the complainant to make enquiries or can anacceptable connection be established?Letters received from solicitors raising a complaint on behalf of an individualshould be dealt with in the same way as all other complaints unless it is explicitthat legal action is intended, in which case the matter will be referred to theBusiness Support Manager (Complaints).If consent is not given, the Business Support Manager (Complaints) will determinewhether the patient would like to receive a response to the complaint themselves.In either case a letter will be sent to the complainant detailing the patient’sdecision.4.4.5 Equality and DiversityEvery opportunity must be given to patients with physical or emotional needs tomake a complaint. Although it is helpful to receive complaints in writing this wouldnot preclude complaints made in Braille, video or audio cassette. Assistance willbe offered to patient’s whose first language is not English. The Business SupportManager (Complaints) will explore all avenues to enable all patients/carers haveaccess to the complaints procedure.4.4.6 Assistance with ComplaintsComplainants will be advised of ways to access assistance, i.e. ICAS-POhWER(Independent Complaints Advocacy Service). They can be contacted on 084512037484.4.7 Complaints about a continuing care decision / Stepdown decisionThe fact that a patient has had their case considered by a continuing care reviewpanel does not affect their rights under the NHS complaints procedure. They cancomplain about the original decision on discharge, or the continuing care reviewprocess, through the NHS complaints procedure.4.4.8 Mixed sector complaintsWhere a complaint involves more than one NHS provider, or one or more otherbodies (eg Social Services), there will be full co-operation in seeking to resolve thecomplaint through each body’s local complaints procedure. The individualorganizations may decide to respond separately or the receiving organisation maycollate responses and respond in one letter. The Business Support Manager8

(Complaints) will act as the liaison and conduit of any multi-organisationalcomplaints.4.4.9 Complaint involving a specific member of staffA complaint involving a specific member of staff will be referred to the appropriateMedical Service Head/Matron/Head of Department, who may decide to contact amember of the Human Resources Directorate to request support.4.4.10 Complaints concerning a possible Criminal Offence, AllegedPhysical Abuse of Patients or an Adverse Incident Involving Harm toa PatientWhere a complaint concerns either a) a possible criminal offence; b) the allegedphysical abuse of patients, c) a serious untoward incident involving harm to apatient or d) a matter which should be referred to one of the professionalregulatory bodies, the Complaints Co-ordinator must inform the appropriateMedical Service Head/Matron/Head of Department immediately. This notificationmay be made at any point during any stage of the complaints procedure. Whereappropriate, the Trust’s policies on Adverse Incidents or the management of adultabuse/child protection will be followed.For possible criminal offences only, the Business Support Manager (Complaints)will refer the matter to the Chief Executive who will decide if a possible criminaloffence has been committed and if the police should be called. This will bereported to the next Confidential Board meeting and the Trust will follow the DoHMemorandum of Understanding (2006).The Business Support Manager (Complaints) will inform the Finance Director ofany possible financial offence.4.4.11 Complaints Involving Litigation or Requiring Legal AdviceLegal advice on particular aspects of a complaint will be sought if there is thepossibility of litigation ensuing. Where a complaint is already a case of possiblelitigation and particularly where the approach is made by solicitors acting on behalfof the patient, the matter will be referred immediately to the Business SupportManager (Complaints).A letter acknowledging receipt of the complaint will be sent. Investigation of acomplaint will not be delayed as a result of legal advice being sought. TheComplaints Co-ordinator will initiate enquiries immediately but any correspondencewith the complainant will be agreed with the Business Support Manager(Complaints) who will seek legal advice if necessary.Following consultation, the Complaints Co-ordinator may wish to explore with thecomplainant the options available, which could prevent the possibility of litigationensuing (eg an apology).9

Copies of the letters will be passed to the consultant and other professional staffinvolved, informing them that the case has been referred for legal advice andadvising them to contact their defence or professional organisation and, ifappropriate, the solicitor acting on behalf of the Trust.Where a complainant explicitly indicates an intention to take legal action andconfirms a solicitor has been instructed, the Business Support Manager(Complaints) will confirm that the investigation under the NHS ComplaintsProcedure will cease immediately. The Business Support Manager (Complaints)will then await confirmation from the relevant solicitors and will then register theclaim and forward details to the NHS Litigation Authority.4.4.12 Correspondence from the PressIf correspondence is received from the press, the Communications Manager will beinformed immediately.4.4.13 Freedom of Information ActThe complaints procedure cannot deal with complaints about non-disclosure underthe Freedom of information Act. These are subject to appeal to the InformationCommissioner.4.4.14 Staff GrievancesStaff grievances will not be reported through the complaints procedure but will bedealt with through the Trust’s Grievance Procedure. Further advice can beobtained from the Human Resources Directorate.4.4.15 Unreasonable Complaints (vexatious complaints)The Trust is committed to treating all complainants equitably and recognises that itis the right of every individual to pursue a complaint. The Trust thereforeendeavours to resolve all complaints to the complainant’s satisfaction. However,on occasions, staff may consider that a complaint is unreasonable in nature, eg.the complainant raises the same or similar issues repeatedly, despite havingreceived full responses to all the issues they have raised.A vexatious complaint is one that is made abusively, very unreasonably or thatinvolves the harassment of Trust staff. At the Business Support Manager’sdiscretion, a complaint may be declared vexatious, and the Trust will notinvestigate it. This will be communicated in writing to the complainant, who will beinformed that the Trust can no longer process the complaint, nor communicate withthe complainant unless the vexatious status is subsequently withdrawn.Complaints (or complainants) may be considered vexatious if they meet one ormore of the following criteria. The list is not necessarily exhaustive.10

Unreasonable, for example pursuing a complaint with the Trust that is theresponsibility of another organisation, where the NHS Complaints Procedure hasbeen fully and properly implemented, or has been exhausted.Change the substance of a complaint or continually raise new issues or seekto prolong contact by continually raising further concerns or questions uponreceipt of a response whilst the complaint is being addressed. (Care must betaken not to discard new issues that are significantly different from the originalcomplaint. These might have to be addressed separately).Are unwilling to accept documented evidence of treatment given as beingfactual, or deny receipt of an adequate response in spite of correspondencespecifically answering their questions.Do not clearly identify the precise issues they wish to be investigated, despitereasonable efforts by Trust staff to help them specify their concerns.Unreasonable complaints are often symptomatic of an illness and the complaintsprocedure may not be the most appropriate means of dealing with the issuesinvolved. There may also be occasions when staff may receive telephone callsfrom complainants where the complainant is abusive and/or uses threatening orbad language. In such cases, the recipient of the call should remain calm andinform the caller that he is not prepared to continue the call and will put the phonedown unless the caller modifies his language. The staff member should documentthe phone call.4.5 Receiving Complaints4.5.1 ProcedureAny member of staff receiving a complaint must notify the Business SupportManager (Complaints) at the earliest possible opportunity and a copy of allcorrespondence will be forwarded by fax or email. All written complaints will bestamped with the date of receipt. There will be no delays in the absence ofComplaints Department staff, who will provide cover during periods of sicknessand absence. This will be achieved through a temporary increase in hours of parttimestaff.The Business Support Manager (Complaints) will maintain a register in which eachcomplaint is recorded and given a unique number. This number will serve as afuture identifier for all future contact and correspondence. The central register willbe maintained to provide statistical returns to the Department of Health and datafor quality monitoring.11

4.5.2 Out of HoursIf a written complaint is received out of office hours, the process described insection 4.4.1 should be followed. If a verbal complaint is received out of officehours, relevant details will be taken and the process described in section 4.4.2 willbe followed.4.6 Acknowledging Complaints4.6.1 ProcedureAll complaints will be acknowledged within 2 working days of receipt by theBusiness Support Manager (Complaints), using the standard letter. Theacknowledgement letter will be sent to the complainant together with a copy of theTrust’s Complaints leaflet. The Business Support Manager (Complaints) willcoordinate the acknowledgement of the complaint and the completion of thecomplaints database to record relevant details of the complaint. A copy of theacknowledgement letter will be retained within the unique complaint file, which willcontain the details of the complaint and the unique complaint number generatedfrom the complaints database. A memorandum will then be generated, togetherwith an issues form and will be forwarded to the Complaints Co-ordinator who isresponsible for handling the complaint and for ensuring it is investigated thoroughlyand that a response is drafted for submission to the Chief Executive for signature.4.6.2 Ethnic MonitoringThe Trust is obliged under the Race Relations (Amendment) Act to request ethniccategory details of complainants. The collection of ethnic category data on writtencomplaints will be valuable in gauging fair and equal access to health care acrossethnic groups. This information will be obtained from the electronic patientinformation database. Whilst Trusts are required to request ethnic categorydetails, patients will not be pressured to respond. If they refuse or fail to respondthe system will be marked ‘not stated.’4.6.3 Patient Confidentiality“Health Service Circular 1998/059 – NHS Complaints Procedures: Confidentiality”states the use of a patient’s personal information to investigate a complaint is apurpose for which it is not necessary to obtain the patient’s express consent. Caremust be taken at all times throughout the complaints procedure to ensure that anyinformation disclosed about the patient is confined to that which is relevant to theinvestigation of the complaint and only disclosed to those people who have ademonstrable need to know it for the purpose of Complaints the complaint.12

4.7 Investigating and Responding to Complaints4.7.1 ProcedureThe target for the response to be sent is within 25 working days from receipt of thecomplaint. Where this is not possible, a ‘hold letter’ or interim reply will be sent bythe Business Support Manager (Complaints) (hold letter) or Chief Executive(interim reply) giving an explanation for the delay and an indication when theresponse is likely to be available. The complainant can agree to an extension tothe 25-day time limit.4.7.2 DocumentationAll aspects of the investigation will be clearly recorded and all documentation,including staff statements, how the facts have been ascertained etc, will beretained by the Complaints Co-ordinator. In the event that the complainantsubsequently requests an independent review, copies of all documentation will berequired by the Healthcare Commission. Staff should be aware that, should thematter proceed to litigation, all the complaints documentation is subject todisclosure. Copies of complaints correspondence will not be held on the patient’shealth records.In addition to ensuring good patient care, complete, accurate and timely recordsallow a clear picture of events to be obtained which is imperative for managingcomplaints, and for auditing practice.4.7.3 The InvestigationThe investigation will be independent and the Complaints Co-ordinator will havethe relevant skills to undertake the task of investigating and responding to thecomplaint.When a complaint involves a serious clinical incident, the investigation will take theform of a RCA (root cause analysis) – see Trust’s Incident Policy for details. Thecomplaint/incident will be placed on the Trust ‘red incident matrix’, which willensure that the investigation and any action plan is monitored by the Patient SafetyGroup which also takes responsibility for ensuring that issues of Trust-widesignificance will be disseminated, as necessary, together with any lessons learned.All complaints will be graded according to severity. Severity 4 (major patient safetyissues) and severity 5 (a number of major/complex patient safety issues) will bereported to the Patient Safety Group. Grading of the complaints will be undertakenby the appropriate Matron and/or senior Clinician and will be returned to theComplaints Co-ordinator for recording in the Complaints database. The Matronand/or senior clinician will assess the complaint and clearly identify the issues atthe outset. The Matron and/or senior clinician will nominate an appropriate leadwho will provide a draft response to the Complaints Co-ordinator.13

The Complaints Co-ordinator will determine how the complaint is to be investigatedand by whom, usually the Medical Service Head/Clinician, Matron or seniormanager for the area concerned. It is desirable that the complaint is dealt with asclose to the point of delivery as possible to ensure a prompt reply and thatappropriate remedial action is taken.Where a complaint in any way concerns the professional care or treatment of apatient or a matter of clinical judgement, the appropriate consultant or professionalhead of service will be provided with a copy of the complaint and given theopportunity to comment. When the matter has been investigated and a replyprepared, it will normally be checked by that person for factual accuracy prior tothe draft reply being submitted to the Chief Executive.If a complaint involves a locum member of staff who is no longer working for theTrust, a report will be gained from the staff member, via the agency from whichthey have been employed. If this is not possible, an investigation will beundertaken obtaining as many details as possible and an explanation provided tothe complainant.Where a complaint involves the professional conduct or competence of medical,nursing or other professional staff, the appropriate director, Medical Service Head,professional head of service, senior manager or matron will be immediately notifiedby the Business Support Manager (Complaints) or Complaints Co-ordinator. Theiradvice will be sought before the reply is sent and they will agree the content of theresponse. The Business Support Manager (Complaints) or Complaints Coordinatormust also immediately notify the Trust’s Medical Director of anycomplaint involving professional medical conduct or competence.Complaints Co-ordinators should ensure staff are aware of their specialresponsibilities towards patients who would have difficulty in making a complainton their own behalf. They will also instruct staff to take any necessary action toprotect the patient's interests.4.7.4 MeetingsThe Complaints Co-ordinator will, in consultation with other senior staff involved,decide whether it is appropriate to offer the complainant a mediation meeting.Where a meeting with the complainant is arranged by the Complaints Co-ordinator,the professionals involved will be consulted to determine how the meeting will bestructured. The Complaints Co-ordinator will conduct the meeting and will ensurethat notes are taken or will record the meeting (with the permission of thecomplainant). Two members of Trust staff should normally attend any meeting andthe complainant will be offered the opportunity to have someone else present atthe meeting to assist them. The meeting will be formally recorded and confirmed tothe complainant.14

4.7.5 Draft responsesWherever practical, replies to all complaints (eg. written and oral) will be agreedwith those involved before the reply is sent. If the response cannot be agreed withthose involved, the Business Support Manager (Complaints) will be informed inorder to agree the wording of the response. Where it is clear that there has been amistake or failure in procedures, this will be clearly stated and an appropriateapology given, except where this could constitute an admission of legal liability. Inthis case, the matter will be referred for legal advice. The Business SupportManager (Complaints) will contact the Trust’s solicitors and then respond to theComplaints Co-ordinator with the recommended course of action. The ComplaintsCo-ordinator will forward the draft response to the Business Support Manager(Complaints) who will organise signature by the Chief Executive.4.7.6 Issues excluded from the Trust’s Complaints Procedurea) a complaint made by an NHS body, which relates to the exercise of itsfunctions by another NHS body.b) a complaint made by a primary care provider which relates either to theexercise of its functions by an NHS body or to the contract arrangementsunder which it provides primary care servicesc) a complaint made by an employee of an NHS body about any matter relatingto his/her contract of employmentd) a complaint made by an independent provider or an NHS foundation Trustabout any matter relating to arrangements made by an NHS body with thatindependent provider or NHS foundation Truste) a complaint, which relates to the provision of primary medical services inaccordance with arrangements made by a Primary Care Trust with a StrategicHealth Authority under section 28C of the 1977 Act or under a transitionalagreement.f) a complaint, which is being or has been investigated by the Health ServiceCommissioner.g) a complaint arising out of an NHS body’s alleged failure to comply with a datasubject request under the Data Protection Act 1998 or a request forinformation under the Freedom of Information Act 2000h) a complaint about which the complainant has stated either verbally, in writingor by email that he intends to take legal proceedingsi) a complaint about which an NHS body is taking or is proposing to takedisciplinary proceedings in relation to the substance of the complaint against aperson who is the subject of the complaint15

Investigations, which have ceased, shall resume:a) In relation to any matter which have not been dealt with by the proceedings ina court of lawb) Should the complainant give sufficient assurance that he no longer intends topursue or is no longer pursuing a remedy by way of proceedings in a court oflaw.c) in relation to any matter which has not been dealt with by the disciplinaryproceedings.The Business Support Manager (Complaints) will notify the complainant, and anyperson subject to a complaint, of any decision not to investigate. The notificationwill be in writing and will state the reason(s) for the decision. A further letter will bewritten should the investigation resume.4.7.7 Investigation which could lead to Disciplinary ActionWhere it is likely that a complaint, if found to be justified, may lead to disciplinaryaction being taken against a member of staff, the Business Support Manager(Complaints) must ensure that the Medical Director, Associate Medical Director,appropriate Head of Service or Matron is notified of the complaint. The member ofstaff may be asked to take part in the investigation but, if not, he/she should bekept informed of the progress being made with the investigation. Any member ofstaff involved in a complaint will be informed of any allegation at the outset and willbe advised of their right to seek the help and advice of a professional associationor trade union before commenting on the complaint.In cases of this nature the Complaints Co-ordinator remains responsible forinvestigating the complaint, but the decision on whether disciplinary action is calledfor is a decision for the line manager or the professional head of service inaccordance with the normal disciplinary procedure. This must be kept separatefrom the Trust's complaints procedure so that the latter is only concerned withresolving complaints and not investigating disciplinary matters.4.7.8 Coroner’s CasesThe Trust’s policy (25B) ‘Coroner involvement after death/requests forstatements/attendances at Inquests should be followed.4.7.9 Support for staffStaff who may be the subject of a complaint can be anxious about the process andtheir position. It is important that they are kept informed about progress with theinvestigation by the Complaints Co-ordinator and that they are offered theopportunity to discuss the matter with a professional colleague. Wherever16

possible, they should have the opportunity to comment on the accuracy of the draftresponse to the complainant and they should be shown a copy of the finalresponse to make them aware of its content.To support healthcare staff involved in complaints, the Trust –• Actively promotes an open and fair culture that fosters peer support anddiscourages the attribution of blame.• Will provide for formal and informal debriefing of the clinical team involved in acomplaint, where appropriate.• Through Matrons/Heads of Service, provides immediate and longer term,follow-up opportunities for healthcare staff to discuss their involvement and/orthe circumstances leading up to the complaint and what they are going to sayto patients/relatives, if required• Provides advice and training on the management of complaints• Encourages staff to access the NPSA e-learning toolkit on ‘Being Open’, whichis accessible through the Trust’s intranet.• Provides support for staff experiencing difficulties through the OccupationalHealth or Chaplaincy Department• Provides legal support via the Business Support Manager (Complaints) ifallegations of negligence are made• Provides support when writing statements and appearing as witnesses.4.7.10 Holding LettersIn exceptional circumstances, where it has not been possible to provide aresponse within 25 working days, the Complaints Co-ordinators will contact allthose involved. Either an interim response will be sent by the Business SupportManager (Complaints) or a ‘hold letter’ will be sent to the complainant explainingthe reason for the delay and confirming a response will be sent as soon asreasonably practicable. Further holding letters should be sent every four weeks toa maximum of three months. Complainants may be contacted to request anextension to the 25-day response time and may agree to an extension.4.8 Final Responses4.8.1 ProcedureAll written complaints (and any verbal complaints which are felt to be sufficientlyserious) will receive a response in writing from the Chief Executive (or in his17

absence, his nominated deputy). Other than in exceptional circumstances, the finalletter will be dispatched within 25 working days from receipt of the complaint. TheComplaints Co-ordinator will forward the draft response to the Business SupportManager (Complaints) who will organise signature by the Chief Executive. A copy ofthe signed response will be returned to the Business Support Manager (Complaints)for filing.The final response will invite the complainant to let the Complaints Department knowif they have any outstanding concerns. In such cases, consideration will be given toany further action which might resolve the complaint, including offering a meeting.4.8.2 Compensation and Ex-Gratia PaymentsThere may be occasions when, having investigated the complaint, the BusinessSupport Manager (Complaints) believes there are grounds for making an ex-gratiapayment (without accepting liability). An apology and gesture of goodwill may avoidsubsequent litigation and offers the opportunity to deal with certain circumstances ina fair and responsible manner. The Finance Director should approve all ex-gratiapayments, having regard to the Trust’s Standing Financial Instructions and StandingOrders.It is recommended that, before any compensation is offered in respect of a complaintinvolving a member of staff, that member of staff will be involved in the discussionswhen the subject of compensation is raised, to ensure that he/she does not feelcompromised by the decision to award compensation.4.9 Action following Complaints4.9.1 Action where the Complainant is Dissatisfied with the Final ResponseA further response from the Chief Executive will be sent to the complainant confirmingthe outcome of any further investigation and advising them of the independent reviewprocess. The Trust will always offer a meeting to complainants who remaindissatisfied with the Trust’s response to their complaint. Complainants will be askedto tabulate issues of outstanding concern and these will be discussed at a complaintsmeeting, if one is requested. A full explanation by the appropriate clinician/matron willbe provided to all issues raised.If the complainant subsequently remains dissatisfied, they may request anindependent review of their complaint by writing to the Healthcare Commission withinsix months of receipt of the letter of response. A copy of the complaints file will beforwarded to the HCC on request, together with a copy of the patient’s health records,if required.The Business Support Manager (Complaints) and the Complaints Co-ordinators willdiscuss to any issues with the Medical Director, Associate Medical Director, MedicalService Head or Matron the provision of the response raised by the HCC. They willalso co-ordinate a response to the complainant and forward a copy to the HCC.18

4.9.2 Changing PracticeWhen the investigation of a complaint identifies that local changes in practice arerequired, the Medical Service Head/Matron/Professional Manager will ensure theseare considered and implemented within a reasonable timescale. Lessons learnedfrom complaints and changes in practice wider than the local team will be reported tothe relevant operations directorate risk management meeting, the Patient SafetyGroup and the Integrated Governance Committee using the reporting mechanismsoutlined below.The Patient Safety Group is responsible for ensuring Trust-wide learning occursthrough specific initiatives and information dissemination, using such mechanisms asthe Trust newsletters and global e-mails. The Patient Safety Group will monitor actionplans of complaints that have undergone root cause analysis.The Integrated Governance Committee will decide on any opportunities for crossorganisationallearning from any complaints.4.9.3 Reporting ArrangementsThe Complaints Co-ordinators will attend monthly Operations Directorate riskmanagement meetings at which the relevant complaints are reported, any locallessons learned discussed and investigations and local action plans monitored. Dueto information from either individual or local trends of complaints, a risk managementcommittee may decide on undertaking a risk assessment on certain issues, which willbe placed on the appropriate risk register and monitored as per the Trust policy (seeTrust Governance Strategy). The Business Support Manager (Complaints) willpresent a Trust-wide quarterly report to the Patient Safety Group, which acts as asingle point of co-ordination for complaints, claims and incidents. Included within thereport will be numbers, types and severity of complaints together with a commentary.Due to information from either individual or Trust-wide trends of complaints, thePatient Safety Group may decide on undertaking a risk assessment on certain issues,which will be placed on the appropriate risk register and monitored as per the Trustpolicy (see Trust Governance Strategy).The Business Support Manager (Complaints) or Complaints Co-ordinator will attendmeetings held by Medical Service Heads on a quarterly basis.An annual report is also completed. This includes the numbers of complaints, by typeand severity together with changes in practice, the complaints answered within thenational targets and the complaints reported to the HCC/Health Ombudsman togetherwith a commentary. A copy of the report is discussed and presented at the following:• Patient Safety Group, Integrated Governance Committee, Trust Board19

4.9.4 Archiving and Disposal of RecordsGuidelines relating to the archiving and disposal of records are contained within theTrust’s Records Management Strategy; complaints files will be retained for 11 years.4.9.5 Access to this policyThis policy will be given, free of charge, to any person who makes such a request. Itwill be available on the Trust’s website www.dudley.nhs.uk under the section“Freedom of Information”.4.9.6 ComplimentsThe Trust keeps a record of all letters of praise / compliments received. All managerswill send copies of all letters received to the Business Support Manager (Complaints).5 INDEPENDENT REVIEW, ROLE OF THE HEALTHCARE COMMISSION ANDHEALTH SERVICE OMBUDSMAN5.1 Independent ReviewIf a complainant remains dissatisfied following local resolution they have the right torequest an independent review of their complaint by contacting the HealthcareCommission.5.2 Role of the Healthcare CommissionResponsibility for the independent review element of the NHS complaints proceduretransferred from the Trust to the Healthcare Commission on 1 August 2004. The Trust’sComplaints Leaflet, sent out with each complaint acknowledgement, explains the role ofthe Healthcare Commission. A leaflet ‘Unhappy with the way your complaint has beenhandled by the NHS?’ is also available from the Business Support Manager(Complaints).5.3 Role of the Health Service OmbudsmanA leaflet ‘Problems with a service provided through the NHS? – How we can help’explains the role of the Health Service Ombudsman in greater detail and is availablefrom the Business Support Manager (Complaints). The Health Service Ombudsmanhas overarching control of the NHS Complaints Procedure. A complainant may contactthe Health Service Ombudsman’s office at any point. However, it should be noted thatthey are not likely to become involved until the NHS Complaints Procedure hasconcluded.Originator: Maria Smith, Business Support Manager (Complaints)Approver: Paul Farenden, Chief ExecutiveDate of Approval: October 2006 Date of Review: October 200920