COMPLAINTS POLICY AND PROCEDURES Prepared by:
Jane Kennedy and Gillian Gabanski
Responsible Area:
Corporate Services
Approval Information:
Date Approved:
29 November 2006
COMMITTEE:-
Trust Board
Approved By:
Sign Print Name
Helena Corder
Version No Approved:
Two (June 2008)
Review Date:
November 2010
Department of Health 2004 Standards for Better Health Reference to Standards First domain Safety for Better Health Fourth domain Patient focused Domain Core/Development standard Performance indicators
C. 1 a C. 14 a) b) c) 1. Number of complaints 2. Compliance with timescales 3. KO returns
COMPLAINTS POLICY AND PROCEDURES Contents 1.
History of Document
3
2.
Introduction
3
3.
Associated Policies and Procedures
3
4.
Aims and Objectives
4
5.
Accountabilities
4
6.
Definition of a Complaint
6
7.
Who Can Make a Complaint
6
8.
Time Limits
7
9.
Child Protection/Vulnerable Adult Issues
7
10.
Complaints from Mentally Ill and Clients with Learning Disabilities
7
11.
Complaints Alleging a Criminal Offence
7
12.
Clinical Judgement
7
13.
Legal Action
8
14.
Patient Authorisation (Third Party Consent)
8
15.
Confidentiality
8
16.
Complaints Received Out of Office Hours
9
17
Anonymous Complaints
9
18.
Complaints Concerning Services Managed by Other Providers
9
19.
Support Available to PCT staff
9
20.
Training
10
21.
Communication with Stakeholders
10
22.
Learning from Experience
10
23.
Sharing Lessons Learnt Across the Health Community
10
24.
Equality Impact Assessment
10
25.
Policy Review
11
26.
Dissemination and Implementation
11
27.
Grading of Complaints
11
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
1
28.
Family Health Services Disciplinary Procedures
12
29.
Monitoring Arrangements
12
30.
Annual Report
12
31.
Monitoring the Ethnicity of Patients
12
32.
Stage 1: Local Resolution
13
33.
Informal Complaints
13
34.
Formal Complaints
14
35.
Conciliation
15
36.
Serious Complaints
15
37.
Serious Untoward Incidents (SUI)
15
38.
Complaints of a Disciplinary Nature
15
39.
Complaints Leading to litigation
16
40.
Complaints Arising from an Incident
16
41.
Complaints Requiring Redirection
16
42
Joint Working with Other Organisations
16
43.
Stage 2: Healthcare Commission Review
16
44.
Stage 3: Health Service Ombudsman
17
45
Recording and Monitoring of Complaints
17
46.
Support for Complainants
18
47.
Complaints made to PCT regarding FHS Practitioners
18
48.
Healthcare Commission Review of Complaints against Non-NHS Providers
19
Appendices A
Verbal Complaint Form
20
B
Writing a Statement
22
C
Learning Lessons from Complaints Form
23
D
Conciliation Leaflet
24
E
Equality Impact Assessment
26
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 1
History of Document Version 2: June 2008
2
Introduction
The aim of the PCT’s policy is to ensure complaints are resolved promptly and effectively and that complainants are treated sympathetically and with respect throughout the process of making a complaint. The policy supports the principle that complaints should positively influence the way services are delivered in the future. This guidance and procedure defines a complaint, explains who is entitled to make a complaint and how the complaint will be dealt with from the initial receipt to its conclusion. Anyone involved in the handling of a complaint, at any level, has an obligation to comply with this policy and procedures and to ensure confidentiality of information at all times. The Complaints Manager will process complaints that cannot be handled at the point of receipt, in liaison with other key people. A summary of responsibilities is provided at page 3 of the Policy. In accordance with national guidance, the procedure is made up of three stages
Local Resolution Healthcare Commission Review Review by the Health Service Ombudsman
The emphasis will be on taking action to resolve the complaint as quickly as possible, as close as possible to the point of service delivery, whilst at the same time ensuring complaints provide us with an opportunity to improve working practices. At Local Resolution stage, the PCT is required to provide a formal written response to the complainant within twenty-five days. Sometimes a patient/user will need a problem sorting out and they can be referred to the PALS service. It is the Trust policy to ensure that patients, relatives and their carers are not treated differently as a result of raising a concern or complaint. 3
Associated Policies and Procedures This policy should be read and used in conjunction with the following: • • • •
Confidentiality Code of Practice Consent Policy Claims Policy and Procedure PALS Policy and Procedure
Depending upon the nature of the complaint the following documents may be helpful: • •
Vexatious and Habitual Complaints Procedure Incident, Complaint and Claims Investigation Policy and Toolkit
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE • • • • • • • • • 4
Serious Untoward Incident (SUI) Procedures Standard of Business Conduct Commercial Sponsorship Policy Procedure for Handling Access Requests for Health Records Child Protection Procedures Disciplinary Procedure FHS Disciplinary Procedure Freedom of Information Policy Vulnerable Adult Procedures Whistle-blowing Policy
Aims and Objectives
The PCT wishes to enable and support patient and public feedback on services; this includes ensuring that the process of making a complaint or compliment is as easy as possible. The PCT also recognises the effect that complaints have on individuals and teams and that they may require support during any complaint investigation. That information gained during a complaint investigation is used to instigate and support service change as appropriate and that this information forms part of the report to the Board. Complaints must be dealt with as set out set out in this document; failure by staff to comply with these may lead to disciplinary action. This document is intended to provide useful guidance on handling all types of feedback received by the PCT. It is intended to help staff view complaints in an objective way, avoiding concerns about blame and also ensuring that feedback can be used to further develop and improve services. The PCT recognises, and will at all times adhere to, the NHS complaints procedure for the resolution of complaints, in the interests of: •
Encouraging a climate of openness and transparency when something has “gone wrong” with a patient’s treatment or the patient is dissatisfied with that treatment and/or the outcome.
•
Encouraging the adoption of a constructive approach to complaints and claims, and accepting that concerned patients are entitled to an explanation and an apology if warranted.
5
Accountabilities
The policy must be complied with by all groups of staff directly employed by the PCT, together with locum and agency staff and independent contractors. All Members of Staff One of the main objectives of the Complaints Procedure is to resolve complaints and grievances as quickly as possible. Any member of staff receiving a complaint should attempt to seek solutions to complaints brought to their attention. The organisation encourages staff to do this, as informal resolution at an operational level is regarded as the best way of dealing with most cases. If the complaint cannot be investigated adequately or necessary reassurances given, the complaint should be referred to a Locality Manager, Senior Manager or the Complaints Manager. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE Non-Executive Directors If a complaint is made known to a Non-Executive Director or a letter of complaint is forwarded to them, this information should be passed immediately to the Complaints Manager to deal with. Line Manager If a member of staff does not feel able to deal with the complaint/grievance then they can contact their line manager/Locality Manager for assistance. Complaints that have been dealt with by staff should be reported to the line manager/Locality Manager who, in turn, will report to the PCT’s Complaints Manager. Chief Executive All complainants have the right to receive a full and prompt reply from the Chief Executive to any written complaint or to oral complaints subsequently put in writing. The Chief Executive or his deputy in his absence will sign all written responses and be responsible for ensuring there is appropriate local policy and procedural guidance available to all staff. Director of Corporate Services The Director of Corporate Services will take responsibility for ensuring compliance with the arrangements made under the National Health Service (Complaints) Regulations 2004 and ensure that action is taken in the light of the outcome of any investigation. Complaints Manager All written and oral complaints that front line staff cannot resolve on an informal basis are passed to the Complaints Manager. The Complaints Manager oversees and monitors the complaints procedure, acknowledging and co-ordinating timely responses and services the Healthcare Commission and Health Ombudsman reviews. The Complaints Manager records all complaints received and analyses the complaint trends. The Healthcare Commission The Healthcare Commission is an independent body established to promote improvement in healthcare through the assessment of the performance of those who provide services. The Health Service Ombudsman The Health Ombudsman will consider whether or not to investigate unresolved complaints or complaints that have been denied a Healthcare Commission review or denied an investigation because they were made outside the time limits. Patient Advice and Liaison Service (PALS) The Patient Advice and Liaison Service focuses on improving the service to NHS patients. The service aims to: • Provide advice and support to patients, their families and carers. • Provide information on NHS services. • Listen to patients’ concerns, suggestions or queries. • Help sort out problems quickly. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE PALS act independently when handling patient and family concerns, liaising with staff, managers and, where appropriate, relevant organisations to negotiate immediate or promote solutions. If necessary, PALS can also refer patients and families to specific local or nationalbased support agencies. Independent Complaints Advocacy Services (ICAS) ICAS offers free, ongoing advice about how to make a complaint regarding NHS treatment. ICAS assist complainants at each stage of the process, interpreting and explaining matters to and on behalf of the complainant. Contact details for the Healthcare Commission, Health Service Ombudsman and the ICAS can be obtained from the PALS or complaints department. 6.
Definition of a Complaint
For the purposes of this policy a complaint is defined as an expression of dissatisfaction with the care, treatment, services or facilities provided or commissioned by the PCT. 7.
Who Can Make a Complaint?
A complaint is defined as an expression of dissatisfaction with care, services or facilities provided or commissioned by the PCT, where any of the following apply:
Action by the PCT or someone working for the PCT has detrimentally affected the experience of a patient or carer in using our service. Examples might include concerns about health visiting treatment, the quality of the night sitting service or the attitude of staff.
The complainant believes there has been a mistake or an error of judgement. For example, if a complainant indicated that a district nurse had failed to visit them following discharge from hospital, it would be necessary to investigate what follow-up care was requested and provided.
The complainant brings to the attention of the PCT something that they expect the PCT to put right. For example, a carer may complain about a shortage in occupational therapy services, with the expectation that this service will be increased.
The following are not complaints:
Requests for information or advice about services Requests for changes to medication or a care plan. Reports of lost or stolen items
In such cases complainants can be directed to the PALS service on 01484 466172 or 01484 466214. Any person who has received care or treatment from the PCT and is dissatisfied with the care or treatment they have received is entitled to make a complaint. If the person has died or is otherwise unable to act for him or herself, a close relative or friend, or an independent advocate may register a complaint on their behalf. An informal carer may also lodge a complaint if the quality of care provided to the person for whom they are caring detrimentally affects them. Complainants requiring access to medical records should be handled with care and advice should be sought from the Complaints Manager in such circumstances due to the complexities resulting Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE from the application of various procedures. Refer to Procedure for Handling Access Requests for a Health Record. Written and verbal requests for access to medical records should be addressed/forwarded to the Director of Corporate Services. All communication arising from a complaint verbal or written will be documented in the complaints file. 8.
Time Limits
A complaint must be made within six months of the incident or within six months from the point of discovery of the problem, as long as this is no more than twelve months since the incident. The Complaints Manager has the discretion to extend this time limit if the circumstances show that the complaint could not have been made earlier and if it is still possible to investigate the complaint. 9.
Child Protection/Vulnerable Adult Issues
Complaints which include allegations of abuse/neglect of a child or vulnerable adult should be dealt with under joint agency protocols for Child Protection or Vulnerable Adults which are outlined in separate procedures. 10.
Complaints from Mentally Ill and Clients with Learning Disabilities
It is appreciated that staff may have some difficulty in assessing whether complaints from mentally ill or learning disability clients should be investigated as set out in this procedure. Complaints may be made which appear confused, imagined or unfounded. All complaints from mentally ill or learning disability clients should be taken seriously and processed as set out in the procedure. 11.
Complaints Alleging a Criminal Offence
There may be occasions when it is necessary to involve the Police (and other agencies) in investigating complaints. Such decisions will normally be taken on the grounds of the investigation being outside of the PCT’s jurisdiction eg an alleged criminal offence. Referral to the Police (or other statutory organisations) would normally be undertaken by the Director of Corporate Services who will be responsible for consulting with the Chief Executive. The involvement of the Police (or other statutory agencies) will lead to the investigation being handed over from the Locality Manager/Senior Manager to the Director of Corporate Services. In addition there may be occasions when the behaviour of a person is so intimidating or threatening to members of staff that the Police are involved. The PCT have made a commitment to “Zero Tolerance�. 12.
Clinical Judgement
Any part of the complaint which refers to matters of clinical judgment should be investigated in conjunction with the clinician(s)/practitioner(s) concerned, as appropriate. Any findings or recommendations from an investigation relating to clinical judgement must be agreed with the clinician(s)/practitioner(s) concerned. If there is any doubt as to the clinical judgement of a specific clinician/ practitioner in relation to a complaint, this matter should be raised with the Director responsible for Clinical Governance or Medical Director by either the investigating officer or the Complaints Manager. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 13.
Legal Action
If at any stage during the investigation, the complainant indicates in writing of their intention to pursue legal action, the Trust will seek legal advice on how to proceed with the complaint and may choose to cease any further action under the complaints procedure. This is consistent with the guidance in the national NHS complaints policy. The Complaints Manager should inform the Director of Corporate Services as soon as possible that legal action has been instigated or is being anticipated. The policy and procedure for handling a claim received by the PCT will be followed from this point onwards. If the complainant’s initial communication is via a solicitor’s letter, the inference should not necessarily be made that the complainant has decided to take legal action. An inappropriate response from the PCT in these circumstances is more likely to encourage the complainant to seek legal redress. It should be remembered that at no point should any legal action prevent a full explanation being given and if appropriate an apology offered to the complainant. An apology is not an admission of liability. Staff should be aware that all documentation generated through this process is open to legal disclosure. 14.
Patient Authorisation (Third Party Consent)
When the complainant is not the patient, patient authorisation is required in order that the PCT can investigate and respond to the complaint. If the patient is unable to give their authorisation, this is not a reason to deny an investigation into the issues raised on their behalf under the complaints procedure. Authorisation is required from the patient’s representative for example spouse, relative, friend, MP and ICAS etc. This must be done before confidential or information of a sensitive nature is released to a third party. Forms will be sent from the Complaints Manager to the complainant to obtain authorisation from the patient. The Complaints Manager will ensure that the Procedure for Handling Access Requests for a Health Record is complied with. If authorisation has not been received by the time the investigation has been completed and the response to the complaint is ready, a reminder will be sent to the complainant by the Complaints Manager restating why it is required and asking for it to be returned, giving a threeweek deadline. This situation will be discussed with the Locality Manager/Senior Manager as how best to proceed if the authorisation is not forthcoming. 15.
Confidentiality
All complainants will be dealt with in line with the PCT’s Confidentiality Code of Practice, the Data Protection Act and Caldicott principles. Should any information need to be divulged to those handling the complaint, this should be made clear to the complainant. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE Any complaint will also be dealt with in line with the up to date guidance on child protection or adult abuse issued between the NHS and other agencies. 16.
Complaints Received Out of Office Hours
If a complaint is received out of office hours, it should be referred to the most senior member of staff on duty and to the PCT’s Complaints Manager as soon as is practical. Complaints can be received at any time by staff and not necessarily on the PCT’s premises (e.g. when working in private homes, residential homes). 17.
Anonymous Complaints
All anonymous complaints received by the PCT will be investigated if there is enough information to carry out such an investigation. Investigating officers will be requested to report to the appropriate director and make appropriate recommendations based on the allegations raised. 18.
Complaints Concerning Services Managed by Other Providers
A complaint concerning a service not managed within the PCT will be passed to the relevant service by the Complaints Manager. If the patient is a resident of the PCT, a copy of the final response will be requested. The Complaints Manager will also notify the complainant of the action taken. 19.
Support Available to PCT Staff
Leaflets outlining the complaints procedure will be made available to all staff to give out to the public. Leaflets outlining the PALS services and ICAS will be made available to all staff to distribute to the public. The complaints policy and procedures are intended to allow effective complaints management for users whilst remaining fair to staff. The majority of complaints should not result in staff feeling uncomfortable with the process. However should PCT staff require support as a result of a complaint being made or investigation, this will be provided in confidence. Staff can selfrefer in the strictest of confidence by contacting the Occupational Health Service on 01924 816049 or 07912 775 350. In the case of a complaint being made in person, the member of staff receiving the complaint may request a colleague (who is more knowledgeable about the particular issue and therefore in a better position to ensure that the complainant is provided with a full response) to liaise direct with the complainant. Staff may also call on the Complaints Manager for advice and assistance in dealing with a complaint. If the outcome of the complaint suggests disciplinary action is needed, this will be handled under the disciplinary procedure. Staff who feel they have been treated badly under the complaints procedure have the right to invoke the grievance procedure or complain directly to the Healthcare Commission or Health Service Ombudsman. 20.
Training
All staff receive training in handling and investigating complaints as part of the PCT’s induction process. All PCT Managers through the PCT appraisal or KSF, be responsible for identifying Approval Committee: Trust Board 9 Version No: Date Approved:
Two (June 2008) 29 November 2006
COMPLAINTS PROCEDURE staff within their service that need training in the handling or investigation of complaints. Approved complaints and Investigation training packages are run by Training Department. 21.
Communication with Stakeholders
During the complaint process the organisation may consider involving external agencies such as: Enforcing agencies, e.g. H M Coroner External stakeholders, e.g. other Trust, PCT, LA External advisors, e.g. clinical experts providing advice. 22.
Learning from Experience
The Trust is committed to learn and make changes to practice to improve services as a result of complaints. A systematic approach to the analysis of incidents, complaints and claims on an aggregated basis will be developed as part of the risk management integrated process, which will include: • • • • •
Organisational sharing of learning Local implementation of action plans Links between claims, complaints and incidents management Identification of risks and inclusion on risk register Reviewing and implementing best practice from other Trusts and organisations.
Complaints will be viewed in conjunction with claims and incidents and the Complaints Manager will report back any learning to the Risk Management Overview Group both as an Annual and Quarterly reports. Learning from complaints will also be shared as widely as possible in the Trust as appropriate. 23.
Sharing Lessons Learnt Across the Health Community
The Trust is represented at the West Yorkshire Complaints Manager Group. This group aims to ensure cross organisational learning and sharing of safety lessons. The Trust also reports serious adverse events through the STEIS reporting system to the Strategic Health Authority providing a further opportunity to contribute to cross organisational learning. The Trust utilises the DATIX electronic reporting system which links to the National Patient Safety Agency (NPSA), National Learning and Reporting System (NRLS) to ensure that incidents reported within the organisation are fed into a central system and further analysis and trend identified performed at a National level to enable National learning. 24.
Equality Impact Assessment
The Trust aims to design and implement service, policies and measures that meet the diverse needs of our services, population and workforce, ensuring that none are placed at a disadvantage to others. Appendix E.
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 25.
Policy Review
This policy will be reviewed every three years or sooner should the need arise. This policy is to be read in conjunction with the NHSLA reporting guidelines and procedures and the following PCT policies and procedures: Claims Management Procedure Incident Reporting Procedure Records Management Policy Risk Management Policy 26.
Dissemination and Implementation
Complaint Policy will be disseminated in line with the Policy for the development of Procedural Documents. 27.
Grading of Complaints
All complaints will be graded 1 to 5 (5 being the most serious). i. Minor failing or failure, no tangible effect on a patient. ii. Moderate failing or failure resulting in minor or moderate effect on a patient. iii. Intermediate failing or failure resulting in moderate to serious effect on a patient. iv. Major failing or failure, very serious or severe effect on a patient. v. Catastrophic system failing or failure result in patient or member of public’s death. Grade 1 complaints will generally be issues related to administration or cleanliness and will be passed to the relevant manager to investigate. An individualised letter of acknowledgement will be sent to the complainant within 2 working days from the Complaints Manager, with a full response from the Chief Executive to follow within 25 working days. Grade 2 complaints will relate to failings or failures that have had a minor or moderate effect, but warrant investigation by Locality Manager or Senior Manager. An individualised letter of acknowledgement will be sent to the complainant within 2 working days from the Complaints Manager, with a full response from the Chief Executive to follow within 25 working days Grade 3 complaints will warrant a full investigation with statements from the staff involved. The Investigation will be led by the Locality Manager or Senior Manager. A letter of acknowledgement will be sent to the complainant within 2 working days from the Complaints Manager with a full response from the Chief Executive to follow within 25 working days. Grade 4 complaints will also warrant a full investigation as complaints in this category will be very serious. Investigation led by the Head of Locality or Senior Manager. The Director of Corporate Services will take a personal interest in all grade 4 complaints. Other relevant staff will be made aware if appropriate, e.g. Communications Manager.
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE Grade 5 complaints will be extremely serious and will also warrant a full investigation. Investigation would be led by Head of Locality or Senior Manager. The Chief Executive and Director of Corporate Services will take a personal interest in all grade 5 complaints. The Complaints Manager will be responsible for grading complaints. As the investigation proceeds, or where circumstances change, the Complaints Manager may change the grading of a complaint, e.g. if a complaint becomes the subject of an Ombudsman’s investigation. 28.
Family Health Service Disciplinary Procedures
The decisive factor as to whether or not disciplinary action should be taken would be the adherence by the practitioner to his/her terms of service. The PCT with whom the practitioner has a contract with may refer allegations of breaches of the terms of service for local disciplinary action based on the final report of the Healthcare Commission review. 29.
Monitoring Arrangements
Governance Committee meets bi-monthly and quarterly to discuss as part of their agenda incidents, complaints and claims. They develop and monitor local action plans as a result of significant risk issues. Service reports are distributed quarterly to managers and senior staff for cascading down to their teams via team brief. Significant risks resulting from incidents complaints and claims are recorded on the Trusts Risk Register and reports are presented to the Risk Management Overview Committee. Aggregated reports on incidents, complaints, claims and PALS are presented to the Risk Management Overview Committee (quarterly) and Governance Committee (quarterly). Trend Analysis Reports are presented to the Trust Board (annually). 30.
Annual Report
The Complaints Manager will prepare an annual report on the handling and consideration of complaints and send a copy to:• • • 31.
the Board the Strategic Health Authority; and The Healthcare Commission.
Monitoring the Ethnicity of Patients
The PCT monitors complaints to meet the requirements of the Race Relations Amendment Act and the Disability Discrimination Act.
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 32.
Stage 1: Local Resolution
33.
Informal Complaints
Patient complaints are initially screened by a PALS Officer, who will seek resolution of the concerns. PALS Officers will assist patients to make a formal complaint. Only verbal complaints may be treated as informal. Whenever a complaint is made in writing it must be treated as a formal complaint regardless of who received the complaint. In many cases dissatisfaction is likely to be raised initially directly with the staff member concerned. Where a patient, their carer or advocate makes a verbal complaint to a member of staff, the member of staff should:
Listen carefully to what the person is saying.
Be clear about what the person is complaining about.
Clearly explain to the complainant what they will do in order to try and resolve their complaint.
Act quickly and do all they can to resolve the issue straight away, and if they are passing the complaint to another person, do so promptly.
If they do not feel able to resolve the complaint, explain who will deal with the complaint, for example Locality Manager.
Show that they are sympathetic towards the complainant by apologising that the complainant has found the service unsatisfactory – this does not mean that they are admitting to a fault.
Not act defensively.
Sometimes a complaint can be too complex to deal with instantly, or the complainant can become angry and aggressive. In these cases the complaint should be recorded on the complaints form (see Appendix A) and a copy of the form passed immediately to the Locality Manager/Senior Manager. An acknowledgement letter will be sent to the complainant within two working days and the investigation commenced. The original completed form to be sent to the Complaints Manager. If the complainant remains dissatisfied with the explanation or outcome they should be advised of their right to make a formal complaint by writing to the Chief Executive (or Complaints Manager) and given a copy of the PCT’s complaints leaflet explaining how to do this. If the complainant requires help with putting their complaint in a written format, staff can offer to help, or refer them to PALS, ICAS or the Complaints Manager. If the complaint contains allegations of a serious nature, details of the complaint should be recorded and sent to the Complaints Manager, Resolution of complaints at an operational level should be regarded as the best way of dealing with most cases and staff should be encouraged to seek solutions to complaints brought to their attention. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 34.
Formal Complaints
Any complaint received in writing must be treated as a formal complaint and must receive a response from the Chief Executive. All written complaints received by the PCT must be date stamped upon receipt. Complaints received face to face or by telephone will also be regarded as formal complaints, if the complainant states that this is how they want their complaint to be treated. Where a complaint is made orally, the acknowledgement letter must be accompanied by the written record of the complaint with an invitation to the complainant to confirm it is an accurate record of their complaint and asking them to sign and return it. All formal complaints will be investigated and responded to by the Chief Executive or the Complaints Manager acting on his behalf. All written complaints should be forwarded immediately by either fax or telephone followed by a hard copy to the Complaints Manager. The Complaints Manager will identify the investigating officer and monitor the progress of the investigation. The Complaints Manager will send an acknowledgement letter to the complainant within two working days of receipt of the complaint. The final response must be factually correct and provided within twenty-five working days of receipt of complaint: • • • • • • • •
Include an apology. Address each of the points the complainant has raised with a full explanation or give the reason(s) why it is not possible to comment on a specific matter. Give specific details about the investigation for example who was interviewed and what was discovered etc. Give details of action taken as a result of the complaint. Provide the name and telephone number of the Locality Manager or investigator for further queries/discussion. Offer to meet the complainant with the key staff involved. Include details of further action available to the complainant. Advise the complainant of their right to request a Healthcare Commission review using the following paragraph:
“If you remain dissatisfied with the response to your complaint, you have the right to ask the Healthcare Commission to review your case. This should be done within six months of receipt of this letter. The Healthcare Commission is an independent body established to promote improvements in healthcare through the assessment of the performance of those who provide services. You can contact the Healthcare Commission on 0845 601 3012 or write to them at: Healthcare Commission, FREEPOST NAT 18958, Complaints Investigation Team, Manchester M1 9XZ or visit their website at www.healthcarecommission.org.uk.” The Locality Manager/Senior Manager will be asked to take any immediate action possible to resolve the problem. The investigating officer will seek information from any relevant staff and from patient records. From their findings the investigating officer will produce a report on what action has been/should be taken to resolve the complaint. The report and draft response will be forwarded to the Complaints Manager, together with any relevant documentation within ten working days of receipt of the complaint. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE Staff who are the subject of a complaint, either individually or as part of a team, will be given the opportunity to contribute to the response and will be entitled to seek support from their professional body or staff side representative. The investigating officer will draft a formal response for the Chief Executive’s signature. The response will be sent within twenty-five days of receipt of the complaint. Where this is not possible, the complainant or any third party acting on their behalf will be advised of the reason for the delay. 35.
Conciliation
If the complainant is dissatisfied with the explanation/outcome, the complainant and the complained against may be invited to a voluntary conciliation meeting. An explanation of the conciliation process is attached at D. 36.
Serious Complaints
An immediate referral to the Director of Corporate Services will be made if it becomes clear that there are serious issues that may require: • • • • • 37.
An investigation under the disciplinary procedure. The need for referral to one of the professional regulatory bodies. An investigation into a Serious Untoward Incident. An investigation of a criminal offence. The potential for significant adverse publicity.
Serious Untoward Incidents (SUI)
Some complaints will also be subject to a SUI investigation. When this is the case, it is often not possible to respond to the complaint until the SUI investigation of the complaint is complete, as the issues raised in the complaint will be similar to those raised in the SUI inquiry. However, throughout the SUI investigation, it should be remembered that the issues raised in the complaint would not always be exactly the same as those raised in the SUI investigation. A separate and full response to the complaint will therefore generally be required. Please refer to the SUI procedures. 38.
Complaints of a Disciplinary Nature
The purpose of the Complaints Procedure is not to apportion blame. Where the initial complaint alleges negligence or malpractice on the part of an individual member of staff, details of the allegation will be passed to the appropriate Director who will consider whether a disciplinary investigation is appropriate. If a disciplinary investigation is considered to be appropriate, the investigation will be separate from the investigation into any other aspect of the complaint. The disciplinary investigation will be carried out strictly in accordance with the PCT’s Disciplinary Procedure. A decision to refer all or part of the complaint for consideration as a disciplinary matter may be taken at any time during the investigation into the complaint. Investigations will continue simultaneously into any aspect of the complaint not subject to the disciplinary investigation and a response should, where possible, be provided within the standard timescale of twenty-five days. The complainant will be advised that those specific aspects of the complaint are being dealt with as a disciplinary matter but, for reasons of confidentiality, will not be advised of the outcome. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE The person managing the investigation into the complaint will play no part in deciding whether to carry out a disciplinary investigation or in determining any disciplinary action arising out of the complaint. 39.
Complaints Leading to Litigation
Litigation Manager will be informed of any possible litigious complaints. Complaints where financial redress is sought will be forwarded to the Litigation Manager (Claims Management Policy and Procedure). 40.
Complaints Arising from an Incident
The Health and Safety Risk Manager will be informed of any complaint arising from an incident such as a fall on PCT premises. The Health and Safety Risk Manager will forward any public complaints on to the Complaints Manager following an incident. (Incident Reporting Policy) 41.
Complaints Requiring Redirection
All written complaints received concerning other Trusts must be passed to the Complaints Manager for redirection. 42.
Joint Working with Other Organisations
The Complaints Managers of all organisations involved in the complaint, will agree which organisation is to lead on the investigation. The organisation where the main essence of the complaint falls will take the lead and will ensure that it is clear what aspects each organisation is to address and milestones will be set up for monitoring progress. The complainant will ideally have one point of contact and be kept informed of progress. Where possible, there will be a single response to the complainant but, if one aspect is more complicated than another and this is not practicable, then the complainant will be kept informed as to who will be responding and by when. 43.
Stage 2: Healthcare Commission Review
If complainants remain dissatisfied following the completion of local resolution, they have the right to ask for a review by the Healthcare Commission. The Healthcare Commission’s primary function in relation to complaints is to assess how best to resolve each case, whether further action is required and, if so, what and by whom. The possible courses of action available to the Healthcare Commission include: Taking no further action, giving reasons. It may be that there is evidence that the complaint has already been thoroughly investigated and answered during the local resolution stage. Referring back to the PCT, suggesting in writing what further action it might take to resolve the complaint or review its procedures and services. This might include arranging a meeting, conciliation or mediation, corrective action or reference to the process related to clinical negligence. If the complaint is referred back for further action locally and the complainant remains dissatisfied after this action has been taken, the complainant can go back to the Healthcare Commission and ask for the complaint to be looked at again. The Healthcare Commission will Approval Committee: Trust Board 16 Version No: Date Approved:
Two (June 2008) 29 November 2006
COMPLAINTS PROCEDURE look at the complaint again and decide on the most appropriate action. The complaint will not normally be referred back to the PCT for local action a second time. Action by the Healthcare Commission, who will investigate the complaint and, following the investigation, set up a panel if the complainant wants this. Referral to the Health Service Ombudsman. The cases where this is appropriate will be agreed between the Healthcare Commission and the Health Service Ombudsman. Referring the complaint to the Healthcare Commission’s system for inspection or investigation to follow up the issues raised in the complaint. Referring the case to other procedures, for example statutory professional regulatory bodies, such as the General Medical Council. 44.
Stage 3: Health Service Ombudsman
If the complaint is not satisfied with the outcome of the Healthcare Commission’s review, the complainant can ask the Health Service Commissioner (Ombudsman) www.ombudsman.org.uk to investigate. The Ombudsman is independent of both the NHS and the Government. The Parliamentary and Health Service Ombudsman The Health Service Commissioners Office for England Millbank Tower Millbank London SW1P 4QP Tel: 0845 015 4033 The Healthcare Commission and Ombudsman will only address a complaint if it has first been taken up locally through the Local Resolution stage of the Complaints procedure. 45.
Recording and Monitoring of Complaints
All files and documentation relating to complaints will be stored centrally. The Complaints Manager will be responsible for ensuring that complaints records are afforded the same confidentiality as clinical records and that records are easily accessible should further investigation be required. Complainants will have the right to request access to records relating to a complaint made by them. Requests will be made and processed through the PCT’s Procedure for Handling Access Requests for a Health Record and release of records will be subject to approval by either the PCT’s Medical Director or the PCT’s Director of Public Health. The Complaints Manager will be responsible for maintaining a comprehensive record of all complaints and for producing quarterly monitoring reports for the PCT Board (via the Governance Committee). In addition reports will also be provided on a quarterly basis to enable appropriate governance committee to analyze complaints. The Complaints Manager will support PCT Managers in analysing trends and data relating to complaints to enable lessons to be learned.
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 46.
Support for Complainants
The Complaints Manager will work with the Yorkshire and Humberside Independent Complaints and Advocacy Service (ICAS) to ensure complainants are adequately supported through the process. 47.
Complaints made to the PCT regarding FHS Practitioners
This section refers to NHS work carried out by Family Health Service Practitioners such as Doctors, Dentists, Opticians and Pharmacists. FHS practitioners operate their own practice based complaints procedures that comply with minimum national criteria under their Terms of Service. Should complainants approach the PCT, the Complaints Manager will refer complainants back to the practice concerned for the matter to be dealt with by the practice based complaints procedure, if this has not already taken place. The person in receipt of the complaint should at once pass the relevant information to the Practice Clinical Governance Lead or Practice Manager, who will ensure that the complaint details are taken. Where complainants do not feel able to contact the practice concerned, the PCT’s Complaints Manager will act as ‘honest broker’ and facilitate between the complainant and practice to ensure that the complaint is dealt with in accordance with the NHS Patients’ Complaints Procedure. The Primary Care Practitioner must have the first opportunity to investigate and respond to complaints. Primary Care Practitioners should aim to respond to complaints within ten working days. Complainants should also be advised of any delays. Situations may arise where it is inappropriate for complaints to be pursued through the in-house practice complaint procedure and will require attention by the PCT. If the complainant is dissatisfied with the explanation/outcome the complainant and the complained against may be invited to a voluntary conciliation meeting. An explanation of the conciliation process is attached at Appendix D. The Practice Clinical Governance Lead is required to inform the Director responsible for Clinical Governance as soon as is practicable of complaints which indicate: • • • • • • •
Serious complaints for example sexual assault. Police involvement. An investigation under disciplinary procedures. Referral to a professional regulatory body. An alleged criminal offence or potential investigation of a criminal offence. Civil litigation. An independent inquiry into a serious incident under Section 84 of the NHS Act 1977.
The Practice Clinical Governance Lead and the Director responsible for Clinical Governance will ensure complaints are passed on to a suitable person who can make a decision on whether to initiate alternative action.
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE 48.
Healthcare Commission Review of Complaints against Non-NHS Providers
The PCT will specify in the contracts with independent providers, for example independent nursing care, that the provider must set up and run a local resolution process. This should be as close as possible to the Local Resolution that NHS providers operate and they must cooperate with the Healthcare Commissioner’s Procedure. References The National Health Service (Complaints) Amendment Regulations 2006 The National Health Service (Complaints) Regulations 2004
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE
Appendix A VERBAL COMPLAINT RECORD - FORMAL/INFORMAL/ANONYMOUS This form must be completed upon receipt of any/all complaints received by telephone or in person and must be forwarded to the Locality Manager/Senior Manager and Complaints Manager for Kirklees PCT. If FORMAL complaint please forward as a matter of urgency to Complaints Manager (fax 01484 466151). Date received ............................
Time .................
Received by
Contact tel no …………………….
............................
Complaint received in person or by phone? Complainant's name ................................. Telephone no Address .................................................................................................................................. …………………………………………………………………………………………………………… ……………………………………………………………………………………… .............................................................................................. Postcode .............................. Complainant's Status: Patient/Relative/Other (please specify) (If the complainant is the patient’s representative patient authorisation may be required)
Patient's Name .......................................... Telephone No Date of Birth Address
............................................................. ... ....................................................................................................................
................................................................................................................................................ .............................................................................................. Postcode
Complained against (name and contact details)....................................................................... ................................................................................................................................................ Which service does the complaint relate to? (ie District Nursing) ............................................ Does the complaint relate to a specific date and time? If so, please state ............... …………. ………………………………. .....................................................................................................
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COMPLAINTS PROCEDURE Brief description of complaint ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Complaint Resolved
Yes / No
Would you say the complaint was Justified/Partially Justified/Not Justified? Have you identified any areas for service improvement? Please outline …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………… …………………………………………………………………………………………………………… ………… Date, time and nature of further action/contact agreed with complainant ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Please forward a copy of completed form to Complaints Manager, Kirklees PCT at St Luke’s House in order that the complaint can be logged. Complaints will be analysed with a view to identifying and sharing good/best practice.
Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE
Appendix B
WRITING A STATEMENT In the event of an enquiry, complaint, incident or litigation, staff may be required to make a statement regarding their involvement with a particular patient or relative. These guidelines should be used when preparing a statement. Seek advice from a Senior Manager, Locality Manager or Complaints Manager if you have any difficulties writing the statement. 1. 2. 3. 4.
5. 6. 7. 8.
9. 10. 11. 12. 13. 14.
Write your full name, address, job title, contact details and service area. In the case of litigation, professional qualifications should be given. Remind yourself of the situation through a careful reading of the relevant notes. State your role in relation to the event (eg District Nurse covering weekend); detailing day, dates on which events took place (and, ideally, times). If you were under supervision, state by whom. Establish the sequence of events (dates should be set out in full, eg 11.01.03) and write a narrative of precisely what you recall of the events. Comment on every point in the situation concerning your involvement. Keep to the facts. Where there is any disagreement between your recollection of events and other accounts – please specify this. If a decision was made then this should be set out in the statement, noting what action was agreed. Write reasons for your actions and also record anything that you omitted to do and your reasons for the omission. List facts only – the content should be objective. Do not include hearsay or any personal feelings/opinions about the event or matters outside your expertise. Identify staff involved. Give full details of their involvement. This should be on the basis of what you saw and heard, recording what they did or did not do. State their job titles. If patient records/notes and other documents are relevant then it may be helpful to refer to these in the statement. If hand-written notes are being referred to or any notes are being referred to, then it is usually helpful to have a transcript of those notes incorporated into the statement. If any shorthand notes or abbreviations are being referred to these should be explained fully. If you discover any inaccuracies in the notes then explain these as part of the statement and prepare an amendment note for the patient’s notes, which must be signed and dated. Under no circumstances alter notes after the event. Where possible, the statement should be typed. A handwritten statement should be legible and written in a pen that will allow photocopying (ie black ink). Sign and date the statement when you are happy with it. Ask a senior colleague to read it through and approve it. Keep a copy of the statement. Do not store the statement in the patient’s notes.
Note: If the matter is taken further through a legal route, any information contained in this statement may need to be disclosed. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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COMPLAINTS PROCEDURE
Appendix C
LEARN ING LESS ONS FR OM COMPLAIN TS
Complaint Reference: ___________________Service: _____________________________ Action identified as a result of the complaint
Responsibility for action (name)
Timescale for completion
Signed off completion
____________________________ (Signature)
____________________________ (Dated)
____________________________ (Printed)
____________________________ (Tel)
Please forward a copy of completed form to the Director of Corporate Services at St Luke’s House. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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Appendix D
CONCILIATION An explanatory leaflet for patients and practitioners What is Conciliation? Conciliation is part of local resolution and aims to resolve the problem between the complainant and practitioner in a safe, constructive and confidential environment. The lay conciliator will assist you to identify the issues of concern and make sure these are aired through full and open discussion. Who are Lay Conciliators? The lay conciliators are specially trained and independent. They are non-judgmental and have no formal connections with the Primary Care Trust (PCT), or any of the people involved in the complaint other than acting as a conciliator. Confidentiality Conciliation is a confidential process between the complainant, practitioner and conciliator and no formal records are kept; however, the conciliator will provide the PCT’s Complaints Manager with a record of any actions agreed by both parties at the conclusion of the conciliation meeting. If no actions are agreed the conciliator will provide a statement to this effect to the PCT’s Complaints Manager. If the complaint is not resolved at local resolution, then any information obtained by the conciliator or any other party cannot be used at the next stage of the complaints procedure. This process is without prejudice to any subsequent proceedings. How Do I Request a Conciliator? Either the complainant or practitioner can ask the PCT to appoint a conciliator at any time during local resolution. Requests for conciliation should be addressed to:Complaints Manager Kirklees PCT St Luke’s House Blackmoorfoot Road Crosland Moor Huddersfield HD4 5RH Tel: 01484 466113
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What Happens Next? The PCT will need to make sure that both parties agree to participate before conciliation can commence and that any consent to release medical records/relevant correspondence to the conciliator has been obtained. The Complaints Manager will then arrange a mutually convenient date, time and venue for both the complainant and the practitioner. You may choose to be accompanied at the conciliation meeting by a relative or friend to provide you with support. The complainant may find it helpful to focus on the main issues of concern prior to the meeting taking place. The Lay Conciliator will meet with the complainant to discuss the issues of concern, inviting them to address the question “What do I hope to achieve from these proceedings?” The Conciliator will then meet the practitioner to outline the concern(s), receive the response and then report back to the complainant. Only at that stage will the Conciliator invite both parties to meet together in the same room, led by the Conciliator, to try and resolve the matter(s). However, if the parties do not wish to meet together the Conciliator will continue to act as intermediary. Under normal circumstances the whole process lasts about 2-2½ hours. Occasionally the conciliator may draw on the help of an independent clinician/adviser to give an explanation on the medical, dental or other specialist issues. When the discussions are finished, the conciliator will ask the complainant if they are satisfied with the outcome or if they wish to take the complaint further. Hopefully the issues and questions will have been dealt with. Either way, the Complaints Manager will write formally to advise the complainant that they have six months in which to implement the next stage of the complaints procedure, if they feel there are areas of their complaint that remain unresolved. The practitioner will be kept informed by the PCT of progress. Who Can Help Me Pursue a Complaint? You can get independent help and advice from the Independent Complaints Advocacy Service (ICAS), which is provided by the Carers Federation – telephone 0845 120 3734 (local rate).
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Appendix E KIRKLEES PCT EQUALITY IMPACT ASSESSMENT To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Yes / no 1.
comments
Does the policy / guidance affect one group less or more favourably that another on the basis of: •
Race
•
Ethnic origins (including gypsies and travellers)
•
Nationality
•
Gender
•
Culture
•
Religion or belief
•
Sexual orientation including lesbian, gay and bisexual people
•
Age
2.
Is there any evidence that some groups are affected differently?
3.
If you have identified potential discrimination, are any exceptions valid, legal and / or justifiable?
4.
Is the impact of the policy / guidance likely to be negative?
5.
If so can the impact be avoided?
6.
What alternatives are there to achieving the policy / guidance without the impact?
7.
Can we reduce the impact by taking different action?
If you have identified a potential discriminatory impact of this procedural document, please refer it to Head of litigation and complaints, together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact Complaints Manager. Approval Committee: Trust Board Version No: Two (June 2008) Date Approved: 29 November 2006
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