Complaints Handling Policy · complaints to NHS Improvement by setting out the arrangements to: ......

DOCUMENT CONTROL

Version: 16

Ratified by: Clinical Policy Review and Approval Group

Date ratified: 1 November 2018

Name of Originator / Author: Head of Patient Safety

Name of responsible committee/individual:

Clinical Policy Review and Approval Group

Date Issued: 27 November 2018

Review Date: November 2021

Target Audience All Staff (including temporary)

Complaints Handling Policy

http://nww.intranet.rdash.nhs.uk/home/corporate-templates/rotherham-doncaster-and-south-humber-nhs-foundation-trust-rgb-blue/

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Section

CONTENTS Page No

1. INTRODUCTION 4

2. PURPOSE OF THE POLICY 4

3. SCOPE 4

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4

4.1 Executive Director of Nursing 4

4.2 Patient Safety and Investigation Team 5

4.3 PALS Coordinator 5

4.4 Head of Patient Safety 7

4.5 Staff involved in the complaint 7

5. PROCEDURE/IMPLEMENTATION 8

5.1 Policy and Procedure for Dealing with Formal Complaints. Stage I - Local Resolution

8

5.10 Policy and Procedure Relating to the Allegations of Patient Ill –Treatment

21

5.11 Supporting Service Users and Complainants 22

5.12 How the Trust makes improvements as a result of a concern or a complaint

23

5.2 How joint complaints are handled between organisations 14

5.3 Policy and Procedure for Dealing with Formal Complaints. Stage II - Referral to the Parliamentary Health Service Ombudsman

14

5.4 Procedure for Complaints concerning Local Authority service which have been integrated with RDASH services

14

5.5 Importance of Good Communication and Engaging All Stakeholders

15

5.6 Links with the Patient Advice and Liaison Service (PALS) 16

5.7 Unreasonably Persistent Complainants 16

5.8 Policy and Procedure for Handling Large Scale Complaints 20

5.9 Policy and Procedure for Complaints that may Involve Criminal Proceedings

20

5.9.1 Calling the Police 20

6. TRAINING IMPLICATIONS 23

5.9.2 Concurrent Investigations 20

5.9.3 Investigation Following Police Enquiry 21

7. MONITORING ARRANGEMENTS 23

8. EQUALITY IMPACT ASSESSMENT SCREENING 25

8.1 Privacy, dignity and respect

8.2 Mental Capacity Act

9. LINKS TO ANY ASSOCIATED DOCUMENTS 26

10. REFERENCES 26

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Section

CONTENTS Page No

11. APPENDICES 27

Appendix Ai Flow Chart of Complaints 28

Appendix Aii Role of the Lead Investigator

Appendix Aiii Complaints relating to medical staff

Appendix Bi Contact Preferences Form 32

Appendix Bii Diversity Monitoring Form 33

Appendix C (i) How joint complaints are handled between organisations: Rotherham and Doncaster Protocol for Handling NHS/ Social Services Inter-Agency Complaints

34

Appendix C(ii) How joint complaints are handled between organisations: Protocol for Handling NHS/Social Services Inter-Agency Complaints (North and North East Lincs)

39

Appendix D NPSA Risk Matrix 43

Appendix E Guidelines for Writing a Statement/Report of Events

45

Appendix F Guidelines for writing a letter of apology to a complainant

46

Appendix G Complaints Evaluation Form 47

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1. INTRODUCTION The Rotherham Doncaster and South Humber NHS Trust are dedicated to delivering high quality, safe and effective services. As part of this delivery, patient feedback is an important aspect and needs to be handled efficiently, promptly and fairly. The following policy described this process. This policy has been developed taking into consideration:

Duty of Candour regulations

The Health Service Ombudsman and related guidance

Independent advocacy services

The Care Quality Commission related guidance

NHS Resolution related guidance 2. PURPOSE OF THE POLICY

The purpose of this policy is to set out the procedures which the Trust has in place to support the effective implementation of The Local Authority Social Services (LASS) and the NHS Complaints (England) Regulations 2009 and the Compliance Framework 2010-11 requirements: reporting serious complaints to NHS Improvement by setting out the arrangements to:

Provide fair and equitable access for service users to make complaints and to provide an honest and open response to these complaints.

Provide service users and those acting on their behalf with support to bring a complaint or to make a comment, where such assistance is necessary

Have mechanisms in place to learn from complaints share this learning across the Trust where appropriate.

3. SCOPE

This policy covers all activities of the Trust and staff in its employ including temporary staff.

4. RESPONSIBILITIES, ACCOUNTABILITES AND DUTIES 4.1 Executive Director of Nursing and Quality

The Executive Director of Nursing and Quality is the nominated board member with responsibility for compliance with the arrangements made under the Complaints Regulations and the Monitor Compliance Framework requirement to report serious complaints to NHS Improvement, and for taking any required action as a result. It is recognised that the Trust should share knowledge and good practice - both internally and externally, whilst maintaining confidentiality - arising from

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complaints, to support improvements for service users and improved risk management

4.2 Patient Safety and Investigation Team

The Patient Safety and Investigation Team will:

Manage the complaints handling function within the Trust and be readily identifiable to complainants.

Advise Complainants of the complaints process, including advocacy services available in their area where appropriate.

Work in partnership with advocacy groups and services representing complainants, to promote equality of access to the complaints process. It is recognised that advocacy is extremely important to service users

Make clear and accessible information about the complaints procedure widely available for service users and carers, which will include how people can contact the Parliamentary Health Services Ombudsman and the Care Quality Commission. Telephone and email contact details will be included in the Trust’s Complaints leaflet which will be made widely available throughout the Trust.

Ensure that consent is obtained where this is required to respond to a complaint. Where consent is required, the investigation should be undertaken whilst consent is being secured. The Lead Investigator’s report should be produced on the assumption that consent has been received. If a complainant has approached their MP who then submits a complaint on their behalf, implied consent is assumed and written consent is not required. If a carer/relative submits a complaint on behalf of a family member written consent is required. If the complaint is regarding a child, dependant on the age of the child, discussion to be held with Head of Patient Safety and the Clinical Team Leader/Service Manager involved with the young person. If the service user is unable to give consent the Lead Investigator should seek guidance from the Caldicott Guardian.

Where the patient is deceased, ensure the complainant is the lawfully entitled personal representative of the patient. Seek guidance from the Caldicott Guardian and Information Governance Manager if this is not clear.

Inform the Executive Director of Nursing and Quality of any serious complaints and significant trends in complaints, in order that these may be reported to NHS Improvement accordingly.

Any comments or complaints received which describe events considered to be an adverse or serious incident should trigger the need for a Serious Incident (SI) investigation to be undertaken. The Head/Manager of the

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Patient Safety and Investigation Team should refer these on to the Executive Director of Nursing and Quality for consideration. Such cases may result in a delay in the response to the complainant, outside of the agreed timescales for responding to formal complaints. If a complaint is to be investigated via the Trust’s Policy for the Management of Serious Incidents, it is considered that this will be the only investigation required to be undertaken, which will inform and advise both the SI and the complaint reporting. Complainants should be advised when this is the case.

Provide information, advice and support to distressed members of the public/patients/carers where large scale failures of services have occurred.

Monitor complaint action plans, reporting progress to the Quality Committee.

Monitor that the procedures are followed in practice, and review the procedures as required.

Confirm that the complaint has been risk assessed following investigation. The risk assessment of complaints is considered good practice by the National Patient Safety Agency (NPSA) (Appendix D).

Work with Care Group Directors, Medical Director, Associate Nurse Directors, Head of Services, Service Managers and Modern Matrons to investigate and resolve complaints.

Lead Investigator to communicate or liaise with Specialist team leaders for topic specific complaints e.g. tissue viability, continence and infection prevention & control.

Liaise closely with Local Authority Social Services (LASS) Complaints Departments, where a review under the Local Authority complaints procedures should be invoked, and where complaints clearly relate to the LASS functions which have been delegated to the Trust

Participate in a range of proactive measures with service users, carers and staff to encourage comments and feedback, with a view to reducing the number of formal complaints and promoting ongoing improvements in service quality.

4.3 PALS Coordinator (see Patient Advice and Liaison Service Policy (PALS)

Policy)

The PALS Coordinator will:

With the agreement of the complainant, work closely with the Patient Safety and Investigation Team to resolve complaints which might be more appropriately addressed via PALS

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Liaise directly with the relevant service areas as necessary to resolve complaints.

Arrange for a member of the Patient Safety and Investigation Team to provide information, advice and support to distressed members of the public/patients/carers where large scale failures of service have occurred.

4.4 Head of Patient Safety The Head of the Patient Safety will:

Ensure they have systems in place to ensure that patients, their relatives and carer are not treated differently as a result of raising a concern or a complaint.

Provide structured, continuous independent monitoring of complaints, implementation of action plans and service improvements within their areas of responsibility.

Consider any comments or complaints received which describe events considered to be an adverse or serious incident to identify the need to trigger a serious incident investigation to be undertaken.

Manage the Patient Safety and Investigation Team.

Ensure that all complaints are fully investigated.

Approve draft investigation response letters.

Ensure information is provided for the Patient Safety and Investigation Team Dashboard, the Quality Committee and the Trust Annual Report.

Approve findings, recommendations, action plans and full draft responses.

Advise the relevant Care Group Director, or Director of Nursing and Quality on the relevant Directorate Risk Register or Corporate Risk of any risk which need to be on the relevant directorate risk register (See the Trust Risk Management Strategy for further guidance.)

Discuss and disseminate learning and implement any required policy and practice changes to promote ongoing improvement and organisational learning.

4.5 Staff involved in the complaint

Staff involved in the complaint, whether named or not, will

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Provide factual, open, honest statements in a timely way. See Appendix E for guidelines on writing statements

Undertake any actions/learning identified as an outcome of the investigation.

5. PROCEDURE/IMPLEMENTATION 5.1 Policy and Procedure for dealing with Formal Complaints: Stage 1 –

Local Resolution

Staff are encouraged to resolve complaints as far as is practicably possible within their local service area. Where this is possible the Service Provider will formally record details of discussions held and actions agreed with the person raising the concerns and details to be recorded on the Ulysses System.

The service provider will inform the Complaints Team Secretary who will store a file note in the Trust PET designated folder for locally resolved complaints.

However, where local resolution is not possible, assistance should be given to the complainant for the complaint to be raised either with the Trust’s Patient Safety and Investigation Team, or for more serious issues formally with the Chief Executive. Throughout the process, the Head of Patient Safety will be readily accessible to all concerned. Each complaint will be treated according to its individual nature and the wishes of the complainant, reinforcing the ethos of ensuring that the whole experience of making a complaint is simpler, more user-friendly and far more responsive to people’s individual needs. The complainant will be advised if the Trust cannot meet their wishes. If, after approaching a member of staff to discuss a concern the complainant remains unsatisfied and wants to raise a formal complaint, the staff member will provide details of the PALS and the Patient Safety and Investigation Team and if appropriate offer to record and submit the concerns on behalf of the complainant. When a complaint is received within the Trust, a letter of acknowledgement explaining the procedure will be sent to the complainant within three working days. (See appendix Ai. Complaints flow chart). The letter will acknowledge the person’s concerns, ask if they wish to be contacted directly to discuss the issues raised and if possible, what the complainant wishes as the outcome of the complaint. The complainant will be sent a “Contact Preferences Form” with the acknowledgement (see Appendix Bi) which outlines their preferences. The letter also advises the complainant of the services provided in terms of advocacy (Cloverleaf, Voice Ability, and Healthwatch).

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In line with national guidance and reporting requirements, the complainant will also be sent, with the acknowledgement, a diversity monitoring form (see Appendix Bii). If the complainant is not the service user, and is complaining on behalf of someone else, a consent form for the release of confidential information should be attached to the letter of acknowledgement, which should include information regarding service user confidentiality for the service user to sign. If there are concerns about the person’s capacity to understand the complaint being made a decision will need to be made under the Mental Capacity Act 2005 in the person’s best interest in sharing information. This decision will need to be made by the Head of Patient Safety. Failure to return the signed form may result in a reduction of the amount and content of the information included in the letter of response, and this will be explained clearly to the complainant from the outset. If a complainant has approached their MP who then submits a complaint on their behalf, implied consent is assumed and written consent is not required. If a carer/relative submits a complaint on behalf of a family member written consent is required. If the complaint is regarding a child, dependant on the age of the child, a discussion should be held with the Head of Patient Safety. The investigation into the complaint will continue, including producing a report and action plan, regardless of whether consent is secured. Where the patient is deceased, it will be ensured that the complainant is the lawfully entitled personal representative of the patient. Advice will be sought from the Caldicott Guardian and Information Governance Manager if this is not clear.

If the complainant is not able to send a written complaint, but wishes the matter to be pursued, the Lead Investigator will arrange for a record of the complaint to be made and agree a process for the complainant to sign and date it (electronically, letter or invitation to attend a meeting). The complaint letter will be sent to the complainant with a request to return a signed copy within two weeks. If the complainant fails to return the signed complaint letter within two weeks a first reminder will be sent and a further two weeks allowed for the signed complaint letter to be returned. If the complainant fails to return the signed complaint letter following a reminder, a final letter will be sent stating that it is assumed the complainant no longer wants the organisation to pursue their complaint providing contact details should the complainant changes their mind at a later date. If a complainant is unable to sign a complaint letter written on their behalf, this does not invalidate the complaint and the procedure should still be followed. However, the response may be limited or not formally

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responded to although a copy of the response will be kept on file and the actions agreed and shared with staff. The investigation could be undertaken by the service area to identify good practice and address care delivery problems if relevant. If the complainant subsequently withdraws their complaint, the Head of Patient Safety will decide based on the evidence available if the investigation into the complaint will continue, including producing a report and action plan. The Lead Investigator will send the complainant a letter to sign and return to confirm they have withdrawn their complaint (Appendix Aiii).

The Local Authority Social Services and NHS Complaints (Regulations) 2009 removed statutory timescales in responding to complaints. The timescale for resolution will be dependent upon the severity and complexity of the complaint. This will be assessed by the Head/Manager of the Patient Safety and Investigation Team, taking advice from the Care Group Director/Medical Director/Associate Nurse Director/Service Area Manager where necessary, on receipt of the complaint. Care Group Directors/Medical Director/Associate Nurse Director and Lead Investigators need to be aware of the need to respond in a timely and comprehensive way in order to meet the timescales agreed. The timescales will be as follows: 25 – 40 working days: simple, non-complex complaints. These will typically, but not always, only involve one service/team. 41 – 60 working days: complex complaints. These will typically, but not always, involve more than one service/team and/or are multi-agency. The timescales may need to be adjusted depending on the nature of the investigation to be undertaken (complaint/SI/or awaiting a Coroner’s verdict), the progression of the investigation, and responses from other agencies. The complainant will be kept informed at all times of any adjustments made to the anticipated timescales. Response times for complaints submitted by an MP are within 10 working days. Response time for a complaint submitted by OFSTEAD is within 28 working days.

The Lead Investigator will consider the best way to respond to the complainant. This may include the offer of a meeting, (which would be between the complainant and Lead Investigator), a review by the Service Manager, or clinician for that speciality/service.

In all cases, complainants should be advised of the role of advocacy services and how to contact them.

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Where the Chief Executive is named in a complaint, the Chairman of the Trust will be informed, who will determine if external support/advice is appropriate to aid investigation of the complaint. If external support is not deemed to be required, the Chairman will delegate an appropriate lead Director to coordinate the investigation. Where a Director is named in a complaint, the Chief Executive will be informed, who will delegate an appropriate lead Director to coordinate the investigation. Where the Medical Director is named in a complaint, the Chief Executive will be informed, who will determine if external support/advice is appropriate to aid investigation of the complaint. If external support is not deemed to be required, the Trust’s Deputy Chief Executive will lead the investigation, with appropriate medical advice.

Depending on the nature of the complaint and the wishes of the complainant, the complaint may be dealt with directly and without the need for a written response, via PALS. This will ensure prompt and appropriate action and help to resolve the complaint at a truly local level.

Complaints will be investigated appropriately in line with the ethos and procedures set out within the policy and within the timescale agreed with the complainant wherever possible. If an investigation cannot be completed on time, direct contact will be made with the complainant as soon as this is apparent, an apology provided and an extension period agreed and confirmed in writing.

When the investigation is complete, the Lead Investigator will submit a report of their findings, recommendations, full draft response and an action plan based on the recommendations, identifying areas for improvement where relevant and how this will be achieved to the Care Group Director/Medical Director/Deputy Director of Nursing and Quality.

The action plan should include actions to address all areas of the complaint where there has been deemed to be a less than satisfactory service. The action plan must have timescales for when these actions will be complete and an identified member of staff to lead on the action. The action plan will also include a risk rating using the NPSA Matrix (see Appendix D.)

The action plan will be monitored by the Patient Safety and Investigation Team to ensure that all actions are completed. Completed action plans will be randomly selected and the Lead Investigator asked to provide evidence of completion in order to assure the Board.

All draft complaint responses will be proof read, and amended where necessary, for quality assurance and monitoring purposes by the Head of Patient Safety to check that all issues have been addressed/and responded to, and that the style and content is in a consistent and

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accessible format for the complainant. The final draft will be approved by the Care Group Director/Medical Director/Deputy Director of Nursing and Quality prior to passing to the Chief Executive.

The Trust will respond to the complainant as agreed, identifying any organisational learning gained as a result of the complaint. The manner of the letter should be open, honest, empathetic, and include an apology where appropriate.

All letters of response will include a contact name, telephone number and details of who to contact, should the complainant wish to discuss the matter further. This will usually be the Lead Investigator. Any action(s) agreed by the Trust should be conveyed to the complainant with an indication of when the actions are expected to be implemented and improvements achieved.

The response may include: an apology; an explanation and acknowledgement of responsibility; remedial action (reviewing or changing a decision provided to the complainant/revising policies, procedures or guidance/training and/or supervision of staff); financial redress for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these. Section 2 of the Compensation Act 2006, states, “An apology, offer of treatment, or other redress, shall not of itself amount to an admission of negligence or breach of statutory duty.”

The complainant will be sent a Satisfaction Survey to ascertain their satisfaction with the complaints process. These will be monitored by the Head of Patient Safety and action taken where necessary. (See Appendix G.)

In the event that the complainant is unhappy with the response, further actions to achieve local resolution of the complaint may be taken. However, at this point, the Trust may be satisfied that all reasonable steps to resolve the complaint have been taken and that Local Resolution is complete. If the Trust can demonstrate that all reasonable and appropriate action has been taken, proportionate to a complaint, it would not be seen as a failure on behalf of the Trust. It is recognised that all complainants cannot be satisfied, and it is the role of the Parliamentary Health Service Ombudsman to consider whether the Trust has responded appropriately to the complainant, and identified opportunities for organisational learning and service improvements.

Following the investigation of the complaint, if any issues of a disciplinary nature need to be considered, this will be carried out in accordance with the Trust’s Disciplinary Procedure. This policy will only be concerned with resolving the complaint, not with investigatory disciplinary issues.

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If a staff member is the centre of the complaint and a disciplinary investigation is also being undertaken, the complaint response cannot be sent until the disciplinary investigation has concluded. This may lead to a delay in the response being issued and the complainant will need to be made aware of the potential delay. If the centre of the complaint relates to a staff member from an agency the Lead Investigator should communicate with the HR department for further advice.

Any member of staff involved in a complaint should be fully informed of any allegations at the outset and given an opportunity to reply to the Investigating Officer. See Appendix E - Guidelines for Writing a Statement/Report of Event. They should be advised of the right to seek the advice of their professional association or trade union before commenting on the complaint.

It may be deemed appropriate for a member of staff to write a letter of apology to the complainant as part of the response to the complaint. See Appendix F - Guidelines for Writing a Letter of Apology. They should be advised of the right to seek the advice of their professional association or trade union before writing the letter.

On receipt of a complaint where legal action is being taken, or the police are involved, the Government expects discussions to take place with the relevant authority (legal advisors, police, Crown Prosecution Service), to determine whether progressing the complaint might prejudice subsequent legal or judicial action. If so, the complaint will be put on hold, and the complainant will be advised of this. If not, an investigation into the complaint should commence.

If the Chief Executive or Head of the Patient Safety and Investigation Team considers the complaint may lead to litigation, advice should be sought from the Trust’s legal advisors. When there is a concurrent investigation i.e. legal or disciplinary proceeding or referral to the Police or other statuary body, the Trust will consider how the complaint should be handled and will only proceed where it believes that its investigation would not compromise or prejudice the concurrent investigation.

If, throughout the above process, a complainant indicates either in writing or verbally that they intend to take legal action, the Claims Manager will be informed of the complainant’s intention by the Head of Patient Safety.

If a complainant withdraws their complaint after the investigation has commenced the Lead Investigator will send a Satisfaction Survey to ascertain their satisfaction with the complaints process.

A master file should be retained for a period of up to ten years in line with guidance. The file should incorporate all the relevant information and should be easily accessible upon request.

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5.2 How joint complaints are handled between organisations

In the event of a highly complex complaint, for example where the complaint relates to a number of different NHS services or organisations, one identified lead organisation will coordinate a response to the complaint following discussion and agreement with the Head of Patient Safety. Each NHS organisation has a ‘duty to co-operate/duty of co-ordinated handling,’ in relation to complaints. If there are valid reasons why this may not be possible, e.g. if it will unduly delay the response, the complainant should be informed and it is there decision whether they have a joint or separate response. See Appendix C. Rotherham and Doncaster Protocol for Handling NHS/Social Services Inter-Agency Complaints.

5.3 Policy and Procedure for Dealing with Formal Complaints: Stage II – Referral to the Parliamentary Health Service Ombudsman (PHSO)

If a complainant remains dissatisfied and the Trust believes it has taken all reasonable steps to resolve the complaint, the complainant should be advised of their right to refer their complaint to the Parliamentary Health Service Ombudsman.

5.4 Procedure for complaints concerning Local Authority services which

have been integrated with RDASH services

Where Local Authority services, e.g. Social Workers, are employed by the Local Authority but who form an integrated part of an RDASH team and are managed by that team, any complaints received about these services should in the first instance be dealt with using this policy.

Following investigation and response, if the complainant is dissatisfied and the complaint clearly refers to functions of Local Authority Social Services which have been delegated to the Trust, a review under the relevant Local Authority complaints procedure should be invoked.

Should the complaint remain unresolved following the Local Authority review, complainants should be advised to write to the Local Government Ombudsman.

Complaints which clearly relate to the functions of Local Authority Social Services which have been delegated to the Trust will be copied to the relevant Local Authority for monitoring purposes.

5.5 Importance of Good Communication and Engaging All Stakeholders

Many complaints by service users are rooted in communication failures, and these can be exacerbated by (but not exclusively) predisposing conditions of service users such as physical disabilities, medical conditions, anxiety, fear, bereavement, psychological withdrawal, and unfamiliar environments. Good communication skills are vital therefore in avoiding the occurrence of complaints and also the resolution of such concerns.

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Members of Trust staff are frequently able to resolve many concerns as soon as they arise by utilising such communication skills. Whilst many minor concerns may be immediately resolved, these issues should still communicated to the appropriate Service Manager for their consideration. This is so that they are able to assess the remedial action taken to resolve the complaint and also take reparative action to avoid a re-occurrence of the situation. There are a wide variety of ways in which service users are able to give their opinion, including service user groups, and these should be utilised by services to address any concerns immediately, wherever possible. Each member of Trust staff has a responsibility to communicate effectively and sensitively to all service users and carers. Where language creates a barrier, staff have access to interpretation services. See Policy for provision of, access to and use of interpreters. It is a requirement that service users have access to (as frequent as is reasonable) adequate explanations about their care and treatment. All front line staff play a crucial role in undertaking this task. However, service users should also be able to discuss matters of concern with their consultant, other senior clinician or service manager should they wish to do so. The Trust operates an opinion/suggestion scheme called Your Opinion Counts. This invites feedback from service users and carers. This scheme acts as a conduit to improve services by addressing service user and carer concerns; it also provides positive feedback to Trust staff when compliments are made. However, when a formal complaint is raised via the Your Opinion Counts form, it must be dealt with promptly as set out in this policy.

5.6 Links with the Patient Advice and Liaison Service (PALS)

The PALS Coordinator is available to discuss any comments and concerns with service users and is also able to provide a range of information on associated support services. However, the PALS should only be utilised for ‘quick-fix/on-the-spot’ resolution to any minor concerns. Any continued dissatisfaction expressed by service users should be referred to the Patient Safety and Investigation Team. The Trust works with the principle that the earlier the concern is mutually resolved the less need there would be to progress to a complaint, claim or litigation.

5.7 Unreasonably persistent complainants

The difficulty in handling unreasonably persistent complainants can place a strain on time and resources and cause unacceptable stress for staff. NHS staff are trained to respond with patience and understanding to the needs of

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all complainants, but there are times when there is nothing further that can reasonably be done to assist them or to rectify a real or perceived problem.

In determining arrangements for handling such complainants staff should identify the stage at which a complainant has become unreasonably persistent but also recognise that even persistent complainants may have issues which contain some substance. The need to ensure an equitable approach and to provide an open and honest response is, therefore, crucial.

This procedure should only be used as a last resort and after all reasonable measures have been taken, i.e. all efforts to resolve complaints following the NHS complaints procedures have been exhausted. This procedure should only be implemented following careful consideration by, and with authorisation of, the Trust's Chair and Chief Executive or nominated deputy and subsequently ratified by the Trust Board through the confidential agenda.

Definition of Unreasonably Persistent Complaints / and or requests for information Complainants and/or anyone acting on their behalf may be deemed to be unreasonably persistent where current or previous contact with them shows that they have met two or more (or are in serious breach of one) of the following criteria:-

Persisting in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted. For example, where investigation is deemed to be 'out of time' or where the Parliamentary Health Services Ombudsman has declined a request for independent review.

Changing the substance of a complaint or persistently raising new issues or seeking to prolong contact by unreasonably raising further concerns or questions upon receipt of a response whilst the complaint is being dealt with. Care must be taken not to disregard new issues, which differ significantly from the original complaint. These may need to be addressed separately.

Unwilling to accept documented evidence of treatment given as being factual, e.g. manual or computer records, or deny receipt of an adequate response despite correspondence specifically answering their questions/concerns. This also includes those persons who do not accept that the facts can sometimes be difficult to verify after a long period of time has elapsed.

Focusing on a trivial matter to an extent which, is out of proportion to its significance and continue to focus on this point. It should be recognised that determining what is trivial can be subjective and careful judgement must be used in applying this criterion.

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Physical violence has been used or threatened towards staff or their families/associates at any time. This will, in itself, cause personal contact to be discontinued and will thereafter, only be pursued through written communication. All such incidents should be documented and reported using the Trust’s Incident Policy, and notified as appropriate, to the police.

The complainant has had an excessive number of contacts with the Trust when pursuing their complaint, placing unreasonable demands on staff. Such contacts may be in person, by telephone, letter, fax or electronically. Discretion must be exercised in deciding how many contacts are required to qualify as excessive, using judgement based on the specific circumstances of each individual case.

The complainant has harassed or been abusive or verbally aggressive on more than one occasion towards staff - directly or in-directly - or their families and/or associates. If the nature of the harassment or aggressive behaviour is sufficiently serious, this could, in itself, be sufficient reason for classifying the complainant as unreasonably persistent. Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this. All incidents of harassment or aggression must be documented in accordance with the Trust’s Incident Reporting Policy.

The complainant is known to have electronically recorded meetings or conversations without the prior knowledge and consent of the other parties involved. It may be necessary to explain to a complainant at the outset of any investigation into their complaint that such behaviour is unacceptable and can, in some circumstances, be illegal.

Display unreasonable demands or expectations and fail to accept that these may be unreasonable once a clear explanation is provided to them as to what constitutes an unreasonable demand, i.e. insisting on responses to complaints being provided more urgently than is reasonable or recognised practice, presenting similar or substantially similar requests for information.

Options for Dealing with Unreasonably Persistent Complainants and/ or Persons requesting information When complainants have been identified as unreasonably persistent, in accordance with the above criteria, the Chair and Chief Executive (or their nominated deputy) will decide what action to take. The Chief Executive (or deputy/representative) will implement such action and notify the individual(s) promptly, and in writing, the reasons why they have been classified as unreasonably persistent and the action to be taken. This notification must be copied, for the information, to others involved in the complaint, e.g. practitioners, advocates, Independent Complaints Advocacy Service, Member of Parliament, etc. Records must be kept, for future

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reference, of the reasons why the decision has been made to classify as unreasonably persistent and the action taken. The Chair and Chief Executive (or delegated deputies/representatives) may decide to deal with unreasonably persistent complainants in one or more of the following ways:

Once it is clear that one or more of the criteria in section 3 has been seriously breached, it may be appropriate to inform the individuals, in writing, that they are at risk of being classified as unreasonably persistent. A copy of this procedure should be sent to them and they should be advised to take account of the criteria in any future dealings with the Trust and its staff. The complainant should be advised that they can seek advice from the Independent Complaints Advocacy Service or the Parliamentary Health Services Ombudsman with regard to taking their complaint further.

The Trust should try to resolve the complaint before invoking this procedure by drawing up a signed agreement with the complainant, involving the relevant staff if appropriate, setting out a code of behaviour for the parties involved. If this agreement is breached, consideration would then be given to implementing other actions as outlined below.

The Trust can decline further contact either in person, by telephone, fax, letter or electronically, or any combination of these, provided that one form of contact is maintained. Alternatively, a further contact could be restricted to liaison through a third party. A suggested statement has been prepared for use, if staff need to withdraw from a telephone conversation. This is shown in the attached staff operational guidance.

Notify complainants in writing that the Chairman or Chief Executive (or delegated deputies/representatives) has responded fully to the complaint, has exhausted local resolution, and that continuing contact on the complaint will serve no useful purpose. This notification should state that that no further correspondence will be sent and that further communications will not responded to.

Inform complainants that in extreme circumstances the Trust reserves the right to refer unreasonably persistent complaints to the organisation’s solicitors/the Information Commissioner and/or the police.

Temporarily suspend all contact, whilst seeking legal advice or guidance.

Withdrawing Unreasonably Persistent Status Once classified as unreasonably persistent, this status may be withdrawn if, for example, a more reasonable approach is subsequently demonstrated or if they submit a further complaint for which the normal complaints procedures would be appropriate.

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Staff should use careful judgement and discretion in recommending or confirming that unreasonably persistent status should be withdrawn. Discussions should be held with the Chairman and Chief Executive (or their delegated deputies/representatives) and, subject to their approval, normal contact and procedures will be resumed. Staff Guidance for Handling Habitual or Unreasonably Persistent Complainants The following form of words – or a very close approximation – should be used by any member of staff who intends to withdraw from a telephone conversation with a complainant. Grounds for doing so could be that the complainant has become unreasonably aggressive, abusive, insulting or threatening to the individual dealing with the call or in respect of other NHS personnel. It should not be used to avoid dealing with a complainant's legitimate questions / concerns which can sometimes be expressed extremely strongly. Careful judgement and discretion must be used in determining whether or not a complainant's approach has become unreasonable.

Form of Words "I am afraid that we have reached the point where your approach has become unreasonable and I have no alternative but to discontinue this conversation. Your complaint(s) will still be dealt with by the Trust in accordance with the NHS complaints procedure. I am now going to put the telephone down but wish to assure you that the situation will shortly be confirmed in writing to you." Follow-Up Action The incident should immediately be reported to the Patient Safety and Investigation Team and agreement reached on future means of communication with the complainant, together with any further action deemed necessary.

5.8 Policy and Procedure for Handling Large Scale Complaints

The Patient Safety and Investigation Team will provide information, advice and support to distressed members of the public/patients/carers where large scale failures of services have occurred.

5.9 Policy and Procedure for Complaints that may Involve Criminal Proceedings

5.9.1 Calling the Police

Following a complaint or investigation of a complaint, if it appears or is alleged that a criminal offence may have been committed, the matter should be reported immediately to the Chief Executive or the most senior manager

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available to advise on whether the police should be called. The Chief Executive or senior manager will advise the Chairman of the Trust. If it is determined that police involvement is necessary, the manager should contact the Police Headquarters (telephone number 0114 220 202). If the allegation is withdrawn, the Chief Executive will consider the circumstances and decide on what action should be taken.

5.9.2 Concurrent Investigations

In its investigations, the Trust should take care not to prejudice police enquiries or court proceedings.

Any member of staff against whom allegations are made and who is involved in enquiries undertaken by the Trust should be advised to seek the assistance of their professional association or trade union before they comment on any such allegations. If there seems to be any danger that investigations by the Trust may prejudice police enquiries or court proceedings, the Trust should consult the police and their own legal advisors before proceeding. If the Trust and the police disagree on the course of action to be taken, the Trust should refer the matter to the NHS England.

5.9.3 Investigation following police enquiries

On conclusion of any criminal proceedings or, having been brought in, the police decide not to institute proceedings, the Trust must then consider what further investigation is required, for example, if disciplinary action is necessary. If the police decide not to proceed, it does not follow that the Trust has no need to act. Staff involved in any enquiry should always be advised to seek the advice and assistance of their professional association or trade union. Suspicions of Fraud When a complaint is received and there are suspicions of fraud this must be dealt with in line with the Counter Fraud, Bribery and Corruption Policy, the Trust’s Counter Fraud Specialist or the Director of Finance should be contacted prior to any investigation commencing.

5.10 Policy and Procedure Relating to Allegations of Patient Ill-Treatment

In respect of allegations relating to the ill treatment of service users, this policy must be followed in line with other relevant policies including Vulnerable Adults Policies.

Allegations may come from service users themselves, their relatives and members of staff or outside agencies.

Reassurance will be given to staff that any concern over the ill-treatment of service users will be brought to the attention of the member of staff’s immediate manager. If the member of staff does not consider this course

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of action to be appropriate, or if any report made is not adequately dealt with, staff should express their concern to a higher level of management.

The Chief Executive must be made aware of all allegations of ill treatment, so that they can discuss the course of action to be followed with the Executive Director of Nursing and Quality and/or the Medical Director and the Chairman. Reports should be made initially by telephone as soon as possible after the event. The Chief Executive, together with the Executive Director of Nursing and Quality (or Professional Lead if another discipline is involved), will carry out an immediate initial investigation to establish the nature and gravity of the complaint and to determine if any immediate action is required to safeguard the interests of the service users and to facilitate further enquiries.

In light of the initial investigation, the Chairman, Chief Executive and

Executive Director of Nursing and Quality/Medical Director may decide that no further action is required.

If, however, it appears that a criminal offence may have been committed, a report will be made to the police.

In other cases, the Chief Executive may feel it relevant to undertake a fact- finding enquiry or, in more serious situations, to appoint an independent Committee of Enquiry. It is important to stress that the function of both these groups would be to establish the facts, leaving the most appropriate form of disciplinary action (if any) to be determined subsequently on the basis of facts and evidence. Staff whose conduct is complained about, however, should be allowed to make their own arrangements to be legally represented at any independent enquiry if they so wish.

Where disciplinary action needs to be considered, it will be in accordance with the Trust’s Disciplinary Procedure.

Replies to complainants where ill-treatment has been alleged, will be sent to the Chief Executive.

Care should be taken to support staff who make allegations of ill-treatment and who have allegations made against them, and they should be advised who to contact if they have further concerns or worries. When staff are required to attend a fact-finding enquiry, they are entitled to be accompanied by a trade union representative if they so wish.

Where complaints of ill-treatment towards service users are made, if the service user does not have capacity or if they agree for the information to be shared, the service user’s immediate next of kin should be informed and following the investigation, made aware of the outcome.

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In certain circumstances, a service user may wish to have an advocate at fact-finding meetings. This request should be made by the service user or next of kin.

5.11 Supporting Service Users and Complainants

Anyone making a complaint, either in their own right, or on behalf of a service user, should be reassured that they and/or the service user whom they are representing, will not be treated any differently as a result of making the complaint. The best way to support the complainant is to provide them with accurate and timely information, and in order to minimise/prevent any feelings of discrimination:

No documentation relating to the complaint or any subsequent investigation is to be held on the service user’s clinical record.

In the event that the complaint is against a member of staff involved in the care of the complainant, consideration should be given to the need for the service users care to be allocated to another worker for the duration of the complaint investigation.

5.12 How the Trust makes improvements as a result of a concern or a

complaint

The Trust systems for monitoring and analysis of complaints will help to facilitate organisational learning and the information will be used to improve services and care available to patients.

PALS, YOC, complaints, incidents, claims data and compliments will be examined together to allow trends to be identified and improvements implemented. This can lead to the prevention or recurrence of incidents and concerns. The sharing of lessons learned from one service to other areas of the Trust will allow for any system failure discovered during investigation to be adopted by the Trust as a whole and prevent pockets of good practice from being isolated.

Action plans developed by service areas following the investigation of concerns/complaints will be monitored quarterly in order to identify emerging themes with other care groups.

Action plan compliance will be reported on the Patient Safety Dashboard

Training will be organised where the analysis of complaints data identifies a need.

The Trust is committed to undertaking this activity in a regular and systematic way to facilitate ongoing improvement through organisational learning.

6. TRAINING IMPLICATIONS

The Training Needs Analysis (TNA) for this policy can be found in the Training Needs Analysis document which is part of the Trust’s Mandatory

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Risk Management Training Policy located under policy section of the Trust website.

7. MONITORING ARRANGEMENTS

The Role of the Board is to receive:

An annual report on the handling of complaints, including:

o number of complaints received o subject matter o outcome of complaint (upheld or not) o record of further referral (Ombudsman) o thematic analysis of complaints, actions taken and lessons learnt

A copy of the report should be shared with the relevant Commissioners and an anonymised copy should be available to the local community population and local agencies, where partnership protocols exist. The role of the Quality Committee is to:

Review themes and trends in complaint reporting.

Monitor compliance with action plans arising from complaint investigations, and seek assurance of risk mitigation for any actions not achieved in the agreed time frame.

Provide assurance to the Board of Directors in relation to complaint management, sharing of lessons leant, and action taken to mitigate any identified risks.

This information is provided to the Quality Committee through a quarterly complaint report, and quarterly patient safety Dashboards.

Areas for monitoring

Monitoring process

Responsibility Frequency Reported to

Duties

Reports:

Patient Experience Report

Head of Patient Engagement and Experience

Annual Quality Committee

Quality Improvement Report

Head of Patient Safety

Quarterly Quality Committee

Complaints Report


Monthly Quality Committee

How the Trust listens and responds to concerns and complaints

Reports:

Complaints Action Plans

Care Group Directors


Following each complaint

Monthly

Quality Committee

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Areas for monitoring

Monitoring process

Responsibility Frequency Reported to

How joint complaints are handled between organisations

Via Complaints Process


Ongoing Quality Committee

How the Trust makes sure that patients, their relatives and carers are not treated differently as a result of raising a concern or complaint

Via PALS/

Complaints

Care Group Directors, Head of Service and Service Managers/

Modern Matrons

Ongoing Quality Committee

How the Trust makes improvements as a result of raising a concern or complaint

Board of Directors Report


Monthly

Quality Committee

8. EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on this Policy’s webpage on the Trust website.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

No additional requirements have been identified in relation to this policy.

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8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court

Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate How This Will Be Achieved.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9. LINKS TO ANY ASSOCIATED DOCUMENTS

Risk Management Strategy - Trust Strategies

Access to Health Records –

Information Sharing, Information and Knowledge Management Policies

Disciplinary Procedure – Employment Policies

Procedure for the safe storage and transfer of service user identifiable data – Information and Knowledge Management Policies

Policy for the provision of, access to and use of interpreters – Clinical Policies

Policy for the Management of Serious Untoward Incidents - General Policies

Policy for Health Record Keeping Standards and Health Records Management – Clinical Policies

Supporting staff who are involved in a claim, complaint, or incident – Employment Policies

Claims Handling Policy for the Management of clinical negligence claim, employer/public liability claims and property expenses schemes claim, General Policies

Being open: communicating openly and honestly with service users and their carers following a patient safety incident or related complaint or claim, General Policies

Patient Advice and Liaison Service (PALS) Policy (Raising Concerns), General Policies

Safeguarding Adults Policy, Clinical Policies

10. REFERENCES

Care Quality Commission (2010), Essential Standard of Quality and Safety Department of Health (1996), Complaints: Listening, acting, improving – Guidance on implementation of the NHS complaints procedure.

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Department of Health (2004), Guidance to support implementation of the National Health Service complaints regulations Department of Health (1994), The Wilson Committee report “Being Heard” Department of Health (2007), Making Experiences Count Health Service Ombudsman (2008), Principles of Good Complaints Handling NHS Resolution (2010), NHSR Risk Management Standards Monitor Compliance Framework Right Honourable Ann Clwyd MP and Professor Tricia Hart (2013), A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture Robert Francis QC (2013), the Report if the Mid Staffordshire NHS Foundation Trust Public Enquiry Mental Health Act 1983; (2015), Code of Practice

11. APPENDICES

Appendix Ai Complaints Flow Chart

Appendix Aii Role of Lead Investigator

Appendix Aiii Standard Operating Procedure: Complaints relating to medical staff

Appendix Bi Contact Preferences Form

Appendix Bii Diversity Monitoring Form

Appendix Ci Rotherham and Doncaster Protocol for Handling NHS/ Social Services Inter- agency Complaints

Appendix Cii Protocol for the handling of complaints/concerns/compliments that involve more than one organisation (Humber MEC Network)

Appendix D NPSA Risk Matrix

Appendix E Guidelines for writing a Statement /report of event

Appendix F Guidelines for writing a letter of apology to a complainant

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Appendix Ai

Rotherham Doncaster and South Humber NHS Foundation Trust COMPLAINTS PROCESS FLOW CHART

No

Yes

Yes

No

No, formal

Yes, PALS

Complaint received into RDASH (whether in Care Group or in Chief Exec Office)

Inform and forward the complaint to Patient Safety and Investigation (PSI) Team or (PSI Team Secretary (TS) on the same day or the next working day

PSI Team to assess if complaint may be managed as PALS

PALS contact complainant to agree with complainant if they would like it to be PALS. If PALS, to be completed wherever possible within 10 working days.

o TS to draw up acknowledgment letter, to be signed by CE, include contact preferences form, diversity form, and consent form where appropriate. (3 working days from receipt of complaint in RDASH).

o Signed letter and enclosures to be sent from CE office o TS to inform PSI Team of complaint o PSI Team to risk assess the complaint, consider whether subject matter

requires forwarding to Head of Patient Safety for consideration as a Serious Incident (SI) and consider the timescale required for r response.

o PSI Team to allocate a lead Investigator (LI) o o o o TS to email LI with complaint and deadline for draft response to be sent to CD,

cc to CD/MD/SD and Clinical Director (CD) for info o

Complainant happy for it to be PALS

End of complaint. Close file on Safeguard.

o LI informs the complainant of the named LI within 7 working

days and undertakes investigation. LI to share letter with staff concerned. LI obtains statements from staff concerned. LI may also contact complainant to clarify further issues.

o Meetings may also take place with the complainant – this will affect the response date agreed with the complainant.

o LI will monitor return of responses and chase where appropriate.

o When the LI is satisfied the investigation is complete a response should be drafted and sent to the Head of PSI Team, CM/MD within the specified number of working days.

o Action Plan to be developed within service area o All staff statements and IO investigation notes must be saved-

master file in case of request by the PHSO.

See Role of LI: Appendix

Aii

See note below re complaints involving both RDASH and other agencies

o The Head of Patient Safety, CM/MD : o Quality checks the draft response. o Liaises with LI for additional information/clarification if

required o Gain approval of final response from LI

Continued next page

Complaints involving BOTH RDASH and other agencies The receiving agency will discuss with the other agencies who will take the lead on responding to the complaint in order that the complainant only receives one response. If, for whatever reason, it is decided to send separate responses, the complainant must be

informed of this.

PALS to liaise with relevant services.

Complaint resolved

TS to:- o scan in letter o email copy to Chief Exec (CE) (if not received in CE

office) o email copy to Care Group Director/Medical Director

(CD/MD) o log complaint onto Safeguard

See Medical Complaint

SOP: Appendix Aiii

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o The TS will be responsible for ensuring the letter is signed by the CE.

o Letter to CE by specified number of working days. o Final response signed by CE and sent to complainant within

agreed number of working days of initial receipt of complaint (or agreed timescale), inc PHSO leaflet

o Copy of final response sent to CD/MD and LI for sharing with staff as appropriate. .

o Close file on Safeguard. o Update Safeguard with outcome and risk rating, and action taken,

when action plan received.

Yes No

Patient may write to Parliamentary Health Services Ombudsman

END

Complainant satisfied?

From previous page

LI will undertake further investigation as appropriate and further letter will be sent to complainant.

Yes

No

Complainant satisfied?

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Appendix Aii

Rotherham Doncaster and South Humber NHS Foundation Trust

Role of Lead Investigator

Contact Service Area Manager and all staff involved in complaint.

Ensure consent requested/obtained if required

Review relevant clinical records (SystmOne/Silverlink)

Request statements from staff involved, providing copy of complaint letter for them to respond to (See Appendix E for guidelines on writing statements).

Collect in all statements

If statements are not obtained send two reminders with return dates. If statements not received send final reminder and escalate to Head of Patient Safety

Arrange interviews if required.

Advice the staff member of the right to be supported via a colleague or union representative if required

Following interview send interview notes for confirmation of key notes of discussion

Update Safeguard ongoing

Respond to the complaint within the timescales identified at the start of the complaint. If this is not possible the Lead Investigator to inform the complainant (verbally or via letter) explaining the reasons why the deadline cannot be met.

Meetings with complainants Meetings with complainants may take place at the onset of the investigation or at any time during or after the investigation. Meeting with complainants will usually affect the timescales within which the complaint can be responded to and the Lead Investigator will discuss this with the complainant. The Lead Investigator/Team Secretary will update the response time as required to reflect revised timescales. If the complainant wishes to meet to discuss the complaint, the Lead Investigator will be responsible for organising the meeting, arranging for additional support (advocacy) or note taker and lead the discussion responding to any concerns raised. The Lead Investigator will be responsible for agreeing the communication process with the complainant (electronically/ letter) to confirm clarity of discussion held following which two copies of the interview notes will be sent to the complainant to sign, date and return. At the end of the investigation the Lead Investigator will:

Write full draft response to complaint based on interviews, statements and a review of relevant clinical records including actions taken as a result of the complaint

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Arrange completion of action plan with Clinical Team Leaders/Service Area Manager

Send original complaint, draft response and completed action plan via email to Care Group Director/Medical Director/Head of Service/Service Area Manager/ Head of Patient Safety and Deputy Director of Nursing and Quality for feedback with two weeks

If feedback is not obtained send a reminder with a one week return date. If feedback not received send final reminder and escalate to Head of Patient Safety

Amend response letter if required following review

Send final response to PSI Team Secretary who will send to complainant via CE office

Update safeguard, scan all documentation onto the K drive and archive documentation in line with policy guidelines

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Appendix Aiii

Standard Operating Procedure: Complaints relating to medical staff

1. All letters of complaint are emailed to the Medical Director, by the Patient Safety and Investigation Team Secretary; cc Medical Directorate Manager, within 3 working days of receipt within the Patient Safety and Investigation Team.

2. The Medical Director will assess if there has been any medical involvement which relates to the complaint and advise the Patient Safety and Investigation Team within 10 working days.

3. Where there has been medical involvement, the Medical Director will nominate a medical investigating officer.

4. The Patient Safety and Investigation Team Secretary will email the Lead Investigator the complaint letter, draft response letter template, and action plan template and advise the Lead Investigator, when a draft response is required by. The lead Investigator will also be informed that staff statement must also be returned with the draft response and action plan. This will be copied in to the Care Group Director for information.

5. On completion of the complaint, the Patient Safety and Investigation Team Secretary will email the final response letter to the lead Investigator. The Patient Safety and Investigation Team Secretary will chase for the action plan and/or statements if these have not yet been received.

6. On completion of the complaint, the Patient Safety and Investigation Team Secretary will email the final response letter to Medical Directorate Manager for use at doctor annual appraisals.

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Appendix Bi Contact Preferences to discuss complaint Ref: IN CONFIDENCE TO: Patient Safety and Investigation Team Rotherham Doncaster and South Humber NHS Foundation Trust PLEASE RETURN IN THE ENCLOSED PRE-PAID ENVELOPE I would like to arrange a meeting to discuss my complaint in person Yes No

How I would like to be contacted: (Please enter the relevant details for your preferred option): 1 By post to my home address (tick if this option is preferred) 2 By telephone - my telephone number is:

The best days/ times to contact me are: 3 By email – my email address is:

4 Via an advocate, e.g. Healthwatch, Cloverleaf - we could contact your advocate and make any arrangements to speak to you through them if you wish. Please provide details.

5 We expect to have a response to you within 25 – 60 working days Intended Outcomes What I would like to see happen as a result of making this complaint is: Signed: Date: Name: If you wish to make any other comments please add them overleaf.

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Appendix Bii

DIVERSITY MONITORING FORM As an NHS Organisation we are required to collect the following details.

This information is collected to fulfil that obligation and is used for monitoring purposes only. You are not obliged to answer any or all of

the questions.

Age

Under 20 30 - 34 45 - 49 60 - 64 20 - 24 35 - 39 50 - 54 65 - 69 25 - 29 40 - 44 55 - 59 70+

Race relations (Amendment) Act 2000

Ethnic origin

White British Irish Irish traveller Traveller/Gypsy/ Romany Any other white background

Black or Black British

African Caribbean Any other Black background

Asian or Asian British Bangladeshi Indian Pakistani Chinese Any other Asian background

Mixed

White & Asian White & Black African White & Black Caribbean Any other White background

Other Ethnic Group Arab Any other ethnic group

Equality Regulations

Gender Sexual Orientation

Male Female Heterosexual Lesbian Gay Bisexual

Religion or belief

No Religion Christian (including Church of England, Catholic, Protestant and all other denominations)

Sikhism Judaism Hinduism Jainism

Buddhism Islam Other – please state I do not wish to disclose

The Equality Act 2010

The Equality Act (2010) sets out the following definition of a person with a disability: ‘A person has a disability if they have a physical or mental impairment which has a long term and substantial adverse effect on their ability to carry out day to day activities.’

Do you consider yourself disabled under The Equalities Act 2010?

Yes No

Not sure

Thank you for completing this form. Please return in the pre-paid

envelope enclosed.

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Appendix Ci

HOW JOINT COMPLAINTS ARE HANDLED BETWEEN ORGANISATIONS

ROTHERHAM DONCASTER AND SOUTH HUMBER PROTOCOL FOR HANDLING NHS/SOCIAL SERVICES INTER-AGENCY COMPLAINTS

Introduction This protocol has been developed by representatives from the agencies mentioned below. This initial version will apply to Rotherham and Doncaster, and may be extended to the whole of South Yorkshire at a later date. 1. Aim To provide a framework for dealing with complaints involving more than one of the participating agencies and, where possible, to result in a single reply 2. Agencies Rotherham Doncaster and South Humber NHS Foundation Trust Doncaster and Bassetlaw Hospitals NHS Foundation Trust Doncaster Metropolitan Borough Council Rotherham NHS Foundation Trust Rotherham Metropolitan Borough Council Yorkshire Ambulance Service NHS Trust 3. Background Recent guidance [SI 2006 No. 2084 Supporting Staff, Improving Services – Guidance supports the implementation of the NHS (Complaints) Amendment Regulations 2006], and emphasises the need for joint working/coordinated handling, to facilitate effective complaints handling, between health and social care organisations. This inter-agency protocol has therefore been developed for handling complaints, which cross boundaries between the responsibilities of both health and social services. 4. Framework 4.1 Complaints will be acknowledged by the receiving agency within two working days. 4.2 The receiving agency will, as soon as possible, but within five working days of

receiving the complaint:

Clarify the complaint;

Check the authorisation of the complainant;

Seek the written consent of the patient or their representative to allow the receiving agency to send a copy of the complaint to other agencies involved. Confidential information should not be shared without such consent (please see Appendix I). If written consent is not possible, verbal consent should be recorded and a copy sent to the complainant;

Offer a single reply, on behalf of all the agencies involved, from the agency against whom the bulk of the complaint has been made (lead agency); however, if the complainant chooses and/or in extreme circumstances, where this is not possible, a

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separate response should be sent from all the agencies involved in the complaint, with the receiving agency monitoring the process of each response.

4.3 Upon receipt of the patient or their representative’s consent, a copy of the complaint

letter and the receiving agency’s responses will be sent immediately, but in any event no later than within 48 hours, to the other agencies involved in the complaint. This may be via safe haven fax initially.

4.4 The lead will be taken by agreement between the respective complaints managers

but will usually be the agency against whom the bulk of the complaint is made. Irrespective of lead responsibility, however, each body retains its duty of care to the complainant and must handle its part of the complaint in accordance with its own regulated procedures. Where agreement to identify the lead is not possible, the relevant Directors should seek to reach agreement. The responsibilities of the lead agency are detailed at paragraph 5.

4.5 If the complainant does not want the complaint forwarded to other involved agencies,

the receiving agency will inform the complainant of a named person, address and telephone number for each part of the complaint should he/she wish to pursue it. The respective agencies will then investigate the complaint via their respective complaints procedures.

4.6 If the complainant does want a coordinated response:

The lead agency will obtain responses from all the organisations involved and prepare a final response to the complainant;

The complaints managers for each agency will coordinate any requests for responses or information to the lead agency, ensuring that agreed deadlines are met;

The local authority will deal with its part of the complaint under the Social Services Regulations and cooperate with the NHS body that received the complaint with the aim of providing a coordinated response and resolving the entire complaint;

The agencies should consider a joint meeting with the complainant, if this will facilitate a more effective outcome. Joint conciliation may be considered;

The complainant must be kept informed of any delays. If difficulties arise with meeting the relevant timescales, the complainant should be consulted at the earliest opportunity and agreement sought in writing, or, if not possible, verbal agreement should be recorded, to any extension of the timescales;

The final reply must identify which issues relate to which agency, state the complainant’s right to refer the matter to a named regulatory body should they wish to pursue the complaint further and be approved by the other agencies involved before being sent;

The Chief Executive of the lead NHS agency, or the responsible manager of the local authority, must sign the response;

Should the second stage of the NHS/Social Services complaints procedure be requested, the agencies will liaise and separate if necessary, keeping the complainant informed.

5. Summary of responsibilities of the lead agency

Identify the responsible agency for each aspect of the complaint;

Consider whether a single response on behalf of involved agencies would be feasible;

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Discuss and agree methods of effective communication between the respective complaints managers throughout the process;

Agree timescales with the complainant and other agencies. Joint handling of a case should not affect the need to meet statutory deadlines for providing a response to the complainant, and both agencies should seek to avoid any unnecessary delay. If difficulties arise with meeting the timescale, the complainant should be consulted at the earliest opportunity, and agreement sought in writing regarding how to proceed;

Keep the complainant updated on action being taken;

Answer any queries during the process;

Ensure a coordinated and comprehensive response is received by the complainant following investigation(s);

Identify any learning points that arise from the complaint and how these might be shared between the complainant and the other agencies.

6. Compliance

There is an expectation that the organisations/agencies highlighted in point 2 of this document will comply with the agreed protocol, and/or national directives.

7. Review of protocol

The respective Complaints Managers will review this protocol every twelve months. 8. Chief Executive Sign-off (individual respective organisations)

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

How joint complaints are handled between organisations

Inter-Agency Complaints Procedure

Complaint made To agency

Agree lead and identify responsibility for each aspect of complaint

Obtain consent* to share complaint with other agencies

(See Appendix I-attached)

Share complaint with other agencies

Consent Obtained

Advise complainant unable to respond to all aspects of

the complaint

Agree if response will be joint or separate

All agencies to investigate within timescales

Respond to complainant within agreed timescale

(refer to individual complaint plan)

*To be requested within five days of receiving complaint

No

Yes

Investigate aspects of complaint within restrictions

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COMPLAINT REF NO. (Joint agencies consent form) Statement of consent for the disclosure of personal records Complainant’s name: ______________________________________________ Complainant’s address: ______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

Telephone number: _____________________________________ I hereby give my consent for the organisations listed below to share any relevant information in order to complete the investigation into my complaint. I understand that this is likely to include disclosure of my personal records. __________________________________________ (Lead organisation) __________________________________________ (Organisation) __________________________________________ (Organisation) This will assist the investigation of my joint organisation complaint, which is being coordinated by: __________________________________________ (Name of Complaints Manager) Of __________________________________________ (Organisation) The reason for, and the implications of this, have been explained to me by the above-named Complaints Manager. I understand that information exchanged as agreed by me must be used solely for the purpose of investigating the complaint. Signed: ____________________________________________________________ Date: ____________________________________________________________ Once completed, please return this consent form in the freepost envelope provided.

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Appendix C (ii) Protocol for Handling NHS/Social Services Inter-Agency Complaints (North and North East

Lincs)

Protocol for the handling of complaints/comments/concerns/compliments that involve more than one organisation

Humber Making Experience Count (MEC) Group 1. Introduction

This protocol applies to feedback (complaints, comments, concerns & compliments) that require co-ordinated handling across organisations. It is approved of and agreed to by the organisations named below. The protocol is to be used by these organisations to address all issues falling under the Making Experiences Count procedure that involve two or more of them. (See appendix 1 for definitions)

The provision of health and social care services is an increasingly complex arrangement of interagency responsibility. Service users, their carers, friends and relatives cannot be expected to have a detailed understanding of these relative responsibilities and should not have to navigate their way through them in order to have their feedback addressed. This protocol is intended to ensure that any feedback about a jointly provided service or that involves services provided by more than one organisation is dealt with seamlessly, promptly and clearly through a single co-ordinated process. Complainants will be given the advice and assistance they need to make the experience as straightforward as it can be. The protocol aims to promote open and honest communication with service users and their carers as soon as possible following an incident and will follow the principles identified in each NHS organisation’s ‘Being Open’ policies and procedures. It also should enable a fair, rapid, open and sensitive response to feedback that respects people’s human rights and diversity. This protocol will require:

openness and co-operation between agencies at each stage of the process

a designated lead and contact for the complainant

clarity about the way in which each issue will be addressed

single response and

shared learning

3.1 Receiving the complaint

Feedback can be made verbally/in person or in writing at any organisation. Front line staff should be aware that they can take issues relating to other organisations and that representatives (see appendix) should not be asked to make their feedback in another form or at another place.

2. Principles

3. Process

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Any feedback that involves more than one organisation should be passed to the person within the organisation designated to deal with these issues (referred to in this document as the complaints manager, see appendix)

The ‘Head of Patient Safety will be responsible for co-ordination of the complaint along with their counterpart in the other organisation(s).

The representative should be made aware of any relevant advocacy service 3.2 Establishing the Lead

For each feedback it will be necessary to establish the lead organisation. The complaints manager for the lead organisation will take responsibility for managing the feedback handling, providing the response and keeping the representative informed. The lead organisation will be that which:

is responsible for an integrated service

Has responsibility for the majority of issues in the feedback.

Is accountable for the most significant issues.

The representative requests.

Received the feedback, should the issues be evenly divided.

Is determined by the respective complaints managers.

In addition the representative’s wishes can be considered. If feedback is received by one organisation, which they have no authority to investigate, the complaints manager will contact the representative within 2 working days and advise them that the feedback will have to be forwarded to the relevant organisation and seeking their consent for this. 3.3 Grading A feature of the making experiences count process is the initial impact/risk assessment. This assessment looks at the potential significance of the issues raised by the feedback. It begins to determine the means by which the feedback will be addressed by allocating a grading. This process of grading the feedback cannot be carried out by one organisation on behalf of another and therefore must be conducted by each of the organisations concerned in co-operation. It will be the responsibility of the lead organisation to co-ordinate the process but each organisation is accountable for the grading of issues relating to its own services. Where it is necessary to contact the representative for the purpose of grading the complaint agreement will be reached between complaints’ managers about how this is best done to avoid repeated contact. 3.4 Planning for Resolution

Clarity will be agreed for addressing the issues raised. This will:

set out each element of the feedback

state how each element will be addressed & by whom

establish timescales

record the preference for method of contact e.g. in person, in writing

Agree advocacy involvement where appropriate

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Establish the relevant consents (consent should be sought only once & should apply to all organisations involved)

In addition clear agreement should be reached about the process of adjudication, arrangements for the response & organisational sign off. It is the responsibility of the complaints manager in each organisation to ensure that the necessary people, records, procedures etc. are available to the complaint investigator, without separate requests having to be made, and check that appropriate consent/s have been received. 4. Response

It should always be the aim to have a single response to inter-organisation feedback. In some circumstances this may not be possible, for example if one issue is going to take significantly longer to deal with than others. Representatives should always be advised of this as soon as possible. If the feedback requires adjudication/management meeting again this should be a joint process to facilitate the single response. If adjudication cannot be held jointly they should take place within a timescale that would not prolong the response. The appropriate managers in each organisation must agree/sign off the responses before they are sent. 5. Findings

If there has been no formal adjudication then the lead manager should seek to identify, with the officer/s who handled the feedback, whether there are any identified learning issues/actions. The manager will forward to the relevant organisation. Learning from feedback is a vital feature of the process and inter-organisation feedback handling offers an opportunity for organisations to learn from each other. The process of adjudication should ensure that issues requiring action/service improvements are identified. If the lead complaints manager is involved in the adjudication process they should ensure that any learning points/identified actions are forwarded to their counterpart in the relevant organisation. The lead complaint manager will follow up with user feedback/satisfaction surveys to the representative. 6. Consent to Information Sharing

In order to deal with feedback effectively it will be necessary for organisations to make information that they hold on individual service users/patients available to investigators from other organisations. Similarly they will be required to give access to internal policies/procedures. In respect of personal information this must be handled in line with the principles of the Data Protection Act, Caldicott and any confidentiality policies the respective organisations may have. Investigators should also be aware of their responsibilities in respect of confidentiality. Consent to share information must be sought from the representative and, if different, from the service user/patient. If the service user/patient is deemed not to have capacity in this respect then consent can be sought from their representative. (See appendix)

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Wherever possible consent should be given in writing, if this is not possible consent should be recorded carefully on file. Consent should be sought only once for each investigation and should apply to each organisation involved If consent is not given to share information then it should be explained to the representative that they can i) take the issues direct to the organisation concerned ii) pursue their issues through the joint route but with the understanding that the investigation will be compromised through lack of access to information iii) withdraw feedback that cannot be effectively looked into without access to some records. Once consent to access to information is given organisations should make every effort to ensure the requested information is readily available to the investigation. This includes verbal information from the staff of the organisation. Information that is made available to the investigation of a complaint must only be used for the purpose for which it was obtained. Only information that is relevant to the feedback and its investigation should be shared.

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Appendix 1 DEFINITIONS Being Open – National Patient Safety Agency initiated policy for NHS organisations to communicate openly and honestly with service users and their carers following a patient safety incident or related complaint or concern. Head of Patient Safety – Person within the organisation designated to deal with complaints under regulation 4(1), (b). Feedback – Complaints, comments, concerns & compliments that require action and a response. Representative – person making the complaint, comment, concern or compliment. It may be the service user or someone acting on their behalf. Service user representative/person acting on behalf of the service user – person defined in regulations 5(2), 5(3) Regulations - The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 Guidance on Duty of Candour Organisations – Where a complaint is received which relates to two or more organisations, the organisations will, wherever possible, co-ordinate the handling of the complaint and ensure that the complainant receives a co-ordinated response to the complaint.

Serious Incidents/Claims/Coroners Court Hearings If the subject matter of the complaint is also being considered as a Serious Incident/claim/Coroners Court hearing, each organisation should refer to their own policy and procedure for the handling of formal complaints.

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Appendix D NPSA Risk Matrix

Table 1 Consequence scores

Choose the most appropriate domain for the identified risk from the left hand side of the table. Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column.

Consequence score (severity levels) and examples of descriptors

1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Impact on the safety of patients, staff or public (physical/ psychological harm)

Minimal injury requiring no/minimal intervention or treatment. No time off work

Minor injury or illness, requiring minor intervention Requiring time off work for >3 days Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident An event which impacts on a small number of patients

Major injury leading to long-term incapacity/disability Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects

Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients

Complaints Criteria

Simple, non-complex issues Delayed or cancelled appointments Single failure to meet care needs (e.g. missed call-back bell)

Several issues relating to a short period of care Event results in moderate harm (e.g. fracture) Delayed discharge

Failure to meet care needs Incorrect treatment

Multiple issues relating to a longer period of care, often involving more than one organization or individual Event resulting in serious harm Medical errors

Multiple issues relating to serious failures, causing serious harm Events resulting in serious harm or death Gross professional misconduct

Table 2 Likelihood score (L) What is the likelihood of the consequence occurring?

The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used, whenever it is possible to identify a frequency.

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Likelihood score

1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost certain

Frequency How often might it/does it happen

This will probably never happen/recur

Do not expect it to happen/recur but it is possible it may do so

Might happen or recur occasionally

Will probably happen/recur but it is not a persisting issue

Will undoubtedly happen/recur, possibly frequently

Note: the above table can be tailored to meet the needs of the individual organisation. Some organisations may want to use probability for scoring likelihood, especially for specific areas of risk which are time limited. For a detailed discussion about frequency and probability see the guidance notes.

Table 3 Risk scoring = consequence x likelihood (C x L)

Likelihood

Likelihood score

1 2 3 4 5

Rare Unlikely Possible Likely Almost certain

5 Catastrophic

5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

Note: the above table can to be adapted to meet the needs of the individual trust. For grading risk, the scores obtained from the risk matrix are assigned grades as follows

1 - 3 Low risk 4 - 6 Moderate risk

8 - 12 High risk 15 - 25 Extreme risk

Instructions for use

1 Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk.

2 Use table 1 above to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated.

3 Use table 2 above to determine the likelihood score(s) (L) for those adverse outcomes.

4 Calculate the risk score by multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score)

5 Include the risk in the Trust/Directorate risk register as appropriate.

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Appendix E GUIDELINES FOR WRITING A STATEMENT/REPORT OF EVENT Staff who have been involved in an event which results in a complaint, may be asked to write a statement in order that facts about events are made clear. The following is intended as practical guidance for anyone asked to write a factual statement: Essential details to be included: (Write in black ink or 12 point Ariel typescript on A4 paper)

Name of person (in block capitals) making statement, position, grade and area of work

Date and time of event/incident

Full name of any other individuals involved, i.e. patient, visitor and other staff members, (or any person in the vicinity at the time)

Detailed account of events and time that they occurred

Signature

Date of making statement Detail a factual account of your personal involvement. How, why and when were you involved? All detail should be in chronological (date/time) order. Refer to any records made. Are there any inconsistencies between the records in question and the content of your statement? Identify other people involved. Only record information involving others, that you saw and/or heard personally. Comment on each point in the complaint regarding your own involvement. State the facts and avoid opinions. Always attach any supporting documentation. If you require assistance, seek advice from your staff side organisation, or if you deem it to be appropriate, your immediate line manager. If you keep a copy of your statement, please ensure that you respect guidelines (Caldicott) regarding the use/retention of confidential patient information.

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Appendix F

Guidelines for writing a letter of apology to a complainant Occasionally, staff who have been involved in a complaint and are named in the complaint may be asked to write a letter of apology to the complainant. It is sometimes appropriate to do so and can help to reach a resolution with the complainant. When such letters have been written previously, they have been recognised by the Parliamentary and Health Services Ombudsman as not only good practice, but over and above what they would expect from a Trust. The following is intended as a practical guidance for anyone asked to write such a letter and for their manager. Whilst these may all seem obvious, they can be easy to overlook when you may be feeling anxious about writing such a letter. Guidelines for staff writing the letter: Remember that saying sorry is not an admission of liability but an expression of your empathy with the recipient. You may feel that you have done nothing wrong; you may in fact have done everything to the best of your ability and according to policy and procedures. Nevertheless, something in your actions or behaviour has caused this person distress, anxiety, or added to their bereavement, for example. Consider how you would feel if your roles had been reversed. 1. It is better to hand write the letter as it will then come across as more personal. 2. Think carefully about your response and you may wish to write out a draft version first. 3. Try to write as neatly as possible, but do not worry if your handwriting is not perfect. 4. Consider if you were the one receiving the letter:-

How would it come across?

Would it sound defensive?

Would it sound sincere? 5. Make sure that you include the “niceties” of letter writing, i.e. address it to “Dear Mrs

Smith” for example and sign off “Yours sincerely”. 6. Check your spelling. In particular, check that you have spelled the recipient’s name

correctly. 7. Check the grammar of the letter. 8. Spelling and grammar may not seem important, but errors in these will make the letter

seem rushed and therefore insincere. 9. Make sure that you date and sign the letter. 10. You may wish to ask a friend or colleague to read your letter to give you a constructive

view on how it reads. 11. Check the letter with your manager. 12. If you feel it is appropriate or necessary, you can seek advice from your staff side

organisation. 13. If you keep a copy of the letter, please ensure that you respect Caldicott and Data

Protection guidelines regarding the use and retention of confidential patient information. Guidelines for managers of staff writing the letter:

Support the staff member in writing the letter. They may be wary of any repercussions of writing a letter of apology or unsure as to how to word the letter.

Check through points 4 – 9 above.

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Appendix G

Ref:

Complaints Evaluation Form

Recently you had reason to complain about NHS services. We would appreciate your

valuable feedback to help us improve our customer care. Please return this form to us in

the enclosed freepost envelope. However, if you do not wish to respond, we would like to

apologise for troubling you. 1. Did you receive enough information about how to make a complaint?

Yes No

2. Did we provide a clear and understandable response? Yes No 3. Did we provide a response within a reasonable time? Yes No

4. Was your contact with the person coordinating your complaint

i.e. by telephone or face to face meeting helpful? Yes No 5. Did you feel that we helped to resolve your concerns and that they

were treated seriously? Yes No 6. Did you understand what to do next if you were not happy with your

response? Yes No If you have said “no” to any of these questions, would you like to make a further comment?

7. Were you worried that your care or treatment would be affected by making a

complaint? Yes No 8. Overall, how do you feel your complaint was handled?

Very Well Well Average Poor Very poor

If you require this form in another language or in larger print, please contact the Patient Experience

Team on 01302 796305.

Thank you for taking the time to complete this form.

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