glasgow city chp item no. 12library.nhsggc.org.uk/mediaassets/chp glasgow/paper... · 2 14 3 0. 19...

Glasgow City CHP Item No. 12 CHP Committee Meeting Date: Tuesday 17th February 2014 Paper No 2015/007 Subject: CHP Complaints 2014/15 – Quarter 3 Presented by: John Dearden, Head of Administration Recommendation(s)

1. To receive information on formal complaints and feedback, comments and concerns received during the period 1st October to 31st December 2014 (Quarter 3), including data on compliance with the target of responding to 70% of complaints within 20 working days of receipt.

2. To receive information on SPSO investigations completed and reported in the last quarter and action plans prepared in response.

3. To review the lessons identified from complaints completed in the last quarter.

4. To comment on any issues arising from this report. Summary/ Background

The Patient Rights (Scotland) Act 2011 introduced an extension of the legal right of patients to complain, give feedback or comments, or raise concerns about the care they have received from the NHS. It placed a responsibility on the NHS to encourage, monitor, take action and share learning from the views received. This has required revision to the Board Complaints Policy and the CHP Complaints Operational Procedure.

Policy/ Legislative Context

Patient Rights (Scotland) Act 2011 Board Complaints Policy CHP Complaints Operational Procedure

Financial Implications None specific. Human Resources Implications

Requires additional collation of information and its analysis to show how we learn from complaints and more general feedback comments and concerns.

Service User/Carer Engagement

The Policy and Procedures adopted are about how we listen to all users and change systems based on learning from formal complaints and other forms of feedback.

Equalities Implications

Currently we do not collect information on the equality aspects of complaints. A previous Scottish Government initiative to collate such information was abandoned due to the poor response rates.

Partnership Working In processing complaints we work with the Patient Advice and Support

Service and a variety of Advocacy Services. The NHS also has access to a Conciliation and Mediation Services funded by the Scottish Government.

FoI/EIR Status tick If not to be made public, exemption (Section/Regulation) to be relied on under FoI/EIR legislation must be inserted below.

Public

Not Public

Contains Personal Data – DPA applies

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27th January 2015 Introduction 1. This report is presented to the CHP Committee as part of a programme of quarterly reporting

on complaints, feedback, comments and concerns. The intention is that the information collated will be shared with local management teams and clinical governance structures to aid in achieving service improvement. Information as presented will also be incorporated into the quarterly report on Complaints made to the Health Board. Additionally the Board’s Q&P Committee are now seeking more information on complaints processing and outcome, particularly in relation to the lessons learned from complaints and Ombudsman Reports.

Complaints Received 2.

During the period 1st October to 31st December 2014 a total of 504 complaints were received as compared with 542 in the previous quarter. Prison healthcare saw a decrease of 9% while sectors saw an increase of 14% against the previous quarter. Of the 504, a total of 452 related to the three prison health care centres at Barlinnie (299), Low Moss (123) and Greenock (30). Of the 452 prison complaints, there were 74 instances where individuals submitted multiple complaints during the quarter. There were 57 instances of two complaints per individual. In one case an individual submitted 8 complaints. Additionally a breakdown of complaints received during the quarter is set out in Table 1. Table 1 – Complaints Received Sector No of Complaints

received Glasgow City – Specialist Services (Forensic and Learning Disability) 1 Police Custody Healthcare 0 Prison Healthcare – Barlinnie 299 Prison Healthcare – Greenock 30 Prison Healthcare – Low Moss 123 Glasgow City – North East Sector 22 Glasgow City – North West Sector 11 Glasgow City – South Sector 18 Total 504

3.

Appendix 1 provides further detail of the Service and Units these complaints relate to together with the trend over the last 12 months.

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4. Within the Board report on complaints it is intended to show for Acute sites and Prisons information on the individual sites where complaints arise. Due to the large number of sites operated by Partnerships, the data presented is split between the following headings, with information included against specific mental health in-patient sites:- Health & Community Care Mental Health Services Specialist Children’s Services Children & Family Services Sexual Health/Sandyford Addiction Services

Completed Complaints 5. The number of formal complaints which were completed within Quarter 3 was 516. This will

include complaints received in previous quarters, but not responded to until Quarter 3. A breakdown of the outcome of these complaints is provided in the table below:

Table 2 – Complaints Completed

6. Thus overall 76% of complaints were not upheld and 21% were partially or fully upheld in the

quarter. A further 3% were withdrawn or otherwise not progressed. 7. An analysis of the service areas where these complaints arose and the outcome is provided

at Appendix 2. The issues raised and the staff group involved are detailed within Appendix 3. Issues raised do not correspond with the number of complaints as more than one issue may be raised in a single complaint.

8. The table below provides detail on the timescales achieved in responding to complaints.

Performance is measured in terms of a normal response within 20 working days, with provision to seek agreement to an extension of this to a total of 40 working days. Where a response is not provided within this timescale the Director has to write with the reasons for delay and giving the complainant the opportunity to await the formal response or to pursue their complaint with the Ombudsman. Where consent to investigate is required, the timescale does not commence until consent has been received.

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Glasgow City Corporate 0 0 0 1 0 0 0 1 Police Custody Healthcare 0 0 0 0 0 0 0 0 HMP Barlinnie 1 26 31 225 5 0 0 288 HMP Greenock 0 4 9 16 2 0 0 31 HMP Low Moss 0 8 6 131 2 0 0 147 North East Sector 1 3 9 6 0 0 0 19 North West Sector 1 3 0 4 1 0 0 9 South Sector 0 6 5 9 1 0 0 21 Total 3 50 60 392 11 0 0 516 % of total (rounded) 1% 10% 11% 76% 2% - -

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Table 3 – Complaints Response Times in Quarter 3

Within 3 working

days

4 to 20 working

days

21 to 40 working

days

Over 40 working

days Total

% of total within 20 working

days Glasgow City Corporate 0 1 0 0 1 100% Police Custody Healthcare 0 0 0 0 0 - HMP Barlinnie 244 35 9 0 288 97% HMP Greenock 25 6 0 0 31 100% HMP Low Moss 54 70 22 1 147 84% North East Sector 2 14 3 0 19 84% North West Sector 0 8 1 0 9 84% South Sector 0 19 1 1 21 90% Total 325 153 36 2 516 93%

9. From table 3 above it will be noted that in 325 cases (63%) resolution was achieved within 3

working days – all but two were prison healthcare complaints. A total of 478 complaints received a response within 20 working days (93%), while in 38 cases the 20 working day timescale for responding was exceeded (7%). This represents an improvement in response times from all Sectors but a decline from HMP Low Moss as compared with the previous quarter. The Board seeks to achieve a target of 70% of all complaints receiving a response within 20 working days. This target is being exceeded this quarter in all services.

Feedback, Comments and Concerns 10. The Patient Rights (Scotland) Act 2011 introduced an extension of the legal right of patients

to complain, give feedback or comments, or raise concerns about the care they have received from the NHS. It placed a responsibility on the NHS to encourage, monitor, take action and share learning from the views received and the concerns expressed about the care they have received from the NHS.

11. Since October 2012 informal feedback has been recorded onto the DATIX system (this is

described as feedback, comments or concerns) and for Quarter 3, there were 219 forms of feedback (including comments and concerns), the majority of which came from Prison Health Care Services and Sandyford (North West Sector). A summary appears below in Table 4.

Table 4 – Feedback, Comments and Concerns

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Glasgow City CHP - Corporate 0 0 0 0 0 HMP Barlinnie 0 0 116 0 116 HMP Greenock 0 0 5 0 5 HMP Low Moss 0 0 63 0 63 Glasgow City CHP - North East Sector 0 2 1 0 3 Glasgow City CHP - North West Sector 0 0 20 6 26 Glasgow City CHP - South Sector 0 1 5 0 6 Totals: 0 3 210 6 219

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12. Of the feedback, comments and concerns received 184 cases related to the prison healthcare service. At Sandyford of the 19 instances of feedback, all were made anonymously. Included in the feedback were 5 positive comments on the service provided and 14 instances of dissatisfaction. Other cases in NW comprised six letters of appreciation.

Lessons Learned 13. The attached Appendix 4 provides details of those service improvements that have been

identified from the completed complaints in the Quarter where the complaint was partially or fully upheld. In some cases no service improvement has been identified. We have emphasised to staff the importance of ensuring that where a complaint is upheld lessons learned are recorded so that these can be shared with colleagues and other clinical teams. In cases where it is indicated “none” this confirms that the investigator has considered this point and identified that there was no specific learning. The extent to which investigators and managers actively review lessons learned from complaints remains variable.

14. Within the Prison healthcare service, the large volume of complaints imposes a significant

burden on staff. In many cases the issues complained about would normally be resolved from discussion with the medical/clinical team involved in care. Within the prison population there is a culture of making complaints to progress issues. From review of prison complaints there are recurring common themes running through complaints and these are often not formally recorded as learning points on Datix. The Prison Healthcare Services have been asked to provide an update on actions being taken in response to recurring themes. That report is reproduced at Appendix 5.

Staff Training 15. NHS NES have developed an e-learning package to assist staff in recognising complaints,

feedback, comments and concerns. This is available on the Board’s Learn Pro e-learning system. A total of 1093 Glasgow City CHP staff have completed the introductory module and 76 all five modules. The full set of modules is being targeted initially at those who have a regular involvement in processing complaints. A further module on complaints investigation will be added to the available modules soon. A recent national survey showed that NHS Greater Glasgow & Clyde achieved the highest take up of this training across all health boards.

Ombudsman Decisions 16. The Ombudsman issues either formal reports, which are laid before Parliament, or decision

letters which are issued to the relevant public sector body. Such decision letters may advise that the authority should comply with recommendations made by the Ombudsman. Formal reports cover those matters of public interest which the Ombudsman considers should receive wide awareness beyond the affected authority.

17. Certain reports or decision letters issued may have an impact on the services provided by

Glasgow City CHP. This Section of the report draws members’ attention to these. Where decisions are made against a General Practitioner it is for the Practice to respond, but through the Sector CDs support may be provided in helping GPs to respond or change systems.

18. There were no formal reports issued in the quarter. 19. The following decision letters were received in the quarter 1st October to 31st December

2014:-

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(a) Complaint against GP Practice (NE Glasgow) xxxx02368 Decision dated 3rd October 2014 – Complaint Upheld The patient’s mother complained that the Practice unreasonably did not register the patient and that the Practice Manager unreasonably did not contact the patient as requested. The patient had missed a new patient appointment with the Practice Nurse. The patient contacted the Practice when she remembered, fifty minutes after the appointment, to be told by the receptionist that she would not be allowed to make another appointment. The Practice responded to the complainant stating the Health Board had recently put in place a new policy for GP Practices, which was stated to be working well for the Practice. The Ombudsman reviewed the legislation and the Practice became clear on their obligations regarding patient registration. The Practice had the right to refuse applications to register on reasonable grounds; the Ombudsman commented that failure to attend a new patient medical appointment was not reasonable grounds. The evidence provided shows the Practice acted unreasonably in this respect. The patient left several telephone messages for the Practice Manager, each time a member of reception staff said the Practice Manager was busy. The patient received the same response when she visited the Practice to speak to the Manager in person. The Practice explained that a breakdown in communication was responsible for the Manager not returning telephone calls. The Ombudsman found that the Practice Manager unreasonably did not contact the patient as requested and therefore upheld both aspects to this complaint. The Ombudsman recommended that the Practice apologise in writing to the patient for their failure to register her as a patient; that the practice offer the patient the opportunity to register with them, if she wishes to do so; and that the Practice provide the Ombudsman with a copy of the Significant Event Analysis and the review of their complaints handling process.

(b) Complaint against GP Practice (NE Glasgow) xxxx03456

Decision dated 6th October 2014 – Decision not to take forward The patient’s son wrote to the Ombudsman to complain that the GP had not diagnosed the patient’s mouth ulcers as potential signs of cancer or treated her appropriately. As the events in question happened outwith the Ombudsman’s time limit, the matters could not be investigated further.

(c) Complaint against Mental Health Services (NE Glasgow) xxxx03090

Decision dated 22nd October 2014 – Decision not to take forward The patient’s wife complained that the Board failed to observe the patient and thus lead to injury. The Ombudsman looked into the patient’s medical records and complaints documentation supplied by the Board, and determined that the Board’s investigation of the issues raised in the complaint was full and robust. The Ombudsman’s Adviser commented that the Board had been open and honest, apologised for the failings and made a number of recommendations and corrective actions. It is noted that the Adviser felt the Board’s actions to be very good practice and demonstrates that lessons were learned. The Ombudsman would have the same information available as the Board and decided nothing further would be gained from further investigation.

(d) Complaint against Prison Healthcare xxxx03434

Decision dated 24th October 2014 – Complaint Upheld A prisoner complained that the Prison Health Centre unreasonably failed to prescribe certain medication. The patient had been prescribed a blood thinning drug (xarelto) for Deep Venous Thrombosis and diazepam for anxiety. On admission to prison, the locum GP requested the patient’s medication to be confirmed by the community GP, this did not happen until 5 days after admission, when xarelto was prescribed. The patient was prescribed citalopram but not diazepam for anxiety. The Ombudsman’s Adviser found an unreasonable delay in prescribing xarelto and the locum doctor should have ensured the prescription was verified and prescribed in a timely manner. The Adviser was concerned that the fax to the community GP was not followed up; in an environment such as a prison with a high rate of movement of prisoners it is essential that all doctors are aware of how to quickly verify a patient’s medication. The Adviser was critical that the on-call doctor refused to deal with the patient’s medication issues, and did not check the electronic system to ensure the patient was not missing essential medication. The Adviser considered it reasonable that diazepam was not

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prescribed as it is not recommended for long term use, and that the citalopram prescription was appropriate for treating anxiety. The Ombudsman concluded there was found to be an unreasonable delay in prescribing the medication and upheld this complaint. The Ombudsman recommended that the Board confirm when the draft medicines reconciliation guidance has been implemented, and that the Board confirm the steps they have taken to ensure all relevant clinicians working for the health centre have knowledge of and access to the ECS. The recommended action has been taken.

(e) Complaint against GP Practice (South Glasgow) xxxx00540

Decision dated 24th October 2014 – Complaint Upheld A representative from a Citizens Advice Bureau complained that the Practice unreasonably failed to properly assess the patient’s symptoms and provide him with further tests in order to determine his increased risk of stroke. When patient attended the Practice with a variety of symptoms the GP requested blood tests and referred the patient to a physiotherapist. The patient contacted the Practice several times with different symptoms, none of which at the time of consultation were suggestive of a stroke. The patient suffered a stroke and was admitted to hospital; the GP completed a Significant Event Analysis. The Ombudsman’s Adviser considered that the GP had made reasonable suggestions and prescribed reasonable treatment based on the patient’s presenting symptoms. The Adviser noted that communication between the three GPs and the patient was not as strong as could have been but the Adviser was reassured to find this noted in the GP’s Significant Event Analysis. The Ombudsman determined the patient was reasonably assessed in view of the symptoms he presented with. This aspect of the complaint was not upheld. The second aspect of this complaint was that the Practice unreasonably advised the patient to attend an appointment at the end of the day, rather that attend hospital immediately, when he told them that he thought he suffered a stroke. The patient spoke to a fourth GP at the Practice regarding arm and leg weakness. The GP saw no record of his arm weakness in previous notes and arranged for the patient to be seen at the Practice later that day. The Adviser made reference to SIGN recommendations that correct procedure for a patient suspected of suffering a stroke was to arrange an immediate emergency ambulance to hospital, he stated that by not doing this the GP was not acting in line with these recommendations. The Adviser stated the GP did not record how long the patient’s arm weakness had been present. The Ombudsman found that the GP’s note taking was not detailed enough to explain why she did not take action in keeping with the SIGN guidelines. The Ombudsman upheld this aspect of the complaint and recommended that the Practice issue a written apology to the patient for inappropriately telling him to attend an appointment later that day, when it was recorded that he had potentially suffered a stroke. That the Practice confirm the fourth GP had been made aware of the decision on the matter. That the Practice confirm that the matter will be discussed at the GP’s next annual appraisal.

(f) Complaint against Dental Practice (NW Glasgow) xxxx04498

Decision dated 19th November 2014 – Decision not to take forward A patient complained that the Dental Practice unreasonably failed to conclude that treatment undertaken was inappropriate, and that the Dentist fitted a porcelain bonded crown rather than a fully porcelain crown as the patient believed was intended. The patient’s current dentist is of the view that root canal treatment carried out was not undertaken properly. The patient complained of this and the former Practice offered to consider this complaint if the patient supplied copies of dental records held by the current Practice and any radiographs. In reviewing this, the Ombudsman cannot investigate complaints until they have been raised with the authority complained of unless it is not reasonable to expect this to have happened. The Ombudsman was of the view that it would have been reasonable for the patient to supply the required information in order that the former Dentist could give a fully considered response. The Ombudsman decided this aspect of the complaint could not be considered further. The former Dentist’s response indicated that her intention was always to fit a porcelain bonded crown and had priced the treatment accordingly. The former Dentist offered to refund the cost of the treatment as a full and final settlement of the complaint. The Ombudsman took account of this and was of the view that there would be no practical outcome to investigating the complaint.

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(g) Complaint against GP Practice (NW Glasgow) xxxx05470

Decision dated 9th December 2014 – Decision not to take forward A patient complained about the attitude of the GP during a consultation. The Ombudsman rarely investigates complaints about the attitude of staff or what was said during consultations as both parties may disagree on their interpretation of events. The Ombudsman acknowledged that the consultation was not deemed to be satisfactory for both parties and that in the absence of a truly independent witness the matter could not be substantiated. Due to this the Ombudsman decided that nothing more would be achieved for the patient than has already been achieved by himself.

20. In summary, during the last quarter to December 2014, there were 7 Ombudsman decisions

involving the CHP or local GP Services. A summary of these decisions is shown in the table below: Service Upheld Not Upheld Not Progressed Dental Services 0 0 1 GP Services 2 0 2 Mental Health Services 0 0 1 Prison Healthcare 1 0 0

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Appendix 1 Complaints Received by Quarter by Service & Sector (This is based on complaints received in relevant Quarter)

13/14 Q4

Jan 14 – Mar 14

14/15 Q1

Apr 14 – Jun 14

14/15 Q2

Jul 14 – Sep 14

14/15 Q3

Oct 14 – Dec 14

Total

Glasgow City CHP - Corporate 411 494 497 453 1403 Health & Community Care (Note 1) 1 0 0 0 1 Police Custody Healthcare 0 0 1 0 1 HMP Barlinnie 233 344 341 299 1217 HMP Greenock 12 34 32 30 112 HMP Low Moss 163 111 122 123 520 Mental Health Services (Note 2) 1 1 1 1 4 Rowanbank Forensic Medium Secure 0 0 0 0 0 Health Improvement 0 0 0 0 0 Other 1 0 0 0 1 Glasgow City CHP - North East Sector 20 18 18 22 56 Children & Family Services 0 0 0 1 1 Health & Community Care 4 2 3 1 10 Specialist Children's Services 4 5 6 2 17 Skye House Adolescent Unit 0 1 0 3 4 Mental Health Services 10 8 7 6 31 Stobhill Hospital 1 1 1 4 7 Parkhead Hospital 1 1 0 2 4 Planning & Health Improvement 0 0 0 0 0 Homelessness Services 0 0 1 3 4 Glasgow City CHP - North West Sector 13 12 12 11 37 Children & Family Services 0 1 0 1 2 Health & Community Care 7 2 4 4 17 Mental Health Services 1 5 2 0 8 Gartnavel Royal Hospital 2 2 2 2 8 Sexual Health/Sandyford 3 2 3 4 12 Human Resources 0 0 1 0 1 Glasgow City CHP - South Sector 10 15 15 18 40 Children & Family Services 0 0 0 0 0 Health & Community Care 3 10 9 8 30 Mental Health Services 3 4 2 6 15 Leverndale Hospital 4 1 4 4 13 Totals: 454 539 542 504 1536

Note 1 – Prison Health Care listed under relevant establishment Note 2 – Covers Forensic Services and Tier 4 Learning Disabilities

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Appendix 2 Outcome of Complaints by Sector/Service Quarter 3

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Glasgow City CHP - Corporate 38 46 373 9 1 0 0 467 Health & Community Care (Note 1) 0 0 0 0 0 0 0 0 Police Custody Healthcare 0 0 0 0 0 0 0 0 HMP Barlinnie 26 31 225 5 1 0 0 288 HMP Greenock 4 9 16 2 0 0 0 31 HMP Low Moss 8 6 131 2 0 0 0 147 Mental Health Services (Note 2) 0 0 1 0 0 0 0 1 Rowanbank Forensic Medium Secure 0 0 0 0 0 0 0 0 Other 0 0 0 0 0 0 0 0 Glasgow City CHP - North East 3 9 6 0 1 0 0 19 Children & Family Services 0 0 0 0 0 0 0 0 Health & Community Care 0 0 0 0 0 0 0 0 Specialist Children's Services 1 1 2 0 0 0 0 4 Skye House Adolescent Unit 1 0 0 0 1 0 0 2 Mental Health Services 0 3 1 0 0 0 0 4 Stobhill Hospital 1 2 0 0 0 0 0 3 Parkhead Hospital 0 2 0 0 0 0 0 2 Planning & Health Improvement 0 0 0 0 0 0 0 0 Homelessness Services 0 1 3 0 0 0 0 4 Glasgow City CHP - North West 3 0 3 1 1 0 0 9 Children & Family Services 0 0 1 0 0 0 0 1 Health & Community Care 0 0 2 1 1 0 0 4 Mental Health Services 0 0 0 0 0 0 0 0 Gartnavel Royal Hospital 0 0 0 0 0 0 0 0 Sexual Health/Sandyford 3 0 0 0 0 0 0 3 Human Resources 0 0 1 0 0 0 0 1 Glasgow City CHP - South Sector 6 5 9 1 0 0 0 21 Children & Family Services 0 0 0 0 0 0 0 0 Health & Community Care 5 3 4 0 0 0 0 12 Mental Health Services 1 1 3 1 0 0 0 6 Leverndale Hospital 0 1 2 0 0 0 0 3 Totals: 50 60 392 11 3 0 0 516

Note 1 – Prison Health Care listed under relevant establishment Note 2 – Covers Forensic Services and Tier 4 Learning Disabilities

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Appendix 3 Issues Raised and Staff Group involved in Completed Complaints Quarter 3 ISSUES RAISED Code

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A - Staff 01 Attitude/behaviour 1 25 13 2 8 49 02 Complaint handling - 4 - - - 4 03 Shortage/availability - - - - 1 1 04 Communication (written) - 2 - 1 - 3 05 Communication (oral) 2 6 1 - - 9 07 Competence 1 1 1 2 1 6 B - Waiting times for 11 Date of admission/attendance - - - - - 0 12 Date for appointment - 139 2 1 1 143 13 Test Results - 7 - - - 7 C -Delays in/at 21 Admissions/transfers/discharge procedure - - - - - 0 22 Out-patient and other clinics - - - - - 0 D - Environmental/domestic 29 Premises - 2 - - - 2 30 Aids/appliances/equipment - 2 - - - 2 32 Catering - - - - - 0 33 Cleanliness/laundry - - - - - 0 34 Patient privacy/dignity - - - - - 0 35 Patient property/expenses - 1 2 - - 3 36 Patient status - - - - - 0 37 Personal records - 2 - - - 2 38 Bed Shortages - - - - - 0 39 Mixed accommodation - - - - - 0 40 Hospital Acquired Infection - - - - - 0 E - Procedural issues 41 Failure to follow agreed procedure - 2 3 - - 5 42 Policy and commercial decisions of NHS Board - - - - - 0 43 NHS Board purchasing - - - - - 0 44 Mortuary/post mortem arrangements - - - - - 0 F - Treatment 51 Clinical treatment - 345 17 3 13 378 52 Consent to treatment - - - - - 0 61 G - Transport - - - - - 0 71 H - Other - - - - - 0

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STAFF GROUP Code

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J - Staff Group 01 Consultants/Doctors - 5 12 3 5 25 02 Nurses 4 250 21 3 16 294 03 Allied Health Professionals - 1 2 2 - 5 04 Scientific/Technical - - - - - 0 05 Ambulance - - - - - 0 06 Ancillary Staff/Estates - - - - - 0 07 NHS Board/hospital admin staff/members

(exc FHS administrative) - 1 1 1 2 5 08 GP (Salaried GPs in prison healthcare) - 224 3 - - 227 09 Pharmacists - - - - - 0 10 Dental (Salaried Dentists in prison healthcare) - 50 - - - 50 11 Opticians - 6 - - - 6 12 Other - 1 - - 1 2 Service Area Accident and Emergency - - - - - 0 Hospital Acute Services - - - - - 0 Care of the Elderly - - 2 - 1 3 Rehabilitation - - - 3 1 4 Psychiatric/Learning Disability Services 4 - 18 1 9 32 Maternity Services - - - - - 0 Ambulance Services - - - - - 0 Community Hospital Services - - 6 - - 6 Community Health Services

- not elsewhere specified - - 12 5 13 30 Continuing Care - - - - - 0 Purchasing - - - - - 0 Administration - - 1 - - 1 Unscheduled Health Care - - - - - 0 Family Health Services - - - - - 0 Prison - 538 - - - 538 Other - - - - - 0

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Appendix 4

Service Improvements Identified for Completed Complaints Quarter 3 where Complaint Partially of Fully Upheld

Ref Description Outcome code

Service improvement/long-term plan

B2014/941 Patient states he did not receive his medication

Fully Upheld

Reiterate to Nursing Staff medication prescription dispensing times.

B2014/944 Patient states he has been requesting a new inhaler for over one week and has not received this.

Partially Upheld

Regarding scheduled clinics, Managers and Clinical leads must ensure that Vision records that cancellation letter is sent. This point was highlighted at the staff handover meetings w/b 27th October 2014 and staff meeting dated 30th October 2014.

B2014/957 Patient states he is not receiving his medication on time

Fully Upheld

Tracker must be updated by staff to ensure all requested are documented.

B2014/959 Patient states he had seen a nurse who listed him to see GP but was not called to his appointment

Partially Upheld

Health Care Staff need to arrange Doctor's appointment if this is agreed with patient.

B2014/968 Patient states he has still not been seen by the Dentist after submitting a referral to be seen and receiving an appointment.

Fully Upheld

Better communication between healthcare staff where appointment has been cancelled and new appointment made.

B2014/979 Patient states he has not seen the Mental Health Team after submitting a referral 4 weeks ago. Patient not happy about having to re-submit his complaint as it was on a photocopy that is not accepted.

Partially Upheld

Health Care Staff require to communicate to patients informing them that referrals have been received and action taken. Hall Staff to be told of ordering system for complaint paperwork.

B2014/982 Patient states he is not receiving the correct amount of medication.

Partially Upheld

Medical Staff to document of Vision when new prescriptions are written and ensure previous prescriptions are discontinued.

B2014/983 Patient states he has not received his medication on time.

Partially Upheld

Not received regular medication on time ordering process for medication reviewed new system implemented to prevent further problems

B2014/989 Patient states he is not receiving his medication.

Fully Upheld

Nursing staff to be more vigilant with prescriptions following a Doctor's Clinic.

B2014/995 Patient states he did not receive his medication and has asked the nurse to change him to supervised but has not received notification on this

Fully Upheld

Nursing staff to update electronic medical records if medication not given to patient on time and reason.

B2014/998 Patient states he is suffering from toothache. He finds waiting until the 03/12/14 is unacceptable

Fully Upheld

Extra Dental clinics would be advantageous as waiting list would go down quicker.

B2014/1002 Patient states he is not receiving his medication

Fully Upheld

Enhance efficiency and minimise delay with electronic prescribing system capable of generating patients whose medication is due.

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B2014/1005 Patient states he is unhappy with his medication as he is not receiving the correct medication and not on time

Partially Upheld

Clinical Manager to check what HC Assistant or nurse was with Doctor or how she managed to miss this medication prescription. If the GP is not making people aware that she is commencing prescriptions and then returning the physical notes to the health centre this is a problem for the patient. I will make the Administration Manager aware of this issue as she may wish to speak to Lead Clinician to raise this matter at the GP meeting.

B2014/1010 Patient states he is still waiting to be seen by the dentist. Patient states his last appointment he was not called for to be seen and has not heard anything since.

Fully Upheld

Strive to improve communication between health care and patients. More dental clinics would benefit HMP Barlinnie to cope with demand.

B2014/1012 Patient states he has not received his medication on time again after signing off his last complaint.

Partially Upheld

Staff to ensure that the medication tracker is completed.

B2014/1013 Patient states he has not received his medication.

Partially Upheld

None


Partially Upheld

Ensure GPs follow up if they record they will check where a patient’s medication is.

B2014/1020 Patient states he has still not received his methadone after being told his confirmation fax had been received.

Partially Upheld

Continue improving patient access to Addiction Services in custody.


Partially Upheld

Medical Staff to check electronic prescription upon admission and prescribe accordingly.

B2014/1023 Patient states he is not receiving his medication on time.

Fully Upheld

Staff to keep in possession tracker up to date to enable tracking of medication ordering.

B2014/1030 Patient states he received an appointment slip for the Dentist and was not taken on his appointment date.

Partially Upheld

Better communication between Health Care and patient if an appointment has to be re-scheduled.

B2014/1051 Patient states he had an appointment with the Sexual Health Nurse on 17/10/2014 but was not seen.

Partially Upheld

Medical Staff to inform patients of their appointments are cancelled and detail new appointment date.

B2014/1064 Patient states he has not been seen for two dental appointments and does not know why.

Partially Upheld

Communicate to patients with new appointment if clinic is cancelled or appointments are re-scheduled.

B2014/1065 Patient states he is not receiving his medication even though it has been confirmed by his prescriber.

Partially Upheld

None

B2014/1070 Patient states he was not seen by the doctor at his appointment due to IT issues and has been given another appointment which the patient is not happy about.

Partially Upheld

Computer system failed to work - awaiting IT input to fix.

B2014/1072 Patient states his course and packet medication is always late.

Fully Upheld

Prescriptions need to be either all course in packet or all supervised.

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B2014/1075 Patient states he is still having issues with his medication.

Partially Upheld

None


Partially Upheld

Ensure prescription clarifies time medication to be dispensed if agreed by Doctor.


Partially Upheld

Send back correspondence to patients informing them if their request for medication has not been authorised.

B2014/1081 Patient states he has not received his medication since coming into prison.

Partially Upheld

If clinics are cancelled patients need to be notified of this.

B2014/1082 Patient states he does not want to be seen again by a particular Doctor and would like to know why he can not receive the medication he was previously prescribed.

Fully Upheld

None

B2014/1085 Patient states he has not received his full dose of medication.

Fully Upheld

None

B2014/1092 Patient states he did not receive his medication on time.

Partially Upheld

New system implemented to prevent further problems.

B2014/1095 Patient states he is still waiting to be seen by Addiction Nurses to be started on Methadone.

Partially Upheld

Improve communication between healthcare and patients.

B2014/1096 Patient states he has not been given his mental health medications. Patient has also submitted several referral forms and not heard anything back.

Fully Upheld

Check case notes for prescriptions in case Doctors have filed them.

B2014/1110 Patient states he has not received his medication this week.

Partially Upheld

GP should have prescribed all medications on ECS Kardexes could have been amalgamated.

B2014/1123 Patient stated he is unhappy with his urine drug dip test. He states the nurse that did the dip test stated his urine was water.

Fully Upheld

None

B2014/1127 Patient states he has not received his medication after submitting repeat forms.

Partially Upheld

None

B2014/1130 Patient states he is not receiving his medication on time again.

Fully Upheld

Computerised system network with pharmacy.


Partially Upheld

None


Fully Upheld

Staff to be vigilant with medication tracker and enter all details on it.

B2014/1160 Patient states he has not received his medication.

Fully Upheld

Health care staff to keep medication tracker up to date.

B2014/1161 Patient states he has had poor aftercare.

Partially Upheld

None

B2014/1179 Patient states that he has not received his glasses after been seen by the Optician because someone else has signed for them and taken them.

Fully Upheld

None

B2014/1188 Patient states that he is not happy with the time he has to wait for his medication.

Fully Upheld

None

15



B2014/1189 Patient states that he is unhappy with treatment form nurse with regards to his dressings.

Partially Upheld

None

B2014/1194 Patient states that he is unhappy with waiting time for dentist.

Fully Upheld

None

B2014/1207 Patient states he is unhappy with time he has to wait for medication.

Partially Upheld

Robust system required in form of network IT to prevent repeated incidents. Make copy of Kardex to make reference to when original Kardexes are misplaced.

B2014/1213 Patient unhappy at time waiting for medication.

Partially Upheld

None


Fully Upheld

None


Fully Upheld

None


Fully Upheld

None


Fully Upheld

None

B2014/1247 Patient unhappy that he has been isolated because of a rash when he has not been properly diagnosed.

Fully Upheld

None

B2014/1248 Patient states that he is not receiving correct medication.

Partially Upheld

None

B2014/1251 Patient states he is not receiving his medication on time and waiting for appointment with mental health team.

Partially Upheld

None


Fully Upheld

None

ECY14-17 Unhappy with care and service provided for daughter with mutism. Particularly before the new school year started.

Fully Upheld

A review system is to be implemented in East CAMHS team. The Clinical Coordinator will meet Case Manager to ensure this is communicated

ECY14-18 Complaint regarding member of staff's demeanour i.e. allegation of undermining patient and carer, being sharp and direct which made the patient and carer uncomfortable.

Partially Upheld

None

ECY14-24 Parent complained that he was denied access to visit his daughter in Skye house

Fully Upheld

Staff reminded of the need to take individual circumstances into consideration when applying rules and restrictions to visiting hours and times. A review of restricted visiting a Wednesday is to take place and to include the views of parents and patients.

G2014/114 Service user states she came to Greenock in July 2014 and after putting in a dental referral has never been seen. Service User believes that females are not being called to attend the dentist and wishes to be told "roughly when we will see someone as I feel lost in their list and don't want this to affect my treatment".

Partially Upheld

None

16



G2014/118 Complainant states before he came into custody he was on 25mls of Methadone and has now gone without this for 5 days and is feeling sick all the time, he does not understand why he has not been given methadone or a detox.

Fully Upheld

None

G2014/119 Complainant was due to see the Hepatitis nurse for a very important scan to determine how much damage has been done to her liver and what kind of treatment will be required. Complainant did not know that while she was in the hairdressers was the same time as her appointment with the nurse. Someone said no to her appointment because she was at the hairdressers but she did not get the option to decide. She would not have gone to the hairdressers if she had known this was the same time as her nurse appointment. Complainant is now very angry.

Partially Upheld

None

G2014/121 Service user states she completed a dental referral form 4 months ago and has not been seen yet. She spoke to assistant 4 weeks ago and she was told she was at the top of the waiting list. Service user states if she was out in the community her treatment would have been completed by now.

Fully Upheld

None

G2014/122 Complainant has been at HMP Greenock for almost 2 weeks now and he's still not had his methadone, which he feels isn't right. He's been sick and awake most of the nights and he's sore. He saw the nurse on Friday and she told him he would get his methadone on Monday which was a lie. Health centre is still waiting for his fax to come through from RDS. He doesn't understand why this cannot be chased up for him as he does not wish to start using drugs again but knows that he will if this does not get resolved soon.

Fully Upheld

None

17



G2014/124 Complainant states that issue began with his medication never being given to him on time. His name was not on the weekly list resulting in him not getting it. He had to keep going down to ask for it despite asking to be put on the weekly list. He has had to go days without medication when nurses knew he needed it. A complaint was made by his brother outside. He has started taking seizures again and injured his head. The doctor upped his medication from 75mg twice a day to 100mg twice a day and he received the proper amount of mediation for 2 weeks. The last 2 weeks his medication was reduced to 100mg once a day and he has spoken to nurses and officers about this. He is complaining because this is half the amount that he feels he should be being given. He is now having dizzy spells and wants someone held responsible.

Fully Upheld

None

G2014/129 Complaint is about medication. He receives his medication every Saturday without a problem then on Saturday 15tth Nov he didn't receive his medication. When he asked the nurse why he was told because he didn't put in a repeat medication slip on time and that he would need to put in another one on Monday. When complainant asked what he was to do without his medication until then he was told he would have to wait. On Monday he put in another slip but still has received nothing and this is now Wednesday. He wishes to speak to someone about this as he's on his medication for mental health and chronic pain and he feels it is a disgrace the way he's been treated.

Partially Upheld

Further communication to the patient group that they are responsible for ordering their medications to ensure continuity of treatment. Apology offered to him for his Mirtazapine not being ordered on Monday 17th November 2014. All patients' medications that are reviewed and discontinued should be informed by the prescriber. Mew system of medicine management within the prison, this includes re-ordering process for prisoners to follow.

G2014/130 Complainant wishes to speak to Clinical Manager as he has seen addictions team and heard nothing since and it is the same with the psychiatrist.

Partially Upheld

None

18



G2014/133 Patient believes the service she received from the dentist was unacceptable -" he tried to remove a tooth" which the patient believes he should have realised was a wisdom tooth. Patient was told by Dentist that she would have to go to hospital. Patient states after waiting a week, she approached a nurse to be told the dentist had not informed them of what had happened. Patient is now left with stitches and roots of the tooth in her mouth. Patient believes the dentist should never have attempted to remove the tooth and believes not informing the nurses is 'shocking'. Patient states the “manner of the dentist was brutish and not dentist like". Patient wants healthcare she is entitled to.

Partially Upheld

Improved communication between healthcare services, deputy manager to discuss with dental service and nursing staff.

G2014/134 Patient was promised that she would be seen by Medical Officer on Monday 1/12/14 but due to high numbers of admissions was told she would not be seen. Patient states she is 6 months into an 18 month sentence, recovering Addict with mental health problems and physical health problems and is trying to sort it all out and has ended up using drugs again. She feels she has been passed between Mental Health Nurse, Addictions Nurse and Addiction Workers. Patient believes that "in Prison if you are told you will be seen by a Medical Officer, you should be seen first, before new admissions or else they will just keep slipping through that loop in the system and even end up dead".

Partially Upheld

None

G2014/137 On 24/10/14 complainant saw the dentist who thought that she had an old root left in her gum. The dentist went to extract it but it turned out to be a wisdom tooth. Now complainant has to go to the dental surgery to have the wisdom tooth removed. This wouldn't be necessary if the dentist hadn't touched it in the first place. The complainant states that the dentist did not look over her x-rays beforehand and after he realised the tooth wasn't budging. The dentist did not apologise and just told her she would have to go to hospital.

Partially Upheld

None

19



G2014/138 Complainant feels he has to complain about the attitude and duty of care given by Medical Officer. The patient has been given prescribed ibuprofen and anti-inflammatories which have had no effect on his condition. During a consultation with the Medical Officer when the complainant asked if he could be referred to the Physiotherapist, the Medical Officer shouted at complainant that "you are on Methadone which is the strongest pain killer". When the patient replied that he was on methadone for addiction not pain relief the Medical Officer stormed to the door and shouted at patient to get out of his office. Patient states at no time did the medical officer examine him. Patient is in pain and has not been given any treatment. Patient wishes to be referred to a specialist or to have a scan for a proper diagnosis and then be given treatment. Patient no longer wishes to be seen by this Medical Officer as he feels he is biased towards him and patient has no faith in him.

Partially Upheld

None

G2014/141 Complainant feels he has been treated unfairly by the Medical Officer. He asked for E45 cream as he suffers from dry skin. He was told by the Medical Officer 'your skin does not look dry'. Complainant feels the Medical Officer was rude in his conduct and does not wish to see that Medical Officer again.

Partially Upheld

None

LM2014/344 Patient states that he has not been receiving his weekly medication on time.

Fully Upheld

Not received regular medication on time ordering process for medication reviewed new system implemented to prevent further problems

LM2014/398 Patient unhappy at having to wait to see the dentist.

Fully Upheld

Dental waiting times. Review of dental services in progress.

LM2014/432 Patient states that he is being ignored by the nursing staff regarding hospital appointments.

Partially Upheld

None

LM2014/441 Patient states that the GP said his bloods were to be taken, until now this has not happened.

Fully Upheld

None

LM2014/455 Patient states that the cream and antiseptic dressings he was given by the hospital and handed to reception have disappeared.

Fully Upheld

None

LM2014/462 Patient states that he is receiving his medication late after receiving a Kidney Transplant.

Partially Upheld

None

20



LM2014/468 Patient states that he has suffered pain due to not receiving his medication Patient unhappy feels that the hall nurse dismissed him regarding his medication.

Fully Upheld

None

LM2014/474 Patient claims that after being in hospital he was prescribed medication. This medication was short when he received it from the health centre and after speaking to 3 members of the nursing team he still didn't get the issue rectified; this caused the patient undue stress.

Fully Upheld

None

LM2014/479 Patient complaining not receiving all his weekly medication.

Partially Upheld

None

LM2014/493 Patient states that he has put in four referrals to see the dentist and he has been told that he is not even on the waiting list.

Fully Upheld

None

LM2014/494 Patient states that he has not received his weekly medication for 2 weeks, patient also unhappy at the time he has been waiting to see the dentist.

Partially Upheld

None

LM2014/495 Patient unhappy at waiting 3 days for his antibiotics for his ear infection also unhappy at the nurse's decision to send him back to work.

Partially Upheld

None

LM2014/516 Patient claims that he was told that he had a hospital appointment and was not given his fasting instructions and therefore could not received his hospital procedure.

Fully Upheld

None

LM2014/534 Patient unhappy at his medication being stopped, also unhappy that it was an SPS officer who took the medication from him.

Partially Upheld

None

NE169 Complainant has raised concerns regarding her sister's stay at in-patient ward: 1. Nobody talks to her, 2. Nurses sit in one room, 3. Nurses don't discuss treatment with family, 4. Dining room has no privacy 5. Patient smashed glass on floor

Partially Upheld

Issues re communication

21



NE172 1.Complainant unhappy that her brother's medication was not available before he left to attend a funeral and why he didn't receive an apology, 2.why he could not see his psychiatrist before leaving to attend funeral 3. why he has not been supported to give up his tenancy and access supported accommodation.

Partially Upheld

1. All nursing staff to be reminded of the importance of completing all aspects of the clinic and admin tasks related to the clinic. 2. All admin staff to be reminded to check that all admin tasks are completed and checked. 3. A review of psychiatry processes regarding discharges, update letters and cancelled appointments. 4. New Care Manager to be allocated, same completed and patient advised on 23 10 14.

NE174 Complainant's father was sent for a CT Scan at the Southern General Hospital in error and had not received any explanation as to why this happened nor an apology.

Fully Upheld

Belmont - Use of CHI as the unique identifier for all referrals and case note requested - rather than patient name and Date of Birth. Checking of patient information whey they attend for OP appointment, and the procedures for dealing with any anomalies. Medical Records - verification of case note requests - process to be reinforced and adhered to by all staff. Radiography - procedure in place now to check back any anomalies between system and referral request information prior to details being changed.

NE175 Complainant unhappy with the treatment her daughter has received from her Consultant Psychiatrist.

Partially Upheld

Circulate advice to all clinical staff about leaving messages on answering machines particularly if the staff cannot confirm that the phone is in the possession of the patient.

NE177 Complainant unhappy with treatment he received: 1. his delay in methadone dispensing 2. inappropriate remark from Senior Charge Nurse 3. treated differently due to suspicion of drug use 4. breach of confidentiality 5. failure to return personal medication 6. prescription change following discharge from hospital 7. process in transferring to Limited Access Clinic

Partially Upheld

1. Staff at hospital should ensure that for an arranged admission, patients' case notes are consulted prior to admission to ensure that prescription needs are planned for. 2. Staff at both hospital and the NE CAT to be reminded of the Mental Health Partnership Risk Screening and Management Plan Tool through meetings/briefings. 3. Limited Access Clinic referral criteria to be reiterated to all staff. A new policy document has recently been developed and will be emailed to all staff and discussed within team meetings.

22



NE178 Complainant is worried about the considerable amount of weight her daughter lost and feels that her treatment was a "one size fits all" whilst in hospital.

Partially Upheld

1. MH Dieticians should participate in training sessions delivered by AEDS Dieticians at least annually in relation to the dietetic role for patients with eating disorders. This should form part of their continued professional development, as part of the KSF process. 2. Consideration should be given to the supervision and support of clinicians working with patients who are admitted to a locality bed for refeeding when there are no available eating disorder beds at Stobhill. In particular, it is recommended that MH Dieticians should routinely access AEDS Dieticians for support and clinical supervision of such cases. 3. A protocol/policy should be developed for refeeding which includes the responsibilities of the specialists and non-specialists involved in the care of a patient. This should include clarification about calculating the refeeding plan and who is responsible for making the decision if a patient is to be commenced on a refeeding plan at less than 20kcal/kg. Once concluded any protocols should be included within the AEDS operational policy and should be held in all mental health acute admissions wards across NHSGGC.

23



NE179 Complainant unhappy with the treatment her father received whilst an inpatient: 1. nursing staff and consultant did not notice poor condition of her father's legs until she pointed it out and no apology was provided 2. she wasn't contacted by anyone to inform of his detention and wanted confirmation that her sister was provided with detention papers. 3.she wanted her father to be addressed as Dr not Mr 4. father complained of nausea and it took 2 weeks before anything was prescribed 5. nurse was abrasive and brusque on telephone 6. father was transferred with someone else's spectacles and was told he only shaves once a week when this is not true 7. she was not invited to planned care reviews and had to ask for a meeting 8. she had to request a referral to advocacy twice

Partially Upheld

All nursing staff will be reminded to document in detail referral to advocacy. All nursing staff will ensure that the need for advocacy is included in the patient care plan and that advocacy attendance is followed up promptly. All nursing staff will be reminded to document that relevant information leaflets have been passed on to patients. A team brief will take place with members of the nursing team to review how difficult conversations with relatives can be handled better. Staff will be provided with relevant customer care training. The SCN will ensure that all staff have access to clinical supervision. All staff will be reminded of the importance of detailed recording of personal items on admission and on discharge. All staff will be reminded of the importance of clear written transfer information to care homes.

NE180 Complainant unhappy that staff did not listen to her when she advised nurses that her husband was unwell, which could have prevented him from attending A&E. She was also upset that her husband was called "an old man" by a nurse.

Partially Upheld

The Senior Charge Nurse will remind all nursing staff to ensure that they do not use unspecific reasons or comments about a patient's presentation when speaking to relatives/carers. The Senior Charge Nurse will remind all nursing staff to ensure that all observations and complaints from patients, relatives and carers are fully documented and include specific actions taken to address these.

24



NE185 Daughter unhappy regarding decision by senior member of staff to reduce the level of observation from one to one to constant observation without notifying daughter.

Partially Upheld

Clearly highlighting that daughter is to be communicated with at the front of the notes Remind all staff that they must contact relatives in relation to incidents or changes to care Ensure that relatives are communicated to at all times and involved in regular reviews Risk assessment of environment to ensure it is as safe as possible to minimise risks. Replace existing bed with a more suitable bed to minimise risk of injury. Physiotherapist review to ensure mobility and balance are fully assessed Update management plan for patient in relation to falls

NWS13514 Client unhappy with Counselling services, Client told counsellor at first session that he would not be able to attend until late August, client never heard anything and call late August to be informed that his appointment was in July. Client unhappy he now needs to wait until November.

Fully Upheld

None

NWS14614 Client unhappy with treatment from Dr regarding implant

Fully Upheld

None

NWS15514 Client unhappy with Vasectomy treatment

Fully Upheld

None

SO35/14 Unhappy with immunisation programme. Appointment was cancelled and now told son too old to get the injection.

Fully Upheld

Health visiting staff reviewing cancellation system.

SO38/14 Unhappy with service, wrong items delivered twice and spent £60 in the meantime buying necessary products.

Partially Upheld

None

SO39/14 Unhappy with service, appointments were cancelled and unhappy with the way the 30 month assessment was carried out. She is happy with the outcome but not the staff member

Fully Upheld

Health visiting staff have received training on assessments in terms of telephone and in person.

25



SO41/14 Unhappy with HVs recording of info in red book and attitude of staff

Fully Upheld

PDN and team leader currently reviewing clinic with a view to identifying ways to improve sessions: - review clinic to see if we can extend timings of appointments to allow fuller discussion with families about immunisation - agree at start of each session what each nurse is doing and that remains same throughout session. - double check computer entry and advise patients as to what injection has been given.

SO42/14 Patient unhappy with service he received at Pollok Health Centre reception.

Fully Upheld

None

SO43/14 Unhappy with Wellbeing service. Issues with missed appointments. Mother not getting support she requires.

Fully Upheld

Ensure staff are aware of patient's requirements and discuss these if they cannot be met.

SO44/14 Lack of support and lack of response re her issues. Unhappy with service provided

Partially Upheld

In June this year we implemented changes to our systems whereby all messages are emailed to staff this ensures there is a trail and no dubiety over whether messages have been passed on and will prevent a similar issue recurring.

SO47/14 Patient feels he requires more pads than he is allowed. His nurse has been trying to increase the number on several occasions but has been unsuccessful.

Fully Upheld

None. DN was following protocol. Products required are not part of normal formulary.

SO48/14 Feels continence nurse is not treating her with right medication. Does not provide support required, feels nurse is domineering.

Partially Upheld

Reminder sent to nurse that patients do not have to accept students and if they say no this should be noted on their file to ensure they are not asked again.

SO49/14 Unhappy did not get certificate after attending course. Felt trainers were not working together and session was stopped by trainer as someone was over emotional. Felt attitude was reckless and irresponsible.

Partially Upheld

Key issues will be taken to the ASSIST Trainers network for discussion.

SO53/14 Unhappy with lack of treatment and lack of care by staff in ward while in Leverndale.

Partially Upheld

The senior charge nurse will make positive efforts to ensure that he and all his staff are courteous, professional and compassionate in their dealings with families and service users.

26

APPENDIX 5 Prison Healthcare Action Plans

Priority Area Objective Action Lead Timescale Progress Complaints KeyThemes

Access to dental services

We aim to reduce the dental waiting time to ten weeks. Emergency appointments should be allocated within a week where possible within 24 hours or access to out of hours emergency service. Provide a recall service for routine check- ups for patients who are in the establishments for more than a year.

Review current waiting lists for dental services across 3 sites and together with data from existing work carried out and the demand for emergency and routine dental care. Agree resource and identify costs allocation to include dental Oral Health Practitioner sessions across 3 sites.

J. Miller F. Gibbons J. Miller F Gibbons

31.12.2014 Completed New review date 31/03/2015

Meetings have taken place between Prison Healthcare and Oral Healthcare Directorate. A further meeting had been arranged but cancelled by Oral Healthcare. Jayne Miller is trying to rearrange a further meeting. Nov 14 Meeting has taken place increased resource has been agreed and implemented for additional dental sessions from 8-10 sessions per week. In conjunction with oral health work is in progress to commence an oral health practitioner. Jan 15 Increased dental sessions in progress between Dec & Mar to reduce waiting lists across all three sites. Oral health

Priority Area Objective Action Lead Timescale Progress

support worker funds available from health improvement, Job description completed and at recruitment for advertising. Oral health practitioner post in progress.

Attitude of General Practitioners (GPs)

Improve the approach and communication style for patients at consultations with the Doctors

Lead Clinician will monitor in conjunction with Healthcare Managers complaints being submitted regards GP attitudes.

Dr Campbell 31.10.2014

Lead Clinician has implemented performance improvement plans and will monitor this with the GPs where concerns have been raised. This will be discussed at the next Prison Healthcare GP Meeting. Jan 15 Lead Clinician to provide update as just returned from absence

Self referral process to access Healthcare Services

To provide information to patients on the self referral process to access all health care services.

A consistent approach across GG&C Prison Healthcare in the use of self referral forms.

F. Gibbons 31.03.2015

Review and update current information leaflets on the use of self referral forms. Information to be provided to patients at Induction how to access health care services.

28

Priority Area Objective Action Lead Timescale Progress Long waits to access to GP appointments

Improve patients understanding of the booking system for appointments and the expectations of appointment allocation. Provide information on the self referral process to access an appointment

Patient will be allocated a routine appointment within ten working days. An emergency appointment within 24 hours. Nurse emergency assessment (triage) in place prior to allocation of appointment within 24hours.

M. Higgins/F Gibbons

31.10.2014 Review 31/03/2015

Review of appointing process. Communication strategy in place to inform patients of there appointments and also were the appointments have been cancelled and a new appointment made Attendance and non attendance protocol developed in August in conjunction with a refusal to attend appointments form to allow closer monitoring and follow up where patients have not attended an allocated appointment. Protocol now implemented and being monitored across all three sites. Jan15 Review of complaints Oct – Dec indicates that there are still concerns regards delay in appointments however reduction in number of complaints and ongoing monitoring indicates improvement in this area.

Delays in Consistent To ensure medication is J Miller 31.12.2014 Ordering process for

29

Priority Area Objective Action Lead Timescale Progress Medication not being dispensed at the correct times.

pharmacy service across GG&C prison sites

dispensed on correct dates and times. Issue with review dates being completed.

J. Roberts M. Chahal N. Lynch F. Gibbons G Scott

medication reviewed and new system implemented. Prison prescribing group developed and have regular meetings. Concerns re complaints is monitored at this group. Develop an information leaflet on ordering medication. Implementation of an electronic tracer system to follow the order and dispensing process Pharmacy protocol has been developed on the completion of Kardexes and reviews. Training has to be delivered to all GPs and has now been included in new GPs induction pack. Clinical Managers at HMP Barlinnie currently undertaking a review of the new process that was implemented at Barlinnie in June. Nov14 new improved Kardex now in use, move to longer review dates and more monthly issue. New ordering

30

Priority Area Objective Action Lead Timescale Progress New review date 31.03.2015

sheets for patients Pilot in Greenock Pharmacy ongoing more intensive pharmacy monitoring. Site visits arranged for January. Jan15 Number of complaints on pharmacy issues have increased in December. Meeting with Health Care managers has taken place, meeting with pharmacy team to discuss systems & processes planned and further education and training for staff being developed.

Pharmacy Errors – Delays in receiving medications due to shortages or delay in receiving balance of medication

To support the contractor in reducing the number of errors and delays in patients receiving their medication. Provide a communication process where pharmacy is aware of delays that this is

Liaise with the senior pharmacist and contract manager to raise concerns regards errors and delays. At a local level Pharmacy and the supporting staff from NHS to provide a letter of communication to the patient advising them of medication shortages and non availability of items that will result in a delay in receiving their medication or

F. Gibbons J. Roberts

31.12.2014 28/02/2015

NHS monitoring in place and issues raised with the contractors. Template letter for communicating issues to patients developed. Nov 14 Pharmacy ongoing more intensive pharmacy monitoring. Site visits arranged for January. Jan 15 Meeting arranged as above to

31

Priority Area Objective Action Lead Timescale Progress communicated to the patient.

that medication will be changed to a different item to accommodate delays.

discuss concerns and review systems and processes. Staff requested to record all errors on DATIX incident module.

Long waits for access to Addiction services

Improve the access to addiction services in line with the HEAT targets for waiting times.

A review needs to be undertaken in regards to service delivery. Monitoring of the waiting lists and ISD reporting to improve the waiting times.

S. Malone G Hannah

31.12.2014 Complete New review date 31.01.2015

Addiction model review in progress. Tiered model approach agreed. Service specification developed. Meeting with Workforce Planning to take place. ISD monitoring in place that requires reviewed locally. Improve communication with patient in regards to allocation of appointment. Explanation of self referral process and what the patient can expect in receiving an appointment. Addiction meeting planned for the 16th December to finalise the model, as part of this progress information leaflet to patients will be presented. Jan15 Addiction model agreed. Final comments for service specification and Standard operating procedures received and final versions to

32

Priority Area Objective Action Lead Timescale Progress be completed. Workforce planning and interventions to progress thereafter.

Information not being transferred between establishments when patient transferred resulting in delays in medication, treatment and reviews.

Improve transfer of information between establishments. Where information is identified as not being transferred health care staff to communicate with the sending establishment within 24 hours to ensure information is sent on.

To review current documentation for the transfer of information. To liaise with other establishments to improve the transfer of information? NPHN forum and via health care managers.

M. Higgins/ J Miller

31.10.2014 New review date 28.02.2015

A protocol will be implemented to ensure all information required is received within 24 hours on arrival at the establishment. Patient transfer check list in place for GG&C establishments when transferring patients to other establishments to prevent delays. Nov 14 Protocol is in early stages of development and work in progress due to national issues across all sites. Jan 15 This work is ongoing at this time.

GP’s changing prescriptions without consulting the patients either face to face or in writing

To reduce these changes or improve communications with patients where changes have taken place.

Clinical lead will raise this at the next GP meeting in October 2014.

G. Campbell 31.10.2014 New review date 28.02.2015

Lead clinician and pharmacy staff have met with Doctors to discuss improving this process and communicate with patients. Complaints review indicates some improvement in the last quarter.

33

Priority Area Objective Action Lead Timescale Progress

Waiting time to access smoking cessation services

To improve waiting times to access services with consideration given to those with significant health problems being prioritised.

Review of current waiting list and liaise with Smoking Cessation Services Manager.

D Williamson 31.10.2014 Nov 14 Review of waiting lists across three sites. Additional groups in progress and waiting lists reduced. Pilot group to be offered to remand population. Additional 1:1 support post group to support smoke free status.

Operational constraints of the Scottish Prison Service for patient healthcare

Improved attendance of patients at appointments.

Issues identified from complaints will be raised through the joint Governance meeting between NHS and SPS and monitored via NHS operational meeting

J. Miller

31.03.2014

Jan15 Governance meeting took place end of 2014 and concerns regards SPS raised at this meeting and will continue to be monitored. Next Governance meeting 24/03/2015

34

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