spotlight on complaints - the national...

Inspecting Informing Improving

Spotlight on complaints

A report on second-stage complaints about the NHS in England

April 2008

ISBN: 978-1-84562-180-3

Concordat gateway number: 120

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© April 2008 Commission for Healthcare Audit and Inspection.

This document may be reproduced in whole or in part in anyformat or medium for non-commercial purposes, provided that itis reproduced accurately and not used in a derogatory manner ormisleading context. The source should be acknowledged byshowing the document title and © Commission for HealthcareAudit and Inspection 2008.

1Healthcare Commission Spotlight on complaints

Contents

Foreword 2

Summary 4

Common themes 10

Issues raised in complaints 12

Types of services that complaints were about 14

Clinical themes 18

Primary care 19

Hospital care 21

Mental health services 28

Ambulance services 30

Services for children 32

Palliative care 32

Prison healthcare 33

Continuing healthcare 33

Improving our independent review service 38

Conclusion and next steps 44

Next steps 47

References 49

Appendix: Process improvements 50

This is our second report that sets out theHealthcare Commission’s work reviewingcomplaints made by patients or theirrepresentatives about NHS services. It coversthe 7,500 requests for independent review thatwe received, and the 10,000 reviews that wecompleted, between August 2006 and July 2007.It also highlights trends and the lessons that wehave learned. Our first report, Spotlight oncomplaints,1 covered complaints that wereceived and reviewed between July 2004 andJuly 2006.

There is much good work being done to dealwith complaints in some areas of the NHS. Ofthe many millions of episodes of treatmentcarried out across the NHS every year, just140,000 are the subject of complaints. Only7,500 of these were referred to us forindependent review this year. We have seen animprovement in the way in which trusts areresponding to complaints, with us returningfewer complaints to trusts to do more work at alocal level: 26% compared with 33% in our firstreport. We are also seeing more evidence oftrusts learning from complaints. For example,trusts have improved their procedures forassessing the risk that complaints representand have developed better mechanisms forfeeding back to their boards information aboutlessons that have been learned.

However, there is still some way to go before allNHS organisations can confidently say that theyhave robust local procedures for handlingcomplaints, which lead to improvements in thecare of patients in a systematic way. This is

shown by the more than 2,500 cases that wereturned this year for further work at a locallevel, and in the findings of our recent audit of complaints.2

There are also some areas that we highlightedlast year where more progress needs to bemade. One involves providers apologising topatients and their families when something hasgone wrong. In almost one in 10 of the casesreferred to us, the person making the complaintwas simply seeking an apology, or anacknowledgement that care could have beenimproved. We are frequently told by the trustsconcerned that they had not apologised for fearof admitting legal liability. However, the medicaldefence organisations and the NHS LitigationAuthority have consistently made it clear thatapologies can be given to try to resolve matterswithout admitting liability. We would like to seemore organisations and healthcare providersprepared to apologise when errors have beenmade and it is appropriate to do so.

We feel that more complaints could be resolvedat a local level if trusts offered clear, evidence-based explanations and apologies whereappropriate, and made good any harm or senseof injustice. But we also emphasise to trusts thatgood handling of complaints needs to involvemore than an apology. It must also demonstrateto patients and to the public that improvementsto services are being made as a result of theircomplaints.

It is vital that the NHS takes account of patients’views if it is to become truly patient-centred.

2 Healthcare Commission Spotlight on complaints

Foreword

Complaints present a great opportunity for managers andclinicians in the NHS to understand what should be done toimprove the services that they provide.

Listening to, and learning from, complaints isone of the key ways it can do this.

Over the next year, we will be working with NHSorganisations to improve measures for handlingcomplaints. We will also help them to preparefor the new system for handling complaints thatthe Government proposes to introduce in 2009.We agree with the Government that the newregulator of health and social care should nothave a role in dealing with individual complaints.Rather, the regulator will have a role in ensuringthat trusts meet their obligations. We also feelthat it is crucial that there are mechanisms forensuring that the lessons learned fromcomplaints on a national level are captured andcommunicated to the NHS. We thereforewelcome the Government’s proposal that thenew regulator, working in conjunction with theDepartment of Health and the Parliamentaryand Health Service Ombudsman, will continue tohave an important role in doing so.

In our first report, we described how we receivedmore than double the number of requests forreview compared with the previous system fordealing with complaints. This was a realchallenge for us – and we have met thischallenge. Now, no complainant has to wait fortheir case to be allocated to one of ourinvestigators; cases are resolved much morequickly, while high standards are maintained;and in the summer of 2007 we met our target of resolving 95% of cases within 12 months.Reviews now take less than three months onaverage to complete, and we have 50% fewer opencases. We have also improved the quality of ourwork and our follow-up with organisations to makesure that our recommendations are acted upon.

Over the coming year, we will continue to refineour processes to ensure that we are providing

consistently high levels of service tocomplainants and NHS organisations that arethe subject of a complaint. We will also workwith the Department of Health, the Commissionfor Social Care Inspection, and theParliamentary and Health Service Ombudsmanto support implementation of the Department ofHealth’s proposals to put more emphasis onresolving complaints at a local level as part ofthe new system for handling complaints. This iswhat complainants tell us that they want and wewelcome it.

Those with concerns about the treatment thatthey or a relative have received from an NHStrust rightly expect that their complaint will belooked at thoroughly and fairly. They also expectthat the NHS will learn from their case and thatthey will have an assurance that services will be improved.

Fairness, robust investigation and assurancethat lessons are being learned can be providedat a local level, but in many NHS organisationsthis will require a significant increase in thecapacity and capability of complaints staff, and in the quality of the process for handlingcomplaints. There are significant challenges inproviding an impartial investigation andindependent clinical advice, as well as indrawing together the lessons from complaintsacross the health sector at national level. Wehave already done much good work in reviewingcomplaints. This work could be built upon totake forward the Government’s newarrangements for handling complaints.


Anna Walker CB

Chief Executive

Professor Sir Ian Kennedy

Chair

Summary

The overwhelming majority of NHS patients are satisfied with thecare and treatment that they received.3 Many millions of episodesof treatments are provided across the health service each year,yet only 140,000 people make a complaint to their local NHS trustabout the care that they or a relative received.


An NHS that aims to make the patient thecentre of care must rise to the challenge ofresponding to more complaints in a sympatheticand flexible way. It must also try to resolveconcerns at a local level, without the need forescalation.

If a complaint cannot be resolved at the locallevel, at present the patient or theirrepresentative can ask the HealthcareCommission to independently review the waythat the trust investigated and responded totheir complaint. This is the ‘second stage’ of theNHS complaints process that was introduced bythe Department of Health in July 2004. The‘third stage’ is when the patient or theirrepresentative takes their complaint to theParliamentary and Health Service Ombudsman.

Complaints cover a wide range of issues, buteach is important to the person raising it andspecific to their circumstances. When complaintsare not resolved at the local level, the providermisses an opportunity to strengthen their bondwith the people they serve.

As in our last report, the concerns of manypatients who have asked us to review theirunresolved complaint have centred on the basicelements of healthcare. For example,communication between clinical staff; theattitude of staff; standards of care and safety;and fundamental aspects of nursing care, suchas nutrition, and privacy and dignity.

This report focuses on these key clinical areas,highlighting the areas of good and poor practicethat we have seen both in handling complaintsand in delivering services. It also includesinformation about the commonrecommendations that we have made to help toresolve complaints and improve services. We

hope that by sharing these trends andrecommendations, other NHS trusts can takesteps to prevent similar issues arising.

We have seen an improvement in the way thatthe NHS handled complaints this reporting year.In the first reporting period, we referred 33% ofcases back to trusts because their originalresponse was unsatisfactory. This year, thisfigure fell to 26%.

However, we remain concerned that in over aquarter of the complaints that we were asked toindependently review (over 2,500 cases), therewas more that the trust could have done toresolve the complaint locally. The findings of ourindependent reviews show that the NHS has a lotof work to do to improve the way that it handlescomplaints, both in terms of its responses toindividual complaints and the way in which trustsuse the lessons that they have learned fromthem to improve patient services.

Our findings in this report reflect those of our2007 audit of complaints2: that the standards ofhandling complaints can vary significantlybetween providers across England.

The reasons we ask a trust to carry out furtherwork are relatively straightforward, and thethings we ask them to do would not have beendifficult to do during local resolution of thecomplaint. For example, the trust may not haveinterviewed or taken statements from therelevant clinical staff; the letter confirming theoutcome of the complaint investigation mayhave been couched in clinical terms, making itdifficult for the complainant to follow; or anapology may not have been offered.

We will continue to work with all NHS trusts tomake sure that their procedures for handling

complaints are refined and that they havesystems in place so that their boards can usecomplaints to drive improvements in services.

Central to this is a new national complaintstoolkit that we released in March 2008. Wedrew on our experience of independentlyreviewing complaints over the past three yearswhen developing this toolkit. We also used theexperience of others, including theParliamentary and Health ServiceOmbudsman, who work at local and nationallevel across health and social care. The toolkitaims to help to resolve complaints at the locallevel by addressing many of the commondeficiencies in the ways in which complaintsare handled. These deficiencies are identifiedlater in this report.

The key findings from our independent reviewsof complaints this year are that:

• In 26% of cases (approximately 2,700), wefound that more work could be done to resolvematters at the local level. Typically this wouldhave involved offering the complainant:

• meetings with relevant staff

• better explanations

• an apology

• information about steps taken to prevent arecurrence of the problem

• simple steps to put things right, such asreimbursing the costs of private treatmentneeded to remedy an error.

• In almost 20% of cases (approximately 2,000),we upheld the complaint. While we may haveacknowledged that the trust provided what

they considered to be a full response to thecomplaint, we found that the response givenwas not as accurate as it could have been. Thiswas usually because the independent clinicaladvice that we obtained showed that the careand treatment provided was not in line with theestablished national standards, and that thetrust had not explained this to the patient ortheir relatives. In such cases, we maderecommendations for the trust to improve its services.

• Around 18% of the complaints that we reviewed(approximately 1,900) were not upheld. Wefound that the trust had given an appropriateresponse to the complaint, and that the careand treatment met the national standards.

• There was a slight fall in the proportion ofcases that were outside our jurisdiction thisyear: 24% compared with 26% in the periodcovered by the first report. These were typicallycases where the complaint had not yet beenmade to the trust. This figure suggests thatpatients and relatives may need to be givenmore accessible information on how the NHScomplaints process works.

• The safety and effectiveness of clinical practicewas the issue most commonly raised incomplaints (24% of cases). Patients felt that thecare and treatment that they had received wasnot of a sufficiently high standard, and therewas actual or potential risk of harm to thepatient or others.

• Many of those who contacted us this year(17%) were also concerned about how the trusthad handled their complaint. Some people feltthat the local investigation was not thorough orobjective enough, or that the trust’s responsewas not presented in a way that they couldunderstand.

Summary continued



• The primary care sector, including complaintsabout GPs and dentists, was the area aboutwhich we reviewed the largest number ofcases (some 3,700) closely followed by theacute sector (over 3,400 cases).

Around 50% of the complaints that we wereasked to independently review raised clinicalissues, so we sought advice from our team ofadvisers. Our key findings on the clinical issuesarising from complaints are that:

• In cases involving GP services, 43% ofcomplainants felt that their examination wastoo brief, with limited discussion abouttreatment options. A further 23% felt that theGP had failed to diagnose a condition, ordelayed diagnosis. Related to this, wereviewed a significant number of complaintsabout GPs who had not referred patients tospecialists soon enough. We oftenrecommended that GP practices shouldreview their referral procedures and that theirprimary care trust should monitor this.

• Communication issues were prominent in GPcases. Twenty per cent of the GP cases thatwe reviewed involved concerns about a GP’sattitude. Our clinical advisers saw a numberof cases when a GP had not told a patientabout the common side effects of atreatment. This may be because some GPsassume that patients cannot understandcomplex information about side effects. Ouradvisers also found that there were manycases where a GP had failed to engage withthe complaint, making it difficult to resolve.

• The most common complaint about dentalpractices (34%) concerned the standard orquality of clinical treatment. We found that

either the dentist had not adequatelydiagnosed the patient’s condition or that theyhad underestimated the difficulty of the case.

• The issue most frequently raised incomplaints about hospital care was also thestandard of clinical care (36%). Around 30% ofthese cases were about the fundamentals ofnursing care, such as hygiene,communication, privacy and dignity, andnutrition. We frequently recommended thattrusts review their practices in line withEssence of Care: Patient-focused benchmarkingfor health care practitioners.*4

• The complaints about care in A&Edepartments primarily concerned:communication and record-keeping(particularly a lack of documentation ofexplanations given to patients’ families); poor clinical handover of patients from A&E to other departments in the hospital;and a failure to recognise abnormal initialvital signs in patients, especially the respiratory rate.

• Problems with communication featuredprominently in the complaints aboutmaternity services. Our advisers on thesecases noted that many complaints were madebecause mothers felt that staff did not listento them when they expressed their needs. We also reviewed a small, but significant,number of cases where our advisers wereconcerned about supervision arrangements,in particular inexperienced midwivesmanaging the care of women with complexmedical needs. In such cases, werecommended that trusts review and improvetheir supervision arrangements.

*Essence of Care is a toolkit designed by the Department of Health to benchmark nursing practice. It covers the majorareas of care, including food and nutrition, privacy and dignity, personal and oral hygiene, and record-keeping.

• The most common issue raised in thecomplaints that we reviewed about mentalhealth services was the poor attitude of staff.Our clinical advisers also highlighted asignificant number of complaints concerninglocal crisis resolution teams. These includedservice users not knowing whom to contact intimes of crisis, poor communication, and poorquality plans for crisis resolution.

• Around a third of the complaints aboutambulance services concerned poor responsetimes. Our clinical advisers found that letterssent to complainants often included highlytechnical terms and cited the guidancearound response times. While the lettershelped to resolve the complaint to someextent, more could have been done toempathise with patients and their relatives.

• Almost 10% of the complaints about the careand treatment provided to children involvedsafeguarding issues. A specialist group withinour complaints team monitors these cases.

• In the almost 50 complaints that wereprimarily about palliative care, the mostprominent issue was families not being given sufficient or timely information to helpthem make informed choices about theirrelative’s care.

• The general standard of healthcare was themost common issue in the 86 complaints thatwe reviewed about healthcare in state-runprisons. In particular, some prisoners wereconcerned that they were unable to see a GPwhen they needed to. We have worked closelywith the Prison and Probation Ombudsman toimprove the way that complaints are handled in prisons.

• Around two-thirds of the over 100 cases aboutcontinuing care concerned funding issues. Weasked trusts to do further work in over half ofthese cases, usually because fundingdecisions were not adequately explained topatients and their relatives.

Issues relating to communication werecommon throughout all clinical areas. We foundthat open, clear communication from trusts,and better involvement of patients and relativesin key decisions about clinical care, can oftenprevent complaints.

Our findings show that the NHS needs to do agreat deal more to improve the way that ithandles complaints, but these improvements arenot usually complex or expensive to implement.

Trusts can be more responsive to those theyserve on the rare occasions when things gowrong. Being more responsive will also helpthem to prepare for the Government’s proposedreforms to handling complaints, which willfocus on trusts resolving concerns locally. Weare recommending that trusts do more toimprove their procedures for handlingcomplaints by making them:

• accessible to everyone who uses the service

• easy to use by anyone who wants to make a complaint

• sympathetic to the complainants

• focused on resolving matters

• non-adversarial

• able to provide a robust examination of theissues raised

Summary continued



• able to ensure that an appropriate remedy isprovided if a problem is found

• linked to each trust’s service improvementagenda.

We will encourage and support theseimprovements to make sure that they happen by:

• launching our toolkit on handling complaints,and helping trusts to implement it

• checking that trusts are complying with thestandards for handling complaints inStandards for Better Health5 and if they aren’t,taking action through the annual health check

• visiting trusts that are not followingrecommendations that we have made in ourreviews of complaints

• visiting trusts to which we have upheld orreferred back a large number of complaints

• improving information about the NHSprocedure for handling complaints on our website

• working closely with the Parliamentary andHealth Service Ombudsman to make sure thatthe importance of having good systems forhandling complaints is reinforced to trusts.

Common themes

Between August 2006 and July 2007, we completed over 10,000independent reviews. This section highlights the trends that wesaw in these reviews and describes the recommendations that wemade to trusts to help them to resolve complaints and driveimprovements in their services.


The most common outcome for cases that weindependently reviewed this year (26%) was torefer the complaint back to the trust for furtherwork (see figure 1 overleaf). This was also themost common outcome in the previousreporting period (33% of cases). While thisreduction is welcomed, because it suggeststhat complaints are being handled betterlocally, we still had to refer over a quarter ofour cases back to the trust involved because wefound that they could have done more to resolvethe complaint. This is too great a proportion.

We have frequently asked trusts to do thingsthat should have been considered as part of thelocal response, such as:

• providing a better explanation of events to thecomplainant

• showing that they have learned lessons fromthe complaint

• arranging meetings between the complainantand the staff members involved to discuss theissues raised by the complaint

• responding to all of the issues raised ratherthan giving selective or partial responses.

We have an ongoing programme of work thataddresses these points and supports trusts tobetter handle complaints locally. This includesus sharing information on the lessons that wehave learned from the cases that we havereviewed and from our recent complaints audit,letting trusts know what works well in dealingwith complaints, and giving trusts practicalinformation on how to deal with complaintsbetter, including our complaints toolkit.

A significant number of cases (24%) fell outsideour jurisdiction, usually because the complainthad not been made to the trust or the process oflocal resolution had not concluded. This is aslight fall on the figure in the previous reportingperiod (26%), but suggests that people who wantto make a complaint need to be given betterinformation about how the system works so thatthey don’t refer their concerns to us prematurely.

Around 20% of the cases that we reviewed wereupheld. While we accepted that the trustprovided a response to the complaint and therewas no further work that could be done to try toresolve matters, we found that the responsewas not accurate. This was usually because ourindependent clinical advice showed that thepatient’s care and treatment was not in linewith established national standards, and thetrust had not fully explained this to the patientor their relatives. We made recommendationsto the trusts concerned so that things could beput right, lessons could be learned, andservices could be improved.

We referred a very small number of our casesdirectly to the Parliamentary and HealthService Ombudsman, because they involvedretrospective claims for funding for continuingcare, there was only a small pool of availableindependent clinical advice, or the complainanthad a terminal illness. These referrals reflected a protocol agreed between our twoorganisations. We always obtained consentfrom the complainant before we made these referrals.

We referred cases to the General MedicalCouncil, the Nursing and Midwifery Council, orother professional regulatory bodies if wesuspected that there was misconduct orconcerns about the provider’s fitness to

Common themes continued


Issues raised in complaints

The issue most frequently raised (24% of cases)by patients or their relatives was about safeand effective practice (see figure 2 opposite).This was usually when patients felt thatsomething had gone wrong with the care andtreatment that they received, and there wasactual or potential risk of harm to the patient or others.

A large number of complainants (17%) wereconcerned about the way that trustscommunicated with them, and with the lack ofinformation they received about theirtreatment. We received many complaints aboutclinicians giving patients information that waseither not sufficient or too complex for them tounderstand. The patients could therefore notmake informed choices about their treatment.

Related to this, in 16% of cases, complainantsraised the provider’s complaints handling as anissue. Usually this was because they felt thatthe investigation was not sufficiently thoroughor objective, and that the response to thecomplaint did not adequately address all oftheir concerns.

Not upheld

Referred to Ombudsman

Negotiated further work Not specified

Withdrawn

Other

Upheld/partially upheld

Out of jurisdiction

Out of 10,366 reviews that we completed

8.6%

18.2%

0.2%

26.0%

19.8%

24%

1.7%

1.5%

Figure 1: Outcomes of independent reviewsfrom August 2006 to July 2007, byresolution type

practise. Additionally, where there may beconcerns about the performance of a doctor ordentist, we suggest that the employer orcontractor seeks the advice of the NationalClinical Assessment Service.


Frequency of issue being raised

0 5% 10% 15% 20% 25% 30%

Safe and effective practice

Communication/informationprovided to patients

Complaints handling

Patient experience, including privacy and dignity

Clinical treatment

Delay or cancellationof appointments

Attitude of staff

Lack of access topersonal records

Access and waiting timesfor service

Carer/family involvementin patient care

Figure 2: Top 10 issues raised in complaints that we independently reviewed from August2006 to July 2007

Types of services that complaints were about

This year we received complaints about the full range of NHS organisations (see figure 3). The highest proportion of the cases wecompleted in the year related to the primarycare sector, including GP practices and dentalpractices, (about 38% of cases), but complaintsabout the acute sector (around 35% of cases)were also very common. The proportion ofcomplaints about foundation trusts increasedsignificantly compared to last year (from 8% to 18%). This principally reflects the rise in thenumber of trusts gaining foundation statussince the last report.

There was a common pattern to the issuesraised in complaints that we received fromdifferent regions of England. The way in whichcomplaints were handled, communication, andconcerns about safety featured highly (seefigure 4).



Figure 3: Reviews completed, by NHS provider

34.5%

0.7%

17.9%7.3%

38.4%

1.3%

Acute trusts

Ambulance trustsFoundation trusts

Mental health trusts

Primary care sectorOther


North

London and South East

South West

Central

Central

London and South East

North

South West

Safe and effective practice

Communication/information to patients

Patient experience Clinical treatment

Complaints handling

Top five issues1. Safe and effective practice 2. Communication/ information to patients 3. Complaints handling 4. Patient experience 5. Clinical treatment

35%

26%

22%

9%

8%

37%

Top five issues1. Safe and effective practice 2. Complaints handling 3. Communication/ information to patients 4. Clinical treatment 5. Patient experience

Top five issues1. Safe and effective practice 2. Complaints handling 3. Communication/ information to patients 4. Patient experience 5. Clinical treatment

23%

22%

10%8%

Top five issues1. Safe and effective practice 2. Complaints handling 3. Communication/ information to patients 4. Patient experience 5. Clinical treatment

37%

23%

23%

8%8%

34%

24%

23%

11%

8%

Figure 4: Breakdown of independent reviews carried out, by Healthcare Commission region



We reviewed complaints about almost everyNHS trust this year. Table 1 lists the trusts thatwe referred the lowest proportion of cases backto for further work. In most cases, we weresatisfied with the work that the trust hadalready done to resolve the complaint. Table 2lists the trusts where we have identified that wereferred most complaints back to for furtherwork. These trusts had a significantly highernumber of cases referred back to them thanthe national average.

*Trusts that have had 10 or more independent reviews and not including primary care trusts

Central and North West London Mental Health NHS Trust 12%

Hampshire Partnership NHS Trust 13%

Northamptonshire Healthcare NHS Trust 14%

Barts and the London NHS Trust 16%

Table 1: Trusts with the lowest percentage of cases referred back for further local work

Pennine Acute Hospitals NHS Trust 51%

Mayday Healthcare NHS Trust 51%

North Cumbria Acute Hospitals NHS Trust 44%

Leicestershire Partnership NHS Trust 41%

Table 2: Trusts with the highest percentage of cases referred back for further local work*

We congratulate the trusts shown in table 1 fortheir consistently high standard of responses tocomplaints that we independently reviewed. Wewill work with the trusts in table 2 to assesstheir arrangements for responding tocomplaints against the requirements of thecore standards and statutory guidance.

Clinical themes

Around 50% of the complaints that we independently reviewedthis reporting year raised clinical issues and required clinicaladvice from our team of advisers. This section highlights the maintrends that our advisers found and what recommendations wemade to trusts to help them to improve their patient care.


In each clinical area, there were unique lessonsto be learned about the care and treatment ofpatients, but a common lesson was to improvecommunication. Our advisers identified manycases where poor communication fromclinicians – mainly not giving patients and theirrelatives a clear explanation about treatment –led to a complaint being made.

The analysis in this section is taken from ourcase management system, a representativesample of 500 case files, and feedback that wereceived from our independent clinical adviserson trends and issues in the cases they havereviewed in the year. This analysis is producedfrom cases seen by the Commission when localresolution has been unsuccessful. Nocomparison between sectors or issues ispossible given the different numbers of cases received.

Primary care

This year, we reviewed a wide range ofcomplaints about primary care services,including complaints made against GPs,dentists, and services directly provided byprimary care trusts (PCTs).

GP services

The most common type of complaint (43%) aboutGPs concerned clinical treatment. Many patientswho requested an independent review of theircomplaint were concerned about GPs who gavea poor quality examination. They told us thattheir examination was extremely brief, withlimited discussion of treatment options.

The significant number of complaints (23%)that we received about a GP’s failure or delay to

diagnose a condition may be linked to thesepoor quality examinations. These complaintswere usually about the diagnosis of cancer andmany complainants told us that the GP hadmissed signs that may have led to an earlierdiagnosis.

Related to this, we also reviewed a largenumber of complaints about GPs not referringpatients to specialists soon enough. In mostcases, our clinical advisers found that GPs hadacted appropriately and in line with relevantclinical guidance, such as the General MedicalCouncil’s Good Medical Practice.6 However, weoften recommended that practices review theirreferral procedures and that their local PCTshould monitor this. Many PCTs have their ownreferral pathways and the performance ofindividual doctors can be measured againstthese, often using the GP appraisal system.

Top five issues in complaints about GP services

1. Clinical treatment 2. Diagnosis – failure/delay 3. Attitude of doctor or practice staff 4. Handling of complaints5. Removal from practice list

Top five recommendations in complaintsabout GP services

1. Improve systems for handling complaints2. Make an apology 3. Review referral procedures 4. Improve record-keeping5. Review removal from practice list

Around 20% of complaints about GPs raisedconcerns about their poor attitude to patients.This included rudeness, not listening topatients, and an unwelcoming environment atsurgeries. A number of complainants were alsoconcerned about the poor attitude andbehaviour of practice managers andreceptionists.

Our clinical advisers told us that a commonproblem they saw was that some GPs assumedpatients could not cope with detailedinformation about the potential side effects of atreatment, so avoided giving them thisinformation. Our advisers noted many caseswhen the GP had not told the patient aboutcommon side effects. The General MedicalCouncil’s guidance on appropriate prescribingsets the standard to which doctors should work.

Our advisers also saw many cases when the GPfailed to engage with the complaint. They foundthat complaints were usually resolved morequickly and at the local level if GPs engagedpositively with them in the early stages, toprevent the views of the complainant and GPbecoming entrenched. The most commonrecommendation that we made to GPs this yearwas for them to improve their procedures forhandling complaints. This includes makingpatients aware of the practice’s complaintspolicy and offering meetings between patientsand staff to try to resolve complaints in a lessadversarial manner.

Dental services

The most common complaint (34%) aboutdental practices that we received concernedclinical treatment. Our dental advisers foundthat these complaints were frequently made

Clinical themes continued


“I would like to express our gratitude forthe help you gave us with my latefather's case. My whole family wasgrateful for the speedy, professional waythis issue was brought to the bestconclusion that we could have hoped for.Dr X of X Health Centre admitted ‘slipups’ had been made, and that a newcode of practice will be put in place toensure no other family will have toexperience such events. Thanks to youand your team.”Feedback following our review of a complaintabout a GP

Top five issues in complaints about dentists

1. Clinical treatment2. Communication with patients 3. Costs 4. Removal from practice list5. Availability of NHS dentists

Top five recommendations in complaintsabout dentists

1. Improve communication2. Improve systems for handling complaints 3. Improve record-keeping4. Improve clinical procedures5. Make an apology


after a treatment failed, or where problemswith the treatment led a patient to seek asecond opinion that revealed specific concernsabout their care. In many of these cases, ourdental advisers concluded that either thedentist had failed to make an adequatediagnosis of the patient’s condition or that theyhad underestimated the difficulty of the caseand attempted to provide care that might haveseemed reasonable, but was beyond their levelof experience and technical ability. Our advisersoften recommended that dentists review theirpractice to make sure that it meets the GeneralDental Council’s Standards for dentalprofessionals.7

Reflecting on the complaints that we reviewedthis year, our dental advisers found that thevast majority of cases where dentistsunderestimated the difficulty of the caseinvolved relatively inexperienced dentists. They concluded that this could have beenbecause less experienced dentists may:

• take more risks and carry out more ambitioustreatments

• be more easily influenced by patients whohave unrealistic expectations of the care thatmight be available

• not understand some of the risks that theyare taking with the care and treatment thatthey provide.

Our advisers recognise that these are difficultand complex situations. In their view, the bestway to learn from some of the errors that theyhave seen is to make sure that all dentists,particularly recently qualified ones, areencouraged to develop their clinical skills.

If there were questions raised about standardsof treatment, our advisers recommended thatthe local PCT referred the dentist to thePractitioner Advice and Support Scheme for awider assessment of their practice. They alsosuggested that shortfalls in clinicalperformance be addressed through asupportive local professional network.

Hospital care

Over a third of the complaints that we reviewedthis year were about hospital care. The threesub-sectors where the most cases originatedthis year were nursing care, A&E care, andmaternity services.

Most people (36%) who asked us to review theircomplaint about a hospital were concerned aboutthe clinical care and treatment that was provided.

Top five recommendations in complaintsabout hospital care

1. Improve communication2. Improve record-keeping 3. Improve staff training4. Review compliance with Essence of Care5. Improve clinical procedures

Top five issues in complaints about hospital care

1. Clinical treatment2. Compliance with Essence of Care4

3. Communication4. Diagnosis5. Handling of complaints

Nursing care

Many complaints about hospitals (around 30%)were about Essence of Care issues in nursing.Patients complained that some of thefundamental elements of nursing care –nutrition, privacy and dignity, and communication– were not delivered to an acceptable standard.Where our nursing advisers told us that thingscould have been done better, we recommendedthat trusts review their compliance with thebenchmarks in Essence of Care.

Communication When complainants raised concerns aboutcommunication in hospitals, our nursingadvisers found the following frequentlyoccurring issues:

• call bells not being provided or being left out ofreach of patients, particularly elderly patients

• a lack of communication and involvementwith relatives and carers about care andtreatment plans

• nurses being “abrupt” or “sharp” whenspeaking to a patient, making the patient feellike they were a nuisance.

Our advisers have also highlighted theseimprovements:

• greater involvement and communicationbetween carers and link workers when caringfor patients who may have special needs. Forexample, staff liaising with community learningdisability services when patients with a learningdisability were admitted, and making an earlyreferral to mental health workers for patientswho may have mental health problems

• using the Essence of Care toolkit to review andimprove current practice.

Privacy and dignity Many complainants felt that their privacy anddignity, or that of a relative, was not maintainedwhile they were in hospital. Our nursing advisersreviewed many complaints that involved:

• patients being left in soiled bedding and clothing

• personal hygiene needs not being met, inparticular patients not being given regularbaths or showers, hair care, nail care or oralhygiene

• clothing being inappropriate or inadequate –for example, gowns or nightdresses notmaintaining patients’ modesty

• bedside curtains or room doors being openedwhen the patient was receiving intimate care,or staff entering without knocking or waitingfor permission to enter.

However, our advisers also noted that trustsmade a number positive improvements in thepast year, including:

• using more signs to designate toilet andbathroom facilities for single sex use

• introducing signs that can be pinned tobedside curtains, and using fastenings tokeep curtains closed to improve privacy

• a trend towards the return of single sexwards, although problems remain inassessment units and facilities that care for‘day cases’ (patients who are not expected tostay in hospital overnight)




• staff being given training and attendinginduction programmes on the National ServiceFramework for Older People8 and meeting theneeds of the older person.

Nutrition Sometimes concerns about nutrition were theprimary complaint, but usually they were acontributing factor to complaints made aboutother aspects of care. For example,complainants were often concerned that arelative could not get better because of thepoor nutritional support that they were offered.Common issues that our nursing advisers sawthis year included:

• a lack of choice or variety of meals

• inedible food being served – for example,solid food being given to a patient who couldonly take liquids, or cold or unpalatable foodbeing served

• meals being poorly presented

• food not being available outside specific mealtimes

• nursing staff not helping patients to eat

• a lack of aids to help patients eat. Forexample, specially designed cutlery forarthritic patients, or special cups and beakersto help patients to drink

• food and drinks being placed out of reach,particularly of elderly people.

Our nursing advisers told us that the reason forthese problems was often that a full nursingassessment was not carried out (or recorded)

during the patient’s admission and that no risk-assessment tools were used to determine therisks posed to the patient or the level of carethat they needed.

Our advisers reviewed a large number of caseswhere trusts had not followed NICE guidelineson nutrition. However, they also saw anincrease in the use of the Essence of Caretoolkit to review nutritional care and implementimprovements in practice. Some positivechanges included trusts:

• developing local nutritional policies and usingrisk assessment tools and guidelines

• using a red tray or red dot to identify patientswho need help at mealtimes

• encouraging relatives and carers to helppatients at mealtimes if they wish to

• introducing ‘protected mealtimes’.

A&E careOur advisers on care in A&E departments toldus that for many patients and relatives, the caregiven in this department “sets the scene” forthe rest of their stay in hospital. If things gowrong in A&E, it will often affect a patient’sperception of their entire stay.

We received a large number of complaintsabout communication in A&E. It is difficult tocomment on this issue because what has beendiscussed with relatives and carers is often notdocumented. Our advisers have frequentlyrecommended that clinicians write down theexplanations they gave to patients’ families andthe context for the explanation.

Our advisers noted some instances of poorclinical handover of patients between teams.This included a lack of written plans that detailcurrent and ongoing issues in a patient’s care.These plans should follow the patient whenthey are transferred between care, but ouradvisers saw a number of cases where this didnot happen.

Another issue that frequently occurred incomplaints about A&E was the failure of staff torecognise or act upon abnormal vital signs,especially in respiratory rates. Patientssometimes arrive in A&E with vital signs thatare initially abnormal, but that then improve.



Case study – Complaint about nursing care

N, an 86-year-old lady, was admitted to hospital through A&E. She had a history of chestinfection and confusion, and had suffered a number of falls at home. N was transferred to amedical ward. Within 24 hours, N had fallen twice during the night. On the following morning,she fell again and fractured her femur.

N’s daughter made a complaint to the trust about her mother’s care and treatment. The trustsaid that it was satisfied that the care and treatment provided was appropriate. N’s daughterwas not happy with the trust’s response, so asked us to independently review her complaint.

We found that the staff on the medical ward had failed to read all of N’s admission history andgave care solely for her chest infection. They had also failed to undertake a moving andhandling assessment and a falls risk assessment, and their notes described the patient asindependently mobile. We concluded that the trust’s record-keeping in relation to the falls waspoor, and no forms were completed or could be found. On reviewing the nursing records, ournursing adviser noted a lack of time, dates and signatures on some of the evaluation sheets,illegible entries, and a lack of detail of the care planned and delivered.

We upheld the complaint and the trust accepted that poor documentation made it impossibleto assure the complainant that N had received an appropriate standard of care. The trustapologised to N’s daughter for the poor care and implemented an improvement programme.This included an audit of nursing documentation, training for staff in record-keeping and riskassessment, and a review of nursing standards using the benchmarks in Essence of Care.


These patients may be sent home because noobvious cause is found for the initial abnormalvital signs. However, many later return to A&Ebecause the underlying problem has worsened.Our advisers found that this was particularlycommon in elderly patients, who often arrivedwith vague or non-specific symptoms, and inpatients who were in the early stages of sepsis.

Using tools to assess risks to patients is aneffective way of detecting early warnings of suchproblems. The timely use of antibiotics early inthe patient’s care could also help in thesesituations. We have told trusts that they shouldmake sure their systems for assessing patientsare reviewed in line with NICE guidance.9

Our advisers found that pain relief was awidespread issue in complaints about A&E.Many patients were concerned about the lack, orinsufficient use, of timely pain relief. A trust’sfailure to give appropriate antibiotics andproblems with their management of warfarin*were also common complaints. We havefrequently recommended that trusts review theirapproach to pain relief against the standards setby the College of Emergency Medicine and theBritish Association of Medicine.

As in many of the other clinical areas, poordocumentation was a recurring issue incomplaints about A&E. This was particularlythe case when A&E doctors examined theneurological and musculoskeletal systems ofpatients. However, our advisers welcomed theincreasingly widespread use of generic andcondition-specific patient care proformas, suchas those issued by the Informatics Unit at theRoyal College of Physicians. These help toimprove record-keeping in line with guidanceissued by the General Medical Council and theRoyal College of Physicians.

“Many thanks for your support andyour research. It is so good to havesomeone who listens to me at last.”

Feedback from a complainant following ourreview of their complaint about hospital care

Maternity services

Communication issues also featured in many of the complaints about maternity services thatwe received this year. Our advisers reviewedmany cases when mothers felt that clinicalstaff did not listen to them when they expressedtheir needs.

Our advisers also noted a large number ofexamples of poor practice, such as:

• women being left alone in labour, withoutaccess to pain relief

• a lack of support and encouragement forwomen during various phases of labour

• midwives being too busy to give good qualitycare during the birth of the baby, and in theimmediate periods before and after

• midwives having poor attitudes andcommunication skills

• poor record-keeping

• a lack of team work and of consistent advicebased on evidence.

*An anticoagulant drug used to prevent blood clots.

This year, we made a number ofrecommendations to trusts to improve theirservices and address these concerns.

• We recommended that one trust should makesure an appropriate escalation plan was inplace to cover maternity services in thecommunity during peaks in activity. Thiswould enable women in its care to receive thequality of antenatal support from midwivesindicated in the National Service Frameworkfor children, young people and maternityservices10 and Maternity matters: choice, accessand continuity of care in a safe service.11

• We recommended that another trust shouldinvite the complainant to be part of the localmaternity service users group, or labour ward forum, so she could help to resolvesome of the communication issues that hercomplaint raised.

• We also recommended that a trust facilitateda workshop on communication and attitudefor staff involved with care delivery, and thatthis workshop should involve representativesfrom the Patient Advisory Liaison Service.

We have frequently reminded trusts that thenational service framework10 places a greatdeal of importance on communication. It urgesmidwifery leaders to address communicationissues by: “having the time to talk, engage andbuild a relationship with women and theirpartners to understand and help meet theirneeds throughout pregnancy.”

Supervision was another issue that frequentlyoccurred in complaints about midwiferyservices. Many incidents involving midwiferycare and practice were dealt with under thegeneral framework for the statutory



supervision of midwives. Our advisers noted asmall but significant number of complaints thatrelated to the competence of midwives. Many ofthem involved inexperienced midwives beingleft to manage the care of women with verycomplex medical needs.

One example of poor practice was when astudent midwife was left alone to care for awoman thought to be in the latent phase oflabour. The woman was actually in active labourand problems went unrecognised because ofthe student’s lack of experience andsupervision. This could have had a seriouslydetrimental effect not only on the patient andher family, but also on the student. Ourrecommendation was that the trust shouldmake sure that the student had the time andopportunity to reflect on her care for thecomplainant with her named supervisor ofmidwives. The student should also discuss withher supervisor things that she could have doneto improve the patient’s perception of her care.

However, there were some very good exampleswhere trusts have used the general frameworkfor the statutory supervision of midwivesappropriately and effectively. These included:

• using a supervisor from another trust toreview a patient’s care and treatment, so thatan independent report could be drawn up

• developing organisational andmultidisciplinary learning to address issuessuch as the management of haemorrhage

• reviewing existing protocols and guidelines tobring them in line with current evidence, andinforming all staff of any changes.


Case study – Complaint about maternity services

Mrs D was in the 38th week of pregnancy. She became unwell and was admitted to thematernity unit at a large NHS trust with contractions and a spontaneous rupture of heramniotic membranes. Following the birth, Mrs D began to bleed and had a postpartumhaemorrhage. She was transferred to theatre for further investigation into the cause of thehaemorrhage, but suffered a cardiac arrest in the corridor outside the theatre and died later.

Mrs D’s husband made a complaint to the trust about her care and treatment. The trust’sresponse was that the care and treatment was of a high standard and that all procedures hadbeen correctly followed.

Unsatisfied with this response, Mr D asked us to independently review his complaint. Weobtained clinical advice from a consultant obstetrician and concluded that there had been anumber of deficiencies in the care and treatment given to Mrs D, including poor record-keeping and inadequate supervisory arrangements.

We recommended that the trust should:

• make sure that midwifery and medical staff fully and accurately record their involvement ina patient’s care, in accordance with guidance from the Nursing and Midwifery Council

• arrange for the midwives involved in Mrs D’s care to have a supervision interview with theirnamed supervisor of midwives to review their practice, and arrange for them to attend askills workshop on managing postpartum haemorrhage

• review its guidelines for the management of postpartum haemorrhage and massiveobstetric haemorrhage

• formally acknowledge that there were deficiencies in the care given to Mrs D

• apologise to Mr D for these failings and for the misleading explanation it gave him in itsresponse to his complaint.

The trust accepted our recommendations and commissioned an independent report into itsmaternity services. The report highlighted a culture of bullying among staff, and resulted in areferral being made to our investigations team, which found some further concerns aboutpatient safety. We have continued to closely monitor the trust’s maternity unit since wereviewed this complaint, and the trust has put in place an action plan to drive improvementsin this area.

“I was fortunate that you wereinvolved, that you were persistent, aufait with regulations and processes,and paid attention to detail. Thank youvery much for all of your assistance.”

Feedback from a patient following our reviewof their complaint about maternity care

Mental health services

A significant number of complaints aboutmental health services were about crisisresolution teams. Our advisers noted that the following issues occurred regularly:

• service users not knowing whom to contact in times of crisis

• poor (or absence of) crisis and contingencyplans for service users who were subject tothe Care Programme Approach (CPA)12

• poor communication between staff, serviceusers and their families, particularly aboutwhat the crisis service was for and how toaccess it out of hours – for example, notelephone number being provided

• service users having different expectationsabout what a crisis team can do comparedwith what service the trust delivers

• inadequate assessments being done over thetelephone, resulting in poor clinical conclusions

• staff having a poor attitude. Some serviceusers felt that they were often referred back



to their GP the next day, or if they were anexisting service user, they were told todiscuss their issues with their carecoordinator

• complainants feeling that the crisis team wasreluctant to assess them at home

• a lack of a clear care pathway into and out ofthe service.

Many complaints about mental health servicesinvolved the CPA. The CPA states that serviceusers should expect an assessment of theirhealth and social care needs, a carecoordinator to be assigned to them, a care planto be drawn up for them, and to receive aregular review of their needs. Our clinicaladvisers found the most common themes inthese complaints were:

• no evidence of a crisis plan* in the care plan

• the care plan not reflecting the assessedneeds of the patient

• the patient not being involved in theformulation of their care plan

• the patient not being given a copy of theircare plan

• crisis plans not being detailed enough or notbeing adequately understood by the patient

• a lack of detailed care planning and riskassessments

• carers not being supported adequately oroffered assessments

*A crisis plan is an explicit plan of action to be implemented in a crisis or in a developing crisis situation. The planshould include early warning signs of relapse, previous strategies that were successful in managing crisis situations,and out-of-hours contact details. This information should be clearly stated on a specific section of the care plan andshould be easily accessible out of normal working hours.


Case study – Complaint about mental health services

D, a 17-year-old girl, was admitted to hospital with a severe infection. She remained in hospitalfor almost two months. D’s parents made a complaint to the trust about her care andtreatment. They believed that she was discriminated against due to her learning disabilities and that she was given sub-standard care because staff felt that she did not have a good qualityof life.

We upheld the complaint made by D’s parents. We found that the trust had failed to consultexternally based professionals who knew D to make sure that it gave her the most appropriatecare. The trust had also failed to appropriately consult with D’s parents, and did not appear towant their input into her care. We concluded that the quality of nursing care was poor, thatsome medications were not administered properly, and that the trust’s investigation of thecomplaint was inadequate.

To resolve this complaint and improve patient care, we recommended that the trust should:

• provide a clear statement of how it planned to improve staff knowledge and understanding ofthe complex needs of people with learning disabilities

• develop an action plan with clear outcomes, and share this plan with the complainant. Thetrust should involve local expert providers and Mencap to help to facilitate this work, andshould identify an individual within its staff to champion this cause

• the trust’s clinical governance committee should review the case to establish what lessonscould be learned. The trust should advise the complainant of the outcome of this review

• the director of nursing should oversee a review of the trust’s administration of medicinespolicy to make sure that nursing staff follow it

• provide a detailed explanation of why additional staffing was not provided and what action itwould take in future if it was faced with a similar situation

• the director of nursing should contact their fellow director of nursing at the neighbouringspecialist service for people with learning disabilities to discuss how to improve theexperience of people with learning disabilities during acute hospital admissions

• confirm that changes have been made to its procedure for handling complaints to make surethat the NHS complaints regulations are followed.

The trust accepted our recommendations. The complainants telephoned us to say how pleasedthey were with the quality of our review and the recommendations that we made forimprovement.



• a lack of evidence that patients were includedin decisions about their care and treatment –for example, the patient and carer not signingthe plans.

However, our clinical advisers also noted manyexamples of good practice within mental healthservices, including:

• clear crisis and relapse plans that were easyto understand and that were signed by theservice user. Such plans included statutoryand non-statutory contact numbers and help lines

• consultant psychiatry ‘emergency clinics’having an open referral system for serviceusers known to community mental health teams

• evidence of detailed crisis and care plansfrom some trusts that were using electronicCPA systems

• 24-hour cover being provided by crisis teams

• good communication tools being sharedbetween crisis teams and community mentalhealth teams – for example, shared careplanning, shared telephone logs, andintegrated electronic records.

Ambulance services

Around a third of these cases concernedcomplaints made about ambulance responsetimes.

Our advisers found that the majority of caseswithin this sector were linked to a complaintabout a trust. For example, a patient or relativeoften complained about the care and treatmentat a trust at the same time as they expressedconcerns about an ambulance transfer. Most ofthe complaints involved the A&E service ratherthan the patient transport service.

Our advisers found that the standards ofrecord-keeping in ambulance services weresometimes inadequate. In some cases, weneeded to review accompanying hospitalrecords to establish what care the ambulancecrew provided because their records were notsatisfactory.

Our advisers noted that in response to acomplaint, some ambulance trusts set out theDepartment of Health’s guidelines and targetson ambulance response times, and explained tothe complainant that they had met these. Thisresolved the complaint to some extent.However, we often recommended thatambulance trusts should take a more roundedview of the complainant’s concerns, and expresssympathy that the person making a 999 call willhave experienced considerable distress.


Case study – Complaint about a child’s care and treatment in A&E

B, a 19-month-old girl, was taken to A&E by her parents with a scald injury. The injuryrequired three follow-up visits at 48-hour intervals so that her dressings could be changed. Bwas then referred to a specialist burns unit where upon admission she was given morphineand a skin graft. B’s parents made a complaint about their daughter’s clinical treatment. Inparticular, they were concerned about what they saw as inadequate pain relief duringdressing changes.

The trust stated that pain relief was not required at dressing changes because the time itwould take for analgesia to become effective would be as distressing for the child as the timeit would take to change the dressing. Its response to the complaint simply repeated thesequence of events rather than properly addressed the concerns that B’s parents had raised.

Our independent review of the case found that:

• the initial assessment of B’s wound was inadequate

• the pain relief was inadequate

• follow-up visits were poorly recorded and the notes were often illegible

• the trust had not provided evidence of any guidelines for the management of burns inchildren, either as an existing policy or one under development.

We therefore upheld the complaint and recommended that the trust should:

• work with the local burns unit to develop guidelines for the management of burns in children

• record burns on specific burns charts

• make the recognition and alleviation of pain a priority when treating ill and injured children.This process should start at triage, be monitored during the child’s time in A&E, and finishwith ensuring adequate analgesia. If appropriate, it should also continue beyond discharge,in accordance with the British Association for Emergency Medicine’s Guideline for theManagement of Pain in Children.13



Services for childrenIn carrying out all of our statutory duties,including the review of second-stage NHScomplaints, we are required to pay particularattention to the need to safeguard and promotethe rights and welfare of children, and theeffectiveness of measures taken to do so.

We have a dedicated children’s complaintsgroup within our complaints team. This groupmonitors complaints involving children to makesure that if there is a serious service failureinvolving the care of a child, or there areunrecognised and/or ongoing child protectionconcerns, appropriate referrals are made toother agencies or to other groups within theHealthcare Commission. The children’scomplaints group reports to our Children’sStrategy Group and to our SafeguardingChildren Board.

This year, we received over 500 complaintsabout the care and treatment provided tochildren. Around 10% of these concerned thesafeguarding of a child or a vulnerable person.

Complaints that involved the care and treatmentprovided to children were most commonly madeabout the primary care sector (39%), closelyfollowed by the acute sector (32%).

The issue most frequently raised was about theway in which the trust handled the complaint(19%). The next most common complaintsrelated to concerns about communication (16%)and diagnosis (10%).

Palliative care

We reviewed almost 50 complaints that wereprimarily about palliative care this year. Themost frequently occurring issue in thesecomplaints was that the family had perceivedthe physical deterioration of their relative, butthat the healthcare team had not kept theminformed, given them choices, or supportedthem to make decisions about the patient’s care.

Our clinical advisers on palliative care foundthat poor communication between and withinteams, specialisms, and different transferareas was another area of concern thatoccurred too frequently in complaints.

In a significant number of cases, our advisersfound that this poor communication limited apatient’s sense of empowerment and theirability to make an informed decision about theircare. Often the decision to move the focus frompatient ‘cure’ to patient ‘care’ was also notclearly communicated. As a result, needlessand painful interventions took place,diminishing the patient’s quality of life. Ouradvisers told us that referrals to specialistpalliative care teams were sometimes madetoo late, or not at all.

Poor support for basic comfort, family andpatient privacy, and spiritual, cultural andpsychological needs were all common issues incomplaints about palliative care. Our advisersfelt that a basic lack of communication led tomany of these problems. Clinical teams oftendid not convey the seriousness of an illness topatients or their relatives, who need thisinformation to make decisions. An early referralto palliative care means that greater emphasiscan be placed on making a patient comfortable,and their spiritual and psychological needs canbe attended to.


Our clinical advisers noted that not all trusts hadadopted the Care of the dying: A Pathway toExcellence,14 the Preferred Place of Care Plan,15

and the Gold Standards Framework.16 So, whilethere were a number of areas of good practice inpalliative care, we also made recommendationsthat trusts put these frameworks into place.

Prison healthcare

We received 86 requests to independentlyreview complaints about healthcare in state-run prisons this year.

Recognising the challenges faced by prisonerswho want to make a complaint, we proactivelyinvolve the Independent Complaints AdvocacyService when we review these complaints. Wereferred over half (47) of the complaints that wereceived this year to the IndependentComplaints Advocacy Service and ourexperience shows that many prisoners will askthem for their support to make a complaint.

About half of the complaints that we receivedwere ineligible for independent review, usuallybecause the complaint had not yet been madeat the local level. As only 25% of all of therequests that we receive are ineligible, thissuggests that there may be some uncertainty inprisons about the correct procedure for makinga complaint about prison healthcare.

Establishing whether a complaint is eligible forreview can be difficult. Often the prisoner willcomplain about matters that concern bothhealthcare and the prison service. The prisonermay also no longer be in the prison that theyare complaining about, so the information weneed to determine eligibility may be located indifferent prisons and trusts.

The most common issue in these complaintswas the general standard of healthcare. Forexample, prisoners being unable to see a GPwhen they needed to; the poor attitude of staff,particularly nursing staff; and nursescontrolling access to GPs. Prisoners also tendto be regularly moved around the prison estate,so can receive a type of service at one prisonthat is not available at another prison. Thiscauses issues about medication – for example,a particular medication may be prescribed inone prison, but not in another.

We found that the informal prison complaintsprocess was sometimes used for complaintsabout healthcare. This process involves theprisoner completing a ‘Comp1’ form and amember of the healthcare team writing aresponse on the back of the form. The prisonerwas often not advised of the correct procedureto follow to make a complaint about theirhealthcare.

During the year, we worked with the Prisonand Probation Ombudsman to consider betterways to handle complaints that involveshealthcare and prison issues. We have seen agenuine willingness from prison healthcareteams and PCTs to resolve complaints aboutprison healthcare, and to improve theirprocedures for handling complaints.

Continuing healthcare

The term ‘NHS continuing healthcare’ meansfully funded care for people who do not needcare in an NHS acute hospital, but still need ahigh degree of ongoing healthcare. Continuinghealthcare funding is intended to cover theentire costs of care, including all medical care,nursing care, personal care, living costs andaccommodation costs.



Case study – Complaint about prison healthcare

A, a prisoner, was admitted to hospital with 23% burns from a fire in his cell. He died as aresult of his injuries. A’s family made a complaint to the trust about his care and treatment.

The trust investigated the complaint and concluded that there was no further action to betaken. A’s family were not happy with this response, so asked us to independently reviewtheir complaint.

Our review found several failings in the way that the trust managed A’s care and treatment:

• it had not carried out toxicology screening on A when he was admitted to hospital

• it had inappropriately prevented A’s mother from taking photographs of him

• it did not take a full medical history of A

• its protocols for the admission of prisoners to hospital were inadequate.

We upheld the complaint and recommended that the trust should:

• urgently review its protocols for the admission of prisoners, and work with the police andprison services to do so

• acknowledge that it would have been good medical practice to carry out toxicologyscreening and apologise that it did not

• review its procedures for dealing with burns patients, especially if there is doubt about thecause of the injuries

• review its policy regarding photography, particularly in special situations – for example,medico-legal cases or if a patient is unconscious.


This year, we reviewed over 100 complaintsabout continuing healthcare. Two-thirds ofthese related to funding issues.

Our approach to reviewing complaints aboutcontinuing healthcare is to review theprocedures that the trust follows when it makesa decision on whether or not to grant funding.We do this to make sure that their proceduresare in line with established Department ofHealth guidance. We then makerecommendations to strategic health authorities(SHAs) and PCTs based on our findings.

We have regular contact with SHAs, PCTs andcomplainants, and have developed a proactiveapproach to reviewing complaints aboutcontinuing healthcare. This has enabled us tonegotiate the resolution of cases with PCTs andSHAs as quickly as possible and identify ifeither the PCT or SHA needs to take any furtheraction. All parties welcome this approach.

We also give the Department of Healthfeedback about any concerns or trends that wenotice in these complaints.

We follow a basic list of steps (below) when wereview complaints about continuing healthcare.It is very closely based on the NationalFramework for NHS continuing healthcare andNHS funded nursing care in England: aconsultation.17 It also takes account of theHealth Service Ombudsman’s approach toreviewing retrospective continuing care cases.

• The PCT should have gathered all available andappropriate evidence, including informationfrom the GP, the hospital (such as nursing,medical, and mental health records, andrecords of any other therapies), communitynursing services, care homes, social services,and the patient and their relatives.

• The PCT should have assessed the patient’shealthcare needs at the relevant point in time,and the patient should be reassessed atappropriate intervals.

• The patient, or their relatives, should beinvolved as much as possible and givenopportunities to input information at all stages.

• All deliberations at review panels should befully and accurately documented.

• All attempts to gather information should befully auditable, even if that information wasultimately unavailable.

• There should be clear and easy-to-understand letters sent to the patient or theirrelatives. The letters should explain therationale behind the panel’s decision onwhether or not the patient is eligible forcontinuing healthcare, based on their overallheath needs.

• The panel should consider whether a patientis eligible for continuing care, and anyrationale for the decision should be fullydocumented and auditable, prior to anyconsideration for Registered Nursing CareContributions (money paid by the NHS for the nursing care component of a patients’continuing care package).

• The panel deliberations and the decisionletter should be consistent.

• The patient should be offered a SHA panel review.

• If the SHA panel chair declines a SHA panel,the chair should send the patient, or theirrelatives, a letter that fully explains why “thepatient falls well outside the eligibility



criteria” or why “the case is very clearly notappropriate for the panel to consider”, asstated in the Department of Health’sdocument HCS2001/015: LAC (2001)18,paragraph 7. The chair should have takenrelevant advice to enable them to make thisdecision, and this advice should be recordedin the patient’s file.

• If the SHA panel chair decides to hold a SHA panel:

• the panel must comprise one PCTmember, one local authority member, andone appointed lay chairman, as per theDepartment of Health’s The Continuing Care(National Health Service Responsibilities)Directions 2004

• the SHA should have gathered all availableand appropriate evidence, includinginformation from the GP, the hospital (suchas nursing, medical, and mental healthrecords, and records of any othertherapies), community nursing services,care homes, social services, and thepatient and their relatives

• the panel must have obtained independentclinical advice where appropriate

• all deliberations at review panels should befully and accurately documented

• patients, or their relatives, should be sentclear and easy-to-understand letters thatexplain the rationale behind the panel’sdecision on whether or not the patient iseligible for continuing healthcare, based ontheir overall heath needs. The letter shouldalso explain what the next stage of theappeals process is.

In over half (57%) of the complaints aboutcontinuing healthcare that we were asked toreview, we either upheld the complaint or askedthe trust to do further work to resolve it.

Improving our independentreview service In the first reporting period, we received a very large number ofrequests for an independent review, largely due to increasedpublic confidence in our independent review service. This sectiondiscusses the improvements that we made to our service tomanage these requests.


Many patients, and staff who had complaintsmade against them, had to wait longer than wewould have liked for their cases to be resolvedbecause we received so many requests toindependently review a complaint. Therefore,we re-evaluated our processes for reviewing acomplaint and implemented a number ofchanges (see appendix), including:

• increasing the number of staff that handlecases

• increasing the number and type of clinicaladvisers that we use

• streamlining our process to make it moreefficient.

These changes have led to significantperformance improvements. As a result:

• at the start of August 2006, we had 5,180open cases. At the end of July 2007, we hadjust 2,298 open cases – a reduction of over 50%

• we closed 10,950 cases in the first two years,and 10,366 cases this year. People are nowwaiting far less time for their case to beconsidered.

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Figure 5: Complaints team output, comparison of first two years with August 2006 to July 2007

The demand for reviews was relatively constantthis year, at around 650 requests per month. Ourchallenge was to shorten the time it takes toreview a case and reduce the number of casesthat take more than 12 months to close. Peoplewho ask us to review their case have oftenwaited some months to get a response from thetrust involved, and we don’t want to extend thiswait. It is also unpleasant for NHS staff who havehad a complaint made against them having towait for resolution, and the opportunity to learnfrom events reduces over time. It is therefore ineveryone’s best interest for the review to becompleted as quickly as possible.

While the number of new cases that we wereasked to independently review was relativelystable, the number of completed casesincreased dramatically. From August 2005 toJuly 2006, the number of case closures permonth steadily increased to 800. This year,there was even more improvement, with onaverage 863 cases closed per month. Over thecourse of the year, 10,366 cases were closed,2,887 more than had been opened. Fewer open cases means that we can use ourresources more efficiently to resolvecomplaints more quickly.

Improving our independent review service continued


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ases

Figure 6: Number of cases opened or closed in a month, from August 2006 to July 2007


This year we reduced the average time it takesto close a case to just below five months –seven weeks less than in the previous reportingperiod. We did this by addressing the profile ofopen cases and using a more effective processto review new cases. As at March 2008, theaverage time for us to resolve cases is now lessthan three months.

We aim to consistently reduce the average timeit takes to close a case, while maintaining ourfocus on quality. Making a complaint can behighly distressing for the patient and for theindividual or trust being complained about.Therefore, it is better for both parties if acomplaint can be resolved as quickly as possible.

We have not only improved our efficiency, butwe have also developed the way in which welearn from complaints and feed our learningback to the NHS to improve patient care.

We use the information that we gather from ourindependent reviews of complaints (in particular,the recommendations that we make to trusts) inour annual health check to assess trusts’ self-declarations of compliance against theGovernment’s core standards. If a trust’s self-declaration varies from the information that weobtained during our reviews, we may inspect thetrust. In turn, this may affect the trust’s rating inour annual health check.

All NHS trusts give us an annual report oncomplaints, setting out the improvements thatthey have made to their services as a directresult of our recommendations. We havestrengthened our process for following up withtrusts and now monitor whether or not theycomply with all of our recommendations. If theyunreasonably refuse to comply, we will escalatethe matter through the relevant strategic healthauthority (SHA) or Monitor (the independentregulator of NHS foundation trusts). We willalso involve our regional inspectorate team towork with the trust locally.

We produce quarterly reports for each SHAarea to keep a better track of trends incomplaints. These reports set out the outcomesof our reviews and the recommendations thatwe have made for each trust in a region.

While we have been resolving a greater numberof cases more quickly, we have never lost sightof the importance of maintaining quality in ourwork. Therefore, we have taken a number ofsteps throughout the year to improve ourindependent review service.

• We have introduced a new quality assuranceprocedure, and trained our staff to follow it.This new procedure is integral to our case-handling process as it is focused on early andsustained contact with both parties to thecase, and on the quality of our written work. Ifa piece of work fails a quality assurancecheck, the case cannot progress until we havetaken remedial action.

• We have also recruited a compliance officerwho checks a random sample of cases eachweek to monitor whether case managers andsupervisors are complying with the newquality assurance procedure.

Since we assumed responsibility for the secondstage of the NHS complaints process, theParliamentary and Health Service Ombudsmanhas reported on 819 of the 21,320 cases that wehave reviewed. Of the 819 cases, just 314 havebeen fully upheld against us* – an indication ofthe high standard of our work.

We have also sent feedback forms to bothparties involved in a random sample of 25% ofclosed cases. The responses to these formsshowed that:

• 63% of people felt that their review was fairand independent

• 74% of people felt that their case managerhad kept them informed about the progress oftheir case

• 66% of people felt that the rationale behindour decision was clearly explained.

We aim to improve these figures in the nextyear, as more cases will be reviewed throughour new process.

This report does not cover complaints madeabout independent healthcare providersbecause we deal with those complaints in adifferent way.

Improving our independent review service continued


*Data received from the Parliamentary and Health Service Ombudsman’s office. It covers all of the cases weindependently reviewed until 1 August 2007.


We consider reviewing a complaint about anindependent healthcare provider when:

• the provider has breached its conditions ofregistration

• there is suspicion or evidence that theprovider is unfit, or that it is not complyingwith the regulations or national minimumstandards for independent healthcare

• patients may be at immediate or potential risk

• a serious failure in services is identified.

We expect the independent healthcare providerto carry out the first stage of its process forhandling complaints and try to resolve thecomplaint at the local level. We check whetheror not there are further options available to thecomplainant within the provider’s process forhandling complaints. If there are none, we canreview the complaint to see if there is evidenceof a breach of the regulations or non-compliance with the national minimumstandards.

More information about our role in reviewingcomplaints about independent healthcareproviders is available on our website:www.healthcarecommission.org.uk.

Conclusions and next steps

We saw many examples of good practice in the over 10,000complaints that we reviewed this year. However, we also saw toomany examples where the trust could have done more to resolvethe complaint.


This year, we referred 26% of the complaintsthat we received back to the trust for furtherwork because we found that the trust had notdone enough to resolve the complaint. When weadded this figure to the complaints we upheldor partially upheld in favour of the complainantbecause the response was not accurate orcomprehensive, we found that procedures forhandling complaints were not satisfactory inaround half of the cases that we reviewed.

This was also borne out by the number ofrecommendations that we made to trusts abouttheir procedures for handling complaints, andabout the need to improve their servicesthrough learning from complaints. Some trustsstill need to make significant improvements tothe way that they handle complaints.

However, we saw some areas of improvementthis year and should remember that complaintswere made about only a small fraction of themillions of cases where the NHS provided careand treatment.

We were pleased that many trusts were usingthe increased timescales in the amended NHScomplaints regulations to deliver betteroutcomes for complainants. We also saw moreevidence that some trusts were using thelessons that they had learned from complaintsto improve their services and prevent furthercomplaints.

Unfortunately, many of the areas of poorpractice that we highlighted in last year’s reportwere still occurring too often.

• Many trusts did not use the full range ofoptions available to them to resolvecomplaints. For example, trusts did not offercomplainants an apology, meetings with staff

to explain what had happened, financialcompensation for loss, remedial treatment, orsupport to get further treatment to remedyany harm or sense of injustice the patient had suffered.

• Letters that confirmed the outcome of acomplaint were often of poor quality, with theemphasis more on the process of theinvestigation rather than the outcome for thepatient. We saw many letters where the trustdid not use empathetic language when it wasneeded and did not explain complex medicalterms.

• Many trusts did not test their responses tocomplaints against existing national guidanceto support their statements that care was of asuitable quality.

We saw many cases where trusts had genuinelylearned from things that had gone wrong andhad taken remedial action, but did not tell thecomplainant. Therefore, the complainant wasconcerned that no action had been taken andasked us to review their complaint.

We call upon trusts to make sure that theirsystems for handling complaints are effective,and focused on resolution and learning lessons.We recommend that their systems are:

• accessible to everyone who uses the service

• information about how to make a complaintis easily available and easily understood byeveryone who uses the service

• staff are trained to respond to an initialcomplaint with confidence, and to make anyimmediate changes required, and knowhow to escalate matters appropriately ifimmediate resolution is not possible

• trusts analyse whether the main source ofcomplaints (such as one particular ethnicor social group) represents the majority ofpeople who use their services, and areproactive in encouraging feedback fromunder-represented groups

• easy to use by anyone who wants to make acomplaint

• complaints can be made in a variety ofways that are convenient to thecomplainant (such as via the trust’shelpline, the internet, an easy-to-completeform, or meetings outside office hours)

• the steps that need to be taken to resolvecomplaints are easy to follow and logical toeveryone involved

• trusts use a range of possible responses toresolve complaints

• trusts direct complainants to otherorganisations that can help them to make acomplaint (such as the IndependentComplaints Advocacy Service)

• sympathetic to the complaints

• staff treat all complainants sympatheticallyand courteously

• trusts offer appropriate counselling or carewhen grave or distressing complaints aremade

• focused on resolving matters

• staff are authorised to use a range ofmeasures to resolve complaints

• trusts seek to resolve complaints, ratherthan just ‘process’ them

• trusts agree the type of response (such asa report, letter or meeting) with thecomplainant, and it is appropriate to theissues raised

• trusts are flexible with the type of remedythat they provide (such as offeringapologies in person rather than in writing,holding meetings with the complainant todiscuss issues, and involving complainantswhen they make improvements to services)

• non-adversarial

• able to provide a robust examination of theissues raised

• a clear plan and policy for examiningcomplaints is available

• recognised techniques (such as root causeanalysis) are used to formulate theresponse, if this is appropriate to theseriousness of the issues raised

• relevant evidence and statements aregathered and explained to the complainant

• staff who are involved in the complaintcontribute to the response whereverpossible

• senior staff manage the overall response tomake sure that it is accurate and appropriate

• independent input is used when it isappropriate (such as in very complex oremotive cases) to demonstrate opennessand transparency in processes and response

Conclusions and next steps continued



• able to ensure that an appropriate remedy isprovided if a problem is found

• a flexible range of remedies is available,and staff are authorised to use them toresolve complaints

• linked to the trust’s service improvementagenda

• trusts gather information about complaintsin a systemic way and use it as a learningtool, and share it with other professionalgroups and departments

• senior staff make sure that recommendedimprovements are followed through, andbuild feedback into models of servicedelivery

• commissioners gather and act uponfeedback about services

• trusts have proactive mechanisms forfeedback that allow those who have made acomplaint to tell trusts whether they havefelt the impact of improvements.

Many complaints would not have been made ifpatients were not concerned about poorcommunication and the attitude of staff. Weoften found that a patient’s care and treatmentwas in line with established standards, but thatthe trust didn’t give the patient or their relativesa clear, understandable explanation of what thetreatment involved. This led to uncertainty aboutwhat happened to a patient and a complaint wasmade. Our clinical advisers saw this trendacross all of the clinical areas. Trusts do notneed significant resources to improvecommunication. We urge them to put a greaterfocus on communication and ‘customer’ care.

Many of the complaints that we highlighted inthis report were about the basic elements ofhospital care, such as nutrition, privacy anddignity, and record-keeping. Although thepatient’s overall treatment may have beensuccessful, issues with these basic elementsmade the patient and their relatives feel likethey had had a bad experience. Trusts can alsomake improvements in these areas withoutneeding a significant increase of resources. Weencourage trusts to make sure that they complywith the benchmarks in Essence of Care,4 and toaudit their compliance regularly.

The key finding of this report is that, althoughthere are many examples of good practice inthe way that the NHS handles complaints, thereis also a great deal of work that needs to bedone before it has a system that meets theneeds of the complainants. The system shouldbe used as a rich and valued tool, using patientfeedback to help to improve services. Thisfinding is consistent with the finding in ourrecent complaints audit2 and in theParliamentary and Health ServiceOmbudsman’s recent annual report.18

Next steps

We aim to build on the improvements that wemade to our performance this year by makingfurther improvements to our independentreview process. We are also committed todelivering on our key targets. In the firstquarter of 2007/2008, we met our target ofresolving 95% of cases within 12 months. Thisyear we are confident that we will also meetour target of resolving 65% of all cases withineight weeks. At the same time, we will remainfocused on maintaining and improving the highlevels of quality of our reviews.

We have a comprehensive plan forcommunicating with our key stakeholders in thenext year. We will regularly feed back what wehave learned from complaints to the NHS – forexample, through a programme of speakingengagements with health and social carecomplaints staff, and through our quarterlyupdates to strategic health authorities andMonitor on complaints about trusts in their area.We will also focus on ensuring that ourrecommendations are acted upon and that ourassessment work reflects the importance of complaints.

Building on our recent complaints audit, we willhelp to drive improvements in the way thatcomplaints are handled at the local level. We willhelp the NHS to prepare for the Government’sproposed new arrangements for handlingcomplaints. We will also give more informationand share best practice on effective ways forhandling complaints, including case studies.

Alongside this report, we are launching a toolkitto improve the way that trusts handlecomplaints. Together with the Parliamentaryand Health Service Ombudsman’s guidance,such as the Principles of Good Administration19

and the Principles of Remedy,20 our toolkit willhelp to support trusts to resolve complaints atthe local level. We will work closely with theParliamentary and Health Service Ombudsmanto make sure that the guidance offered in thesedocuments is consistent.

We firmly believe that the best way to resolve acomplaint is for the trust to engage effectivelywith the complainant. This will ensure thatthere is an appropriate response, that lessonsare learned, and that these lessons are used toimprove patient care. We are committed tofeeding back what we learn from complaints tothe NHS so that improvements can be made.

We will work with other interested parties, suchas the Parliamentary and Health ServiceOmbudsman, the Commission for Social CareInspection, and the Department of Health, toprepare for the proposed new arrangements forhandling complaints. We welcome theemphasis on local resolution of complaints, andthe enhanced role for the Parliamentary andHealth Service Ombudsman in the process.

However, there is a lot of work that still needsto be done in some areas. Trusts will need toincrease the capacity of frontline complaintsdepartments, as well as having strongleadership at board level on handlingcomplaints and learning lessons from them, tomake sure that the proposed newarrangements work.

The proposed new regulatory framework will bean excellent opportunity to make NHS trustsaccountable for their services. Trusts should beencouraged to better respond to cases throughthe new clear and measurable nationalstandards, which are focused on local resolution.Boards should have a clear legal responsibilityfor responding effectively to complaints andensuring that lessons are learned from them. Inaddition, contracts that commission servicesfrom trusts need to clearly set out theexpectations for the trust’s performance. Thisneeds to be followed up with vigour bycommissioners, whose activity in this area shouldalso be accountable through the standards.

The new regulator should continue to beinvolved in assessing trusts’ performanceagainst the national standards, and localimprovement networks should be involved inevaluating how trusts are performing on a locallevel. This evaluation should be considered inthe proposed new regulatory framework.

Conclusions and next steps continued



1 Healthcare Commission (2007) Spotlight oncomplaints: A report on second-stagecomplaints about the NHS in England

2 Healthcare Commission (2007) Is anyonelistening? A report on complaints handling inthe NHS

3 Healthcare Commission (2007) The views ofhospital inpatients in England: Key findingsfrom the 2006 survey

4 Department of Health (2003) Essence ofCare: Patient-focused benchmarking forhealth care practitioners

5 Department of Health (2004) Standards forBetter Health

6 General Medical Council (2006) Good MedicalPractice

7 General Dental Council (2005) Standards fordental professionals

8 Department of Health (2001) National ServiceFramework for Older People

9 National Institute for Clinical and HealthExcellence (2007) Acutely ill patients inhospital: recognition of and response to acuteillness in adults in hospital

10 Department of Health (2004) NationalService Framework for children, youngpeople and maternity services

11 Department of Health (2007) Maternitymatters: choice, access and continuity of carein a safe service

12 Department of Health (1999) Effective CareCo-ordination: Modernising the CareProgramme Approach – A Policy Booklet

13 British Association for Emergency Medicine(2004) Guideline for the Management of Painin Children

14 Ellershaw J, Wilkinson S (Editors). Care ofthe Dying: A Pathway to Excellence. OxfordUniversity Press, 2003

15 http://www.cancerlancashire.org.uk/ppc.html

16 http://www.goldstandardsframework.nhs.uk/

17 Department of Health (2006) NationalFramework for NHS continuing healthcareand NHS funded nursing care in England: aconsultation

18 Parliamentary and Health ServiceOmbudsman (2007) Annual Report 2006-07:Putting principles into practice

19 Parliamentary and Health ServiceOmbudsman (2007) Principles of GoodAdministration

20 Parliamentary and Health ServiceOmbudsman (2007) Principles of Remedy

References

Improving our independent review service

The first two years of our independent reviewservice were characterised by a need to keepup with demand. Our review process wasdesigned on the basis that we would receivearound 5,000 requests for an independentreview each year, reflecting the number ofrequests made through the previous system.The actual number of requests that wereceived, some 8,000 per year, created anumber of challenges for us – bothorganisational and in terms of the process thatwe used.

Our review service aims to meet our servicelevel agreements in three key areas:

1. acknowledging all requests for anindependent review within two working days

2. completing 65% of all reviews within eightweeks of receipt

3. completing 95% of all reviews within 12months of receipt.

We met the first point consistently in the firsttwo years, but the second and third points werenot achieved in this timeframe.

As we did not meet these last two key areas, weconducted a comprehensive review of ourprocess for handling complaints, which wasdesigned to help us to:

• deliver a service within an agreed timeframe

• reduce the amount of work in progress,measured by having fewer than 3,000 casesopen at the end of the reporting year

• provide greater visibility of the way that welearned lessons from the independent reviewprocess

• give assurance that we resolve all cases assoon as it is practical to do so, whilemaintaining the quality of our work.

The review focused on four key areas:

• improving our processes

• consistency

• establishing a performance-centred culture

• improving our access to clinical advice.

Improving our process for independentlyreviewing complaints

To inform the review of our process forhandling complaints, we not only looked at thelearning and experience that we had acquiredin the first two years of our operation, but wealso actively sought the input of some of ourkey stakeholders. For example, we organised anumber of conferences with NHS complaintsmanagers and sought the views oforganisations such as the Parliamentary andHealth Service Ombudsman and theIndependent Complaints Advocacy Service.

Following our internal review, we implementedan improved process with seven clearly definedstages for managing second-stage complaints(see figure 7). It aims to:

• allow a case to be managed by one person

• facilitate case resolution at the earliest stage


Appendix – Process improvements


within the process, while maintaining high-quality standards

• address ‘bottlenecks’, where the processcould be constrained by a lack of resources

• use administrative support for routine, well-defined tasks

• improve communication across ourcomplaints team

• improve our communication with thecomplainant and the people complained about

• provide a clear end for the review, where allfollow-up activity is done by anotherspecifically resourced and directed team.

Through stages 2, 3, 4 and 6, our improvedprocess works around a cycle of gathering andconsidering information, and making decisions.The aim is to reach a fair and robust decision atthe earliest stage so that the interests of bothparties are addressed as quickly as possible.Our improved process puts greater emphasison early contact between the case manager

and all parties involved – usually by telephone –to discuss the issues that have not beenresolved by the trust. This makes it easier forus to explain to trusts why complainants arenot satisfied, so that all parties can worktogether more effectively to resolve thecomplaint.

The seven-stage process improves ourpotential to resolve a case as quickly aspossible, but in no way compromises the depthof the review that is required to fully addressthe complaint. Figure 8 overleaf shows theinputs and outputs of our processes.

Consistency

When we reviewed our process, we evaluatedall aspects of our work to ensure consistency.We updated our standard response anddecision letter templates, considered the rulesthat govern the progression of a review fromone stage of the process to the next, andimplemented an improved quality assurancesystem and more comprehensive performancereporting.

CHANGE ALL TO CMYK

Trustdeclaration

Final closure point

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6

Receive new case

Start reviewspecificationand obtainingclinical advice

Establishjurisdiction

Specificationand collectionof data

Procurementof clinicaladvice

Final decisionand close

Potentialdecisionpoints



Finaldecision

point

Stage 7

Post caseclosureand learning

Figure 7: Our improved seven-stage process for independently reviewing complaints

Appendix – Process improvements continued


Entrance

Exit

3 Out of jurisdiction3 Further local review3 Upheld3 Not upheld

Information

ConsiderationDecision close orrecycle

3 Request3 Files3 Conversations3 Statements/ interviews3 Records3 Research3 Clinical advice general/specific

3 Completeness3 Accuracy3 Regulations3 Guidance3 Reasonableness

Figure 8: Process steering model Performance management

We have improved the way that we measureand report our performance in both quantitativeand qualitative terms. This is crucial in buildingstakeholder confidence, and is the centre of ourimproved way of working.

Improved access to clinical advice

High-quality advice from clinicians is crucial toour independent review service. We can oftenonly test how reasonable a trust’s responsewas by obtaining the input of a clinician who isqualified to comment on the clinical matters inthe complaint.

Problems accessing clinical advice caused amajor bottleneck in our review service in its firsttwo years. We have taken measures, such asforming a discrete clinical advice procurementteam, to make sure that clinical advice can beaccessed much more efficiently. This allows usto resolve complaints more quickly.

Our clinical advice procurement team supportscase managers by providing clinical advice andmanaging a clinical adviser database thatmakes contacting relevant specialists easier.

Our improved process was developed duringthe first half of the first review year, andestablished during the second. It is now fully inplace and undergoes continual development.

We reviewed our processes at the same time aswe continued with a ‘business as usual’approach. Consequently, our level of work fromthe review period shows a trend of consistentimprovement. We expect this trend to continue.

This publication is available in other formats and languages on request. Please telephone 0845 601 3012.

9 781845 621803

ISBN 978-1-84562-180-3

Telephone 020 7448 9200Facsimile 020 7448 9222Helpline 0845 601 3012

Email [email protected] www.healthcarecommission.org.uk

This publication is printed on paper made

from a minimum of 75% recycled fibre

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