Annual Report for Complaints 2010 -2011

Introduction

The past year has seen the Local Authority and NHS Complaints (England) Regulations embedded into practice adhering to the principles of the Department of Health document Listening; Responding; Improving: A Guide to Better Customer Care

On receipt of a complaint the concerns raised by the complainant are ’triaged’ using the matrix provided by the Department of Health document to assess the seriousness of the complaint against a rating of low, medium or high and the likelihood of reoccurrence.

Rare / Unlikely / Possible / Likely / Almost certain
Low / Low
Moderate
Medium
High
High / Extreme

All complaints are acknowledged within 3 working days (not counting the day of receipt) and complainants are provided with information about advocacy services if they are not already represented by an independent advocate.

In most cases the complainant is offered the opportunity to talk to a Senior Manager in the acknowledgement letter either in a consultation meeting or via the telephone where the details of their complaint, the context in which they occur and the response they would want or be satisfied with discussed and agreed. The initial practice was to provide a form and freepost envelope asking the complainant to indicate when it would be convenient to arrange a meeting but logistically this was difficult to manage and the current practice is to offer a consultation and ask the complainant to contact the complaints office either by phone or e-mail if they which to proceed and allowing 10 working days for this to take place.

Practice has also identified that there are some instances where the issue raised might be a single issue and where a consultation meeting would not add to the understanding of the complaint or where the complainant has indicated in their original letter that any meeting with the Trust would not be indicated

In cases where triage has identified a high risk and where immediate actions might be indicated a Senior Manager from the service that is the subject of the complaint is required to attend the consultation meeting. In cases where the risk is low or moderate and there is no indication that actions are likely to be required the consultation meeting will be led by the Complaints Manager. Consideration is also given to whether there are any risk factors which might indicate a lone visit to be potentially unsafe.

Start of the investigation process can follow four timelines

  • When a consultation takes place: from the agreement of the notes of the consultation meeting and action plan with the complainant.
  • When a consultation is offered and declined by the complainant: from the date of the consultation being declined
  • When a consultation is offered but no response received: from 10 working days of the offer of the consultation meeting
  • When a consultation is not considered to be appropriate or indicated: from the date of the triage

It is expected that the Trust will continue to respond to complaints not identified as being complex or of a nature that would require a more detailed investigation within 25 working days.

For complainants where it has been agreed that an investigation will go beyond this timeframe progress reports will be provided to the complainant at periods agreed at the consultation meeting.

An investigation template has been developed to ensure that there is continuity in the manner in which complaints are investigated and recorded and it is expected that all Investigating Officers use this.

At the completion of the investigation a response will be made by the Chief Executive to the complainant. The complainant is offered the option to return to the Trust if dissatisfied with the response made to them and an undertaking that the Trust will review the investigation. If the complainant remains dissatisfied they then have the right to refer their case to the Parliamentary and Health Service Ombudsman for consideration.

It is also a requirement of the National Health Service Litigation Authority (NHSLA) Mental Health and Learning Disability Standards that all informal/verbal complaints are recorded and a reporting form for this purpose was developed.

Complaints received in the year 2010/11

There were 134 formal complaints made to the Trust during this period an increase of 55 on the previous year.

It was identified that during the second quarter of the year there was a significant increase in complaints. Examination of the files showed no evidence of an increased number of complaints for any one service other than those detailed below and the issues raised remained broadly varied with no disproportionate increase.

It was identified in the second quarter that one service user, a patient on an acute ward at the time had written multiple letters both for himself and for other patients who had signed them. The script of each letter was very similar and there was little disparity in the content of the letter. Each individual was offered the opportunity to meet with a Senior Manager but declined by all bar the author.

Ethnicity of Service User

For the first time the Trust has captured the ethnicity of the service user who had either made the complaint or is the person whose care is the subject of the concerns raised.

Codes as per standard categories for collection of ethnicity information

A / White: British / J / Asian/Asian British: Pakistani
B / White: Irish / M / Black/Black British: Black Caribbean
C / Any other White background / N / Black/Black British: Black African
F / Mixed: White & Asian / P / Any other Black background
G / Any other mixed background / Z / Not stated
H / Asian/Asian British: Indian

Outcome of triage of risk

High Risk:

  • Related to equipment and working practices on the Mother & Baby Unit on Ward 12 - upheld

Moderate Risk:

  • Alleged clinical negligence of a doctor - open
  • Allegation against staff – not upheld
  • Failure to allocate Care Manager – not upheld
  • Failure to respond to a crisis situation leading to admission – upheld
  • Concerns raised about response of adolescent services – upheld
  • 4th complaint raised relating to concerns raised about the lack of continuity of care due to difficulty in filling Consultant posts – upheld
  • Concerns over the conduct of a locum AMHP – upheld
  • Concerns raised by family over care and treatment – not upheld
  • Concerns at lack of support provided to school by CAMHS through poor communication – partially upheld
  • Concerns about care and treatment of elderly father prior to his death – upheld
  • Concerns over care and treatment and proposed discharge – consent not given

Source of Complaints

All complaints raised by individuals other than the service user are required to have the consent of the service user to proceed unless they are deceased, are a child or lack capacity as defined in the Mental Capacity Act.

Twenty complaints were made with the support of Independent Advocacy Services, however, if not represented by independent advocacy services at the source complainants are provided with information about advocacy services. The complaint office has contacted both the PALS Officer and Advocacy Services on behalf of complainants following the consultation process requesting that they be contacted to offer support

Consultations

The feedback from consultation meetings remains positive in that complainants feel that their concerns have been acknowledged and listened to and that they have a degree of assurance that the Trust will investigate and respond to their concerns.

The time span in arranging consultations remains variable with some taking place relatively quickly and at other times when the client had requested a delay. The time span between the consultation meeting and the agreement of the complainant to the notes can also be variable.

The process of offering consultations remains a labour intensive process that is dependent on the complaints received, arranging meetings to accommodate the complainant, the content of the consultation meeting and the quantity of notes to be prepared and cannot be predicted.

Services subject to complaints

Nature of complaints received

Some complaints may contain concerns with regard to more than one issue

Nature of concerns / Quarter 4 / Quarter 3 / Quarter 2 / Quarter 1
Attitude/behaviour of staff / 3 / 6 / 25 / 5
Care & treatment issues / 11 / 20 / 11 / 11
Communication/liaison / 5 / 6 / 2 / 5
Lack of consistency with medical cover in CMHT / 5 / 2
Confidentiality / 1 / 2 / 1
Medication / 2 / 1 / 1
Food / 3
Property / 2 / 5 / 1
M&B Unit / 1
Environment / 1 / 5
Admission process / 1 / 3
Discharge Process / 4 / 1 / 2
Inaccuracy of report / 1
Alleged assault by patient towards member of public / 1
Deprivation of liberty / 1
Alleged unfair charge for damages / 1
Appointment process / 1
Alleged covert assessment / 1
Bed allocation on ward / 1
Lack of disabled access to ward garden / 1
Availability of service to GP / 1
Lack of support by services/staff / 6
General dissatisfaction with service / 1
Not offered an assessment / 1
Conduct of meetings / 2
Safety on ward / 1
Alleged medical/clinical negligence / 1
Management of difficulty with fellow client / 2
Cessation of home visits / 1

The issues around ‘attitude of staff’ in quarter 2 corresponded with an unprecedented spike in complaints received during that period and was spread across the services provided by the Trust and not restricted to one area.

Following an apparent increase in issues relating to care and treatment in quarter 3 the files were examined. This identified that the increase in care and treatment issues was explained by complainants raising generic concerns related to their overall care and treatment and did not indicate any increased risk factors in the provision of care and treatment in any one service

However, whatever the primary issue raised by the complainant there remains a recurring theme of poor communication for a significant number of the complaints

Lack of communication to service users, carers and relatives about basic treatment plans, medication and appointments remains a primary concern.

Ombudsman

There were six complaints in respect of Older Person Services, five of which fell within inpatient services. Five of the complaints were triaged as being of Low Risk and one of Moderate Risk

Issue raised were

Concerns that a failure to monitor medication prescribed for Alzheimer’s contributed to admission to hospital – investigation identified that admission to hospital was not related to medication

Concerns from elderly lady over ability to attend to her husbands laundry – Resolved on ward and clothes washed on ward

Issues raised by MP on behalf of her constituent about his admission to the ward – concern that patient becoming unwell as issues similar to those raised when detained and arrangements made to visit at home

Concern raised at safety of wife on ward and physical deterioration- Identified that risk factors with other patients managed and patient and no evidence of any physical deterioration

Concerns over communication and care and treatment to mother. identified that there are some communication difficulties which MDT are working towards resolution and physical problem not explained clearly to relative.

Issues over care and treatment provided to patient prior to his transfer to acute hospital where he subsequently died. Concerns led to Internal Investigation which identified that care and treatment did not always reach the standard that would be expected

Outcome of investigations

Of the 2 complaints that remain open, one relates to an allegation that is subject to an internal investigation and the second where the complainant has attended a consultation meeting and requested additional time to consider the notes of the meeting.

Complaints registered as being partially upheld are those where the main body of the complaint may not be upheld but where it has been identified that there has been some issues where the concerns raised have been upheld and the percentage of complaints partially upheld has increased significantly with the introduction of the new legislation. Consultation with complainants has allowed for the concerns raised to be put into context and better understood by the senior manager undertaking the consultation and identified in the action plan developed wit the complainant.

Timeline for responses

It is the expectation that a response will be made by the Chief Executive within 25 working days of the agreement of the consultation notes and action plan by the complainant unless an extended response time is agreed with the complainant during the consultation meeting or in consultation with them after this has taken place . Responses were made in 121 cases with 21 either being withdrawn or not receiving consent and 2 outstanding.

Issues and actions

Issues raised by complainant or identified during investigation / Actions taken to address identified issues
Patient confidentiality /
  • Ensuring that the limits of confidentiality as it applies within mental health services are clearly explained and that clients understand these limitations
  • Ensuring that clinicians inform clients that clinical notes are being taken during the assessment and that these notes will be stored confidentially
  • Informing patients about how they can access their notes or files
  • Reiterating at the end of all assessments that a summary of the assessment will be written in a report and to ensure that clinicians remind clients that they can receive a copy of this report, if they wish
  • Ensuring that clients are clear as to which other professionals who are involved in their care will be receive a copy of the assessment report

Poor response by services due lack of information /
  • Assertive Outreach team will provide the Crisis Response Team with a ‘Crisis Management Plan’ so that irrespective of who will be on duty they will be able to carry out any of the actions according to the Crisis Plan.
  • The Crisis Response Team will carry out a Home Visitwhenever they are told that a patient may be relapsing.
  • For the Care Coordinator to provide a copy of care plan to the Crisis Response Team and where necessary inform the CRT that the patient is in crisis and might contact the service.

Expectation of new referrals and lack of information /
  • Ensuring that those individuals new to the services are provided with a clear explanation of the role and purpose of the Alternatives to Admission service.

Alleged failure to allow patient to contact their solicitor /
  • Senior Nurse to make it clear to all staff of the right of any individual to contact their solicitor and to assist in facilitating this when necessary.

Concerns raised over care & treatment /
  • The management team to ensure that CPA meetings are arranged at regular intervals during admission with immediate action required
  • All client files to contain treatment plans /actions that are transparent to all and are evidenced as being reviewed and updated regularly.
  • Activity plans should offer a range of opportunities both within the unit and off the unit and should include both structured and unstructured opportunities for engagement, maintenance of daily living skills and individually tailored activities.

Issue over patient on PICU being denied visit from grandchild /
  • Staff should ensure they give full and explicit information to relatives when restricting visiting by children to wards.

Relatives not being informed of incident /
  • When there is a serious incident involving a service user relatives should be informed at the earliest opportunity and staff should ensure that they are fully aware of the circumstances to prevent inconsistent information being given.

Concern raised that patient admitted for planned crisis intervention not seen by doctor /
  • Individuals admitted for short term crisis intervention should be seen by a doctor during the course of an admission.

Concern raised that disabled patient unable not responded to. /
  • If an individual is disabled and immobile the means to summon help should be accessible when they are in their room.

Concern raised by patient that staff not able to respond to an individual experiencing a seizure /
  • Ward Manager to check the competency of all staff to respond to any individual suffering a seizure and where necessary to ensure that training is attended

Concerns raised about the Mother & Baby Unit /
  • Baby chair in Mother & Baby unit found to be not fit for purpose and removed from unit.
  • The Mother & Baby Unit policy document which outlines the provision of care for both mother’s and their babies has been discussed with individual staff liable to work on the unit, who have signed to record this has taken place and of their understanding of the policy and procedures in place
  • Steps have been taken to ensure that all staff are familiar with all the equipment provided for the babies admitted to the ward, the use for which they are designed and that they check the age appropriateness of each piece of equipment for each individual baby when in use
  • The Ward Manager to explore further ‘Practical Care of the Baby’ training which had previously been provided by a Health Visitor as refresher training for all staff.

Concern that some patients are allowed to use their own electrical equipment while other s denied this /
  • All electrical items brought to the ward must be tested in line with the Portable and Fixed Electrical Equipment policy and this should apply to all personal electrical items without exception.

Concerns over lack of courtesy of staff when admission to ward delayed /
  • If there is a delay in admission to the ward, staff should ensure that the patient and anyone accompanying them are made fully aware of the reasons and drinks should be made available.

Alleged ambiguity of information given /
  • Information given to individuals should be clear and concise and there should be awareness of the understanding by the recipient and if necessary documentation that the information be re-given.

concerns about availability of diet for inpatients of Eating Disorder Service /
  • Consideration must be made to provision of the prescribed diet of inpatients within the Eating Disorder Service and to ensure that the full diet is provided.

Concerns over lack of information /
  • Clinical Health Psychology will identify a more effective system of note keeping which will ensure that the information available to each professional is full and comprehensive and in the interim period information will be copied to each file.
  • Ensure that service users are copied into all letters/referrals
  • Ensure that an acknowledgment is made to all voicemails/e-mails

Concern that risk related to reduction regime not assessed and shared /
  • Assessment of risk and a management plan should be part of the treatment plan when medication is being reduced and this information should be provided to all professionals working with the service user including the GP

Dementia medication sent to address of patient and not to relative as agreed /
  • Review of systems within Pharmacy

Service user contacted on 2 occasions re- assessment appointment due to duplication on system
Lack of response when service user arrived in reception as reception area continuously manned /
  • Review of systems and entry system within IAPT
  • Admin office within IAPT moved next to reception to ensure staff available to arrivals

Inadvertent breach of confidentiality /
  • All staff need to be robust in maintainingconfidentiality reinforced to all staff

Unable to confirm if document sent to another organisation when Consultants PA on sick leave /
  • to be recorded on RIO when documents sent recording date and recipient

Husband contacted re- his wife when she had been admitted to hospital /
  • Spreadsheet developed within Locality to monitor admissions/discharges from hospital

Concerns raised by mother of the child being present at consultations with CAMHS and of the impact hearing sensitive information might have for them /
  • Clinical staff now offer separate appointment to families without their children to give families an opportunity for more information about the child’s mental health difficulties to be shared and to avoid children listening to sensitive information about themselves which can contribute to a child’s self-esteem

Concerns raised by the same complainant that she was given insufficient information about treatment available to allow her to make an informed choice. /
  • Reinforced to all clinicians the need to explain to parents about the process of the assessments and information that will be discussed during the assessment stages especially if there is a dual diagnosis of ASD and ADHD which increases its complexity.

Concerns that an incorrect entry was made in the notes, based on the nurse being given information by a third party /
  • staff to ensure that they check all documentation being entered especially when provided to them by a third party such as an agency nurse

Issues raised over the alleged conduct of staff in attending the home of a service user and the expectations of the service user as to the purpose of the visit. /
  • there should be closer working with Early Intervention in Psychosis and the Therapeutic Day Unit, to include regular joint reviews of the need for CRT to visit and supervise medication and for clarity over the expected outcomes of such visits.
  • Staff to consider how a situation can be deescalated when the service user presents as being agitated to reduce the risk both at the time of their visit and subsequent to them leaving the premises

Concerns raised by the mother of a service user, known to EDS but who had been advised by them to contact her local crisis service for support, of the lack of support offered /
  • As detailed by Investigating officer to be discussed with Clinical Lead for future implementation - It would have good practice for the member of staff to contact the EDS to seek some background history that would support the assessment made, to share the information gained from the contact and to determine what actions should be taken.
  • When dealing with a distressed or concerned relative/patient and the call is suddenly terminated, consideration should be given to making further contact after allowing a period for them to calm

Issues raised with regard to lack of support and failure to provide notes of a meeting for a prolonged period of time. /
  • To ensure clear and effective communication between parties when there is a multi-agency approach to care
  • All practitioners to ensure that minutes of meetings are circulated to all parties promptly.

Many of the responses are individual to the complainant and do not result in identification of wider issues that are applicable to shared learning.