Corporate Complaints: Standard Operating Procedure · 2016-06-01 · Corporate Complaints: Standard Operating Procedure Document Control Summary Status: ... Customer Services Manager

Corporate

Complaints: Standard Operating Procedure Document Control Summary

Status:

Replacement. Supersedes: Complaints Procedure (28.10.10) and the Patient Advice and Liaison Service Policy (28.07.11)

Version: v1.2 Date: 01.11.15

Author/Title: Owner/Title:

Paula Johnson - Customer Services Manager Alison Bussey - Chief Operating Officer/Director of Nursing

Approved by: Policy and Procedures Committee Date: 19/11/2015

Ratified: Policy and Procedures Committee Date: 19/11/2015

Implementation Date: November 2015

Review Date: November 2018

Key Words: Complaints, concerns, information requests, compliments, suggestions; PALS

Associated Policy or Standard Operating Procedures

Complaints and PALS Policy

Contents

Part One 1.1 Thinking about Making a Complaint……………………………………………………….2 1.2 Making a Complaint………………………………………………………………………….. 2 1.3 Mental Health Act 1983 as Amended 2007………………………………………………..4 1.4 Service User and Carer Complaint Process…………………………………………….. 5 1.5 Complaints at Source (Local)……………………………………………………………….6 1.6 Serious Complaints (Formal)………………….……………………………………………8 1.7 Outcome of Complaint…………………………………………………………………..… 10 1.8 Learning from Complaints………………………………………………………………....11 Part Two 2.1 Joint Complaint (Multiagency)…………………………………………………………….14 2.2 Compliments……………………………………………………………………………........14 2.3 Persistent Complainants …………………………………………………………………. 14 2.4 Litigation …………………………………………………………………………………….. 14 2.5 Independent Review ………………………………………………………………………..14 2.6 MP Letters …………………………………………………………………………………….15 2.7 Investigations Outside of the Complaints Procedure ………………………………...15 2.8 Coroner………………………………………………………………………………………...16 2.9 Service Users too Unwell to Receive a Response …………………………………….16

Complaints SOP/November 2015

Page 2 of 17

Change Control – Amendment History

Version Dates Amendments

v1.0 01/11/2015 SOP created

v1.1 02/12/2015 Duty of Candour details added.

v1.2 04/12/2015 Page 15 of SOP – time given to appeal for Independent review amended from 6 to 12 months.

Part One 1.1 Thinking about making a complaint There are many ways in which people can raise their comments, concerns or complaints with us. If someone wants to make a complaint, we need to know: What happened? Who was involved? When? Where? Why they were unhappy? Staff should encourage service users, carers and relatives to tell us what they would like us to do to put things right. This could be an apology or action to prevent the same mistake from happening again.

Support Tools

NHS Complaints Advocacy in Shropshire, Telford and Wrekin (POhWER)

http://www.pohwer.net/Resources/POhWER/NHS%20complaints%20advocacy/Leaflets/p

ohwer-nhs-complaints-advocacy-leaflet-shropshire-telford-and-wrekin-july-2014.pdf

NHS Complaints Advocacy in Staffordshire (Healthwatch) and for details of advocacy

organisations throughout England, http://healthwatchstaffordshire.co.uk/nhs-complaints/

Asist www.asist.co.uk

Shropshire Independent Advocacy Service (SIAS) www.siasonline.org

‘Are You Satisfied? – We’re Here to Help’ leaflet – available in all

wards/departments/Customer Services Department

‘Are You Satisfied? – We’re Here to Help’ Poster – available in all


‘Are You Satisfied – We’re Here to Help?’ (easy read leaflet) available in all


Appointment Cards – available from Customer Services Department

Freephone – 0800 318850

‘Our Complaints Process Explained’ Associate Document 1

1.2 Making a Complaint

Time Limitation for Complaints Complaints should be made within 12 months of the incident or of becoming aware of the incident that give rise to the complaint.

http://www.pohwer.net/Resources/POhWER/NHS%20complaints%20advocacy/Leaflets/pohwer-nhs-complaints-advocacy-leaflet-shropshire-telford-and-wrekin-july-2014.pdf


http://healthwatchstaffordshire.co.uk/nhs-complaints/

http://www.asist.co.uk/

http://www.siasonline.org/


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Where the complaint is made after the 12 month time limitation, discretion may be used by the Executive Director/Chief Executive to accept the complaint where it is considered to be sufficiently serious or where there were reasonable grounds for the delay and it is still possible to investigate fairly and effectively despite the delay.

Support for Complainants Complainants will be signposted to independent complaints advocacy support when making a complaint and relevant information leaflets on advocacy services will be included within the acknowledgement letter. Complainants will be given support to overcome any communication or other difficulties to enable them to make a complaint eg provision of interpreters. Further information can be found in the Policy for Interpretation and Translation Services on the Trust’s intranet, the Trust’s website or follow this link: http://www.sssft.nhs.uk/working-here/trustpolicies/22-corporate-policies/35-translation-and-interpreting-policy

Consent

When a complaint is made on behalf of a service user, or by a carer, and it is necessary to share patient sensitive information, it will usually be necessary to obtain the service user’s written consent before a response can be made and this should be obtained where capacity is not in question. Where the service user who has died or who does not have capacity to give consent, the representative must be a relative or other person who had or has sufficient interest in the welfare of the service user and is a suitable person to act as a representative including any person with enduring power of attorney. Consideration should also be given to the use of the Mental Capacity Act and prior to a decision being made; advice from the Caldicott Guardian should be sought. Where the person is not a suitable representative they will be written to outlining the limitations of the information that can be shared. In the case of a child, the representative must be a parent, guardian or other adult who has care of the child. Where the child is in the care of a local authority (LA) or voluntary organisation (VO) the representative must be a person authorised by the LA or VO. If a child is over the age of 12 years, the clinical view of the professional should be sought in relation to capacity and if it is felt that it is appropriate, Section 2 of the consent form should be completed and signed. If an MP representing a constituent, who is acting on behalf of a service user, then consent must be obtained from the service user. Information must not, under any circumstances, be disclosed without the permission of the service user. If the MP has obtained this consent, then the MP: must provide evidence of this. Where more than one organisation (health or social care) is involved in a complaint, the Trust will ensure consent is obtained from the complainant prior to involving other organisations.

http://www.sssft.nhs.uk/working-here/trustpolicies/22-corporate-policies/35-translation-and-interpreting-policy

http://www.sssft.nhs.uk/working-here/trustpolicies/22-corporate-policies/35-translation-and-interpreting-policy


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1.3 Mental Health Act 1983 as Amended 2007 Complaints relating to the provision of care and treatment, prior to, during and after the period of detention, should be investigated in line with this guidance.

Complaints relating to the appropriateness of detention under the Mental Health Act 1983, i.e. service users expressing disagreement with their detention and wish to be released from Section, should be asked to apply for a Mental Health Act Hospital Manager’s Review or Mental Health Act Tribunal.

Support Tools

Template acknowledgement letter Associate Document 2

Template consent form: Adults Associate Document 3

Template consent form: Children Over 12 Years Associate Document 3a

Complaint Investigation Plan “I” Drive, Customer Services, Standard Documentation


http://www.pohwer.net/Resources/POhWER/NHS%20complaints%20advocacy/Leaflets/p

ohwer-nhs-complaints-advocacy-leaflet-shropshire-telford-and-wrekin-july-2014.pdf





Are You Satisfied? – We’re Here to Help’ leaflet – available in all






‘Our Complaints Process Explained’ Associate Document 1







Page 5 of 17

1.4 Service User and Carer Complaint Process (all verbal and written complaints/concerns)

↓

If you receive a complaint directly into your service/ ward/team If you receive a complaint in Customer Services or via an Executive Director/Chief Executive

Determine the seriousness of the complaint in consultation with Customer Services

The complaint is deemed serious if relates to one of the following: safeguarding, possible litigation, damage to Trust’s reputation, breach of confidentiality, serious allegation against a staff member, reopened complaint or serious incident, Duty of Candour issue.

If serious, bring to the immediate attention of the Customer Services Team and inform your direct line manager.

All serious complaints will need to be co-ordinated by Customer Services and signed off by an Executive Director/Chief Executive

Determine the seriousness of the complaint

The complaint is deemed serious if relates to one of the following: safeguarding, possible litigation, damage to Trust’s reputation, breach of confidentiality, serious allegation against a staff member, reopened complaint or serious incident, Duty of Candour issue.

If serious, formal complaints process will be invoked.

If the complaint can be resolved at ward/team level, Customer Services will contact the relevant manager for local resolution.


Try to resolve the complaint within 3 working days or sooner

Inform Customer Services on [email protected] of receipt of complaint and forward supporting documentation

Manager of service/ward/team telephones the complainant to acknowledge receipt of complaint, agree the boundaries of the complaint and how the complainant would like to receive the response.

Try to resolve.

If unable to contact complainant by telephone, acknowledgement must be done, in writing, within three working days of date of receipt.

Complaint resolved within 3 working days of receipt

Make a note on progress notes/service user record if clinically relevant

Respond to the complainant on the outcome of their complaint in the format agreed at the outset.

Manager formally notifies Customer Services on [email protected] of the complaint, date of receipt, details of response and any learning.

Customer Services makes contact with complainant within 5 days to confirm satisfaction and makes entry on customer services database.

Manager to ensure that all learning is shared and actions completed. File of evidence to be kept for future reference.

Customer Services will

Risk assess the complaint and if SI/ Duty of Candour issue, liaise with Risk Management

Determine if multiagency approach required

Acknowledge receipt within three working days following date of receipt and include details of advocacy and PHSO.

Obtain consent if required

Appoint an investigating officer from rota and prepare relevant documentation

Make an entry on Safeguard database and monitor completion of investigation to conclusion.


Review and quality assure response

Arrange sign off by Executive Director/Chief Executive.

Send out complaint response with details of action agreed, with copies to team manager and immediate manager.

Send copies of any complaint where third party consent is not received or withdrawn, to the relevant Directorate for learning purposes.

Update Safeguard database.

Complaint not resolved within 3 working days of receipt As soon as the complaint exceeds the 3 working days resolution target:

Agree suitable timescales for completion with complainant (within 10 working days).

Update/notify Customer Services by email (address as above)

Continue local resolution of complaint.


Update/notify Customer Services by email (address above) of outcome and learning.


mailto:[email protected]



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1.5 Complaints at Source (Local)

Wherever possible, straightforward complaints should be dealt with by staff at source and this can usually be done by the person to whom the complaint is directed. Dealing with issues effectively, and as early as possible, can often prevent them escalating into more serious complaints. Complaints received by Customer Services, that can be dealt with locally, will be forwarded to the relevant ward/team manager for resolution.

Where a complainant alleges serious misconduct or criminal offence, including physical/sexual abuse, this will be a formal complaint. It must immediately be reported as an incident, bought to the attention of the relevant Manager and investigated in accordance with the Trust’s Safeguarding Policy.

Once the complaint has been completed, it is important that the Manager shares the complaint and resultant learning with staff in team meetings. This is to ensure everyone has an opportunity to reflect on what has been done well and what needs to be improved. All actions, if not undertaken immediately, must be completed within three months and evidence retained for future reference.

Determine the seriousness of the complaint in consultation with Customer Services

The complaint is deemed serious if it relates to one of the following: safeguarding, possible litigation, damage to Trust’s reputation, breach of confidentiality, serious allegation against a staff member, reopened complaint or serious incident/ Duty of Candour issue.

If serious, bring to the immediate attention of the Customer Services Team and inform your direct line manager.


Try to resolve the complaint within 3 working days or sooner

Inform Customer Services on [email protected] of receipt of complaint and forward supporting documentation.

Manager of service/ward/team telephones the complainant to acknowledge receipt of complaint, agree the boundaries of the complaint and how the complainant would like to receive the response.

Try to resolve.

If unable to contact complainant by telephone, acknowledgement must be done, in writing, within three working days of date of receipt.

Complaint resolved within 3 working days of receipt

Make a note on progress notes/service user record if clinically relevant


Manager formally notifies Customer Services on [email protected] of the complaint, date of receipt, details of response and any learning.

Customer Services makes contact with complainant within 5 days to confirm satisfaction and makes entry on Customer Services database.


Complaint not resolved within 3 working days of receipt As soon as the complaint exceeds the 3 working days resolution target:

Agree suitable timescales for completion with complainant (resolution must be within 10 working days)

Update/notify Customer Services by email ([email protected])

Continue local resolution of complaint.


Update/notify Customer Services by email (address above) of outcome and learning.





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Where the complaint is not resolved within 3 working days, the service/ward manager (for locally received complaints) will contact the complainant immediately and agree a timescale for resolution (no later than 10 working days). The service/ward manager will update the Customer Services Department on progress. Service/ward manager will ensure that the learning from the complaint is shared with staff, actions completed and evidence retained for future reference. If complaint is not resolved within 10 working days, Customer Services will escalate the complaint to relevant Head of Mental Health Services or Service Manager.

Support Tools

Trust’s Safeguarding Policy http://www.sssft.nhs.uk/component/dpattachments/?task=attachment.download&id=6

Draft concluding letter on “I” drive, Customer Services, Standard Documents


http://www.pohwer.net/Resources/POhWER/NHS%20complaints%20advocacy/Leaflets/poh

wer-nhs-complaints-advocacy-leaflet-shropshire-telford-and-wrekin-july-2014.pdf











http://www.sssft.nhs.uk/component/dpattachments/?task=attachment.download&id=6







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1.6 Serious Complaints (Formal)

Investigation Process

In order to ensure that the Trust responds fully to the concerns raised, it is important for those investigating the complaint to speak or meet with the complainant. This initial contact should be made within 24 hours of the Investigating Officer being appointed. The purpose of this contact will be to arrange for a time when it is convenient for a discussion to take place with the complainant, regarding the nature of their complaint. This will enable the complainant to discuss their concerns and for the Trust to provide assurance that the Trust is taking their complaint seriously. The Investigating Officer must also ensure:

Complete the Complaint Investigation Plan contemporaneously, including final risk rating.

Check on RiO any identified patients risks.

Immediately following arranged discussion, ensure that a letter confirming the nature of the complaint issues to be investigated and timescale for conclusion (25 working days from the date of agreeing the investigation issues), method of agreed feedback, is forwarded to the complainant, ensuring that a copy is inserted on the “I” drive. Customer Services should also be informed that this discussion has taken place and letter has been sent.

Review health records, Trust policies, NICE guidance etc.

Identify individuals to be interviewed/contacted in relation to the complaint.

Telephone or face to face interviews with staff members need to be conducted according to the severity of the complaint. Signed and dated statements are obtained or a full record of the interview is prepared and agreed with the individual.

All interviews must be conducted with sensitivity and staff should be offered support throughout the process, e.g. immediate manager, Team Prevent.

Obtain independent clinical advice if appropriate, by liaising with Customer Services.

Draft a response letter, based on the template contained within the Complaint Investigation Plan, and submit to the Customer Services Department, ten working days prior to the agreed date. This draft letter will also include recommendations which should be shared and agreed with the relevant service/ward manager prior to submission.

Determine the seriousness of the complaint

The complaint is deemed serious if relates to one of the following: safeguarding, possible litigation, damage to Trust’s reputation, breach of confidentiality, serious allegation against a staff member, reopened complaint or serious incident.

If serious, formal complaints process will be invoked.

If the complaint can be resolved at ward/team level, Customer Services will contact the relevant manager for local resolution.



Risk assess the complaint and if SI liaise with Risk Management

Determine if multiagency approach required

Acknowledge receipt within three working days following date of receipt, including details of advocacy and PHSO

Obtain consent if required.

Appoint an investigating officer from rota and prepare relevant documentation

Make an entry on Safeguard database and monitors completion of investigation to conclusion.


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Support

The Trust acknowledges that being involved in a complaint can be a stressful experience for service users, carers, members of the public and staff. The member of staff’s Line Manager is responsible for ensuring that support is given at the time of the event or at a later date if it becomes apparent that additional support is required. Any member of staff experiencing difficulties can be referred to Team Prevent. Please see the Trust’s Stress Management Policy for further information. Information on Advocacy services for complainants will be provided at the acknowledgement stage by Customer Services.

Support Tools

Investigating Officer Rota (Updated regularly and obtainable on “I” Drive)

Complaint Investigation Plan Associate Document 4

Acknowledgement Letter Template Associate Document 2

“Our Complaints Process Explained” leaflet Associate Document 1

Trust’s Stress Management Policy http://www.sssft.nhs.uk/working-here/trustpolicies/34-human-resources/242-stress-management-policy?highlight=WyJzdHJlc3MiLCJtYW5hZ2VtZW50IiwibWFuYWdlbWVudCciLCInbWFuYWdlbWVudCIsInN0cmVzcyBtYW5hZ2VtZW50Il0


http://www.pohwer.net/Resources/POhWER/NHS%20complaints%20advocacy/Leaflets/poh

wer-nhs-complaints-advocacy-leaflet-shropshire-telford-and-wrekin-july-2014.pdf











Letter confirming complaint issues, timescales etc. Associate Document 6

http://www.sssft.nhs.uk/working-here/trustpolicies/34-human-resources/242-stress-management-policy?highlight=WyJzdHJlc3MiLCJtYW5hZ2VtZW50IiwibWFuYWdlbWVudCciLCInbWFuYWdlbWVudCIsInN0cmVzcyBtYW5hZ2VtZW50Il0










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1.7 Outcome of Complaint

Following investigation into the complaint, the Investigating Officer will draft a response, based on the Trust’s template, which is embedded within the Complaint Investigation Plan, for agreement by all relevant staff and other agencies involved in the complaint. If multiagency, Customer Services will act as the liaison point with the partner agencies and will communicate with the Investigating Officer accordingly. If a verbal response has been requested, a report, based on the letter template, will be prepared and submitted as part of the Complaint Investigation Plan. Arrangements to meet with the complainant should be made by the Investigating Officer and Customer Services kept informed thereof and the outcome. The written response will:

Be clear, accurate, balanced, simple, fair and easy to understand.

Summarise the investigation’s findings providing clarity and explanation where required.

Provide information relating to names of staff interviewed and any guidance considered

Acknowledge the complainant’s experience and provide an apology where appropriate to

do so.

Include a response to all the points raised in the original complaint by offering a full and

honest explanation.

Avoid technical terms, but where they are used that these are explained in full.

Include an outcome, or explanation of actions being taken within the service and give assurances that lessons have been learnt.

Draft should be placed on the “I” drive and notification to Customer Services, by email, to

[email protected] alerting them of this action

Customer Services to quality assure and send to Executive Director/Chief Executive for signature

Leaflet regarding the option to request consideration of an independent review of the complaint by the Parliamentary and Health Service Ombudsman will be enclosed with the concluding letter.

All correspondence should be marked Private and Confidential and sent using first class

post with a safe haven label on the envelope.

All letters will be copied to the relevant service/ward manager to ensure any learning is shared with the Team and actions identified, as a result of the complaint, are taken forward with a timescale of three months.

Complaint letters or responses should not be filed in the service user’s integrated health and social care clinical record (RiO). This includes any reference to the complaint if not clinically appropriate.


Review and quality assure response

Arrange sign off by Executive Director/Chief Executive.

Send out complaint response with details of action agreed, with copies to team manager and immediate manager.

Send copies of any complaint where third party consent is not received or withdrawn, to the relevant Directorate for learning purposes.

Update Safeguard database.



Page 11 of 17

Support Tools


Final response template embedded within Complaint Investigation Plan Associate Document 5

Parliamentary and Health Service Ombudsman Leaflet http://www.ombudsman.org.uk/__data/assets/pdf_file/0003/1011/FINAL_What-to-do-if-your-unhappy-with-the-NHS-A5-leaflet-2.pdf

1.8 Learning from Complaints

It is vital that the Trust looks for the underlying causes of all complaints and learns from them in order to ensure that they are not repeated.

Action Planning Part of the complaint response will include, where relevant, the actions taken to resolve the complaint and how the Trust will learn from the complaint to ensure that it does not recur.

After the final response has been sent to the complainant, it is important for the Team/Service to review the complaint. To facilitate this, a copy of the concluding letter and action plan will be shared with the service/ward manager. It is important that this process is discussed at team meetings to ensure shared learning can take place. Discussion should include:

What we did well,

What we did not do well

What we should have done

Improvement action taken

Monitoring complaints and compliance

All service areas and departments will be required to have systems in place to ensure complaints monitoring and evaluation.

Service/ward managers are required to maintain comprehensive records of the complaints received, action taken, any recommendations and improvements, as a result of the issues raised for future reference. Learning from complaints needs to be “active”. Any changes made, as a result of a complaint, need to be incorporated into the way staff work at all levels of the organisation. Actions should be realistic, sustainable and cost effective.

Complaints involving staff will be sent to Line Managers of staff involved (or the Medical Director in the case of medical staff) to facilitate review and learning via supervision.

It is expected that lessons learnt are shared at team meetings to ensure cross learning is disseminated with all staff and to encourage learning from complaints.

http://www.ombudsman.org.uk/__data/assets/pdf_file/0003/1011/FINAL_What-to-do-if-your-unhappy-with-the-NHS-A5-leaflet-2.pdf

http://www.ombudsman.org.uk/__data/assets/pdf_file/0003/1011/FINAL_What-to-do-if-your-unhappy-with-the-NHS-A5-leaflet-2.pdf


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Reporting

Monthly reports are produced by the Customer Services Team and shared with the Locality/Directorate Teams. These include details of complaint, outcome and actions. In addition, each department has access to two dashboard reports (Complaints and PALS), based on information contained within the Safeguard database.

A quarterly report on Complaints and PALS is received by the Trust’s Quality Governance Committee, which is attended by Directorate representatives. In addition, each Directorate receives a copy of action details as a result of complaints resolved during the quarter, in order to consider any systemic learning.

On an annual basis, a Thematic Review is presented to the Trust’s Quality Governance Committee and Trust Board, on complaints handling, PALS and lessons learnt.

A random review of cases is undertaken on a quarterly basis by the named Non-Executive Director for complaints and any learning on the handling explored with the Customer Services Team.

The Trust routinely invites complainants, in writing, to ascertain what their experience has been in relation to the handling of complaints. These results influence future policy planning and training.

Support Tools


Flowchart for the Implementation of Recommendations Associate Document 7


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Part Two

This section of the standard operating procedure relates to the handling of compliments and to the handling of areas of complaints that you may not come across that frequently, but still need to know about:

2.1 Joint Complaints

2.2 Compliments

2.3 Persistent Complainants

2.4 Litigation

2.5 Independent Review

2.6 MP Letters

2.7 Investigations Outside of the Complaints Procedure

2.8 Coroner

2.9 Service Users too unwell to receive a response


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2.1 Joint Complaints When a complaint is received by one organisation, which also involves a complaint about Social Care or a partner NHS organisation, the receiving organisation will have the responsibility of acknowledging the complaint and will generally take the lead on the investigation. Further information on this approach can be obtained from the Multiagency Protocol on the Handling of Complaints Associate Document 8.

2.2 Compliments

All compliments/ letters of appreciation received within the Trust must be shared with the staff referred to within them. Should a compliment / expression of appreciation, (verbally or in writing), be received locally, it is the responsibility of the service/ward manager to provide feedback to their staff and, where appropriate, write an acknowledgement letter (within one week) to the service user/relative/person who made the compliment.

If a compliment is received by an Executive Director of the Trust, the Customer Services Department will prepare a response to the correspondent, ensuring that a copy of all documentation is forwarded to the relevant service/ward manager. Copies of all compliments and responses should be forwarded to the Patient Advice and Liaison Service for logging on Safeguard database. This information will then be included within monthly and quarterly reports.

2.3 Persistent Complainants A persistent complainant is a person who, in the opinion of the Chairman and Chief Executive, has been unreasonably persistent in the number of, for example:

(a) unsubstantiated complaints made against the Trust; or

(b) attempts made to pursue a complaint when the complaints process under the NHS Complaints’ Procedure is complete

In determining arrangements for handling such complainants, a copy of the Trust’s guidance can be obtained at Associate Document 9.

2.4 Litigation

If a complainant, at any time during the complaints process, explicitly indicates an intention to initiate legal action, the complaints process will continue. If teams receive a solicitors letter initiating legal proceedings, these should be sent to the Risk Management Department at Trust Headquarters immediately, who will then acknowledge the letter accordingly.

The service/ward manager or the Customer Service Department (for serious complaints) will also notify the relevant Director/Service Lead and the Director of Quality and Nursing of the complainant’s intention, so that the appropriate authorities are notified.

2.5 Independent Review The complainant has the right to request the Parliamentary and Health Service Ombudsman to conduct an independent review of their complaint where:


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The complainant is not satisfied with the organisation’s response

An investigation has not been completed within six months of the date the complaint was received

The Director of Nursing/Chief Operating Officer has decided not to waive the time limits for investigating a complaint.

This request should be made, in writing, to the Parliamentary and Health Service Ombudsman within 12 months of receiving the response/being due a response from the Director of Nursing/Chief Operating Officer. The address of the Parliamentary Ombudsman is:

The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London SW1P 4QP

Helpline: 0345 015 4033 The Customer Services Manager will respond to any request for information from the Parliamentary and Health Service Ombudsman. The Ombudsman may not request information which is confidential and relates to a living individual, unless that individual has consented (either express or implied consent) to its disclosure and used in investigating the complaint.

Following the investigation, the Ombudsman will prepare a draft written report summarising the complaint, describing the investigation, summarising its conclusion and identifying recommendations or further action to be taken for comment by the Trust and the complainant. The Trust can only comment on accuracy and not the conclusion. The final report will be published and any resultant actions will be planned, monitored and responded to accordingly, in line with the guidance provided by the Parliamentary and Health Service Ombudsman. Further information can be obtained from:www.ombudsman.org.uk

2.6 MP Letters Responses to all Member of Parliament enquiries will be co-ordinated by the Customer Services Department. Therefore, any communications from MPs must be forwarded to the Customer Services Department on receipt. All enquiries of this nature are logged by Customer Services on the Safeguard database.

2.7 Investigations outside of the Complaints Procedure The complaints procedure is concerned only with resolving complaints and not with investigating disciplinary matters or criminal matters. It is recognised that some complaints will highlight information about serious matters and the Investigating Officer may feel it appropriate to consider invoking the Disciplinary Procedure or involving the Police at any point, in liaison with the relevant Directorate. However, investigation of other aspects of the complaint will only be taken forward if they do not, or will not, compromise or prejudice the concurrent disciplinary or Police investigation. Nevertheless, information gathered during the complaint investigation may be made available for a disciplinary investigation.


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Where it is decided to take disciplinary or Police action before a complaint investigation has been completed, the complainant should be advised of the decision, being mindful of service user and staff confidentiality at all times. When any action has been concluded, that part of the complaint which has been returned to a different procedure should only recommence through the Complaints Procedure where there are outstanding matters in the complaint that have not been resolved. A letter from the Customer Services Department will be forwarded to the complainant outlining the above, being mindful of service users and staff confidentiality at all times.

2.8 Coroner In circumstances where a death has been referred to the Coroner’s Office, this does not automatically mean that an investigation, under the Serious Incident Procedure, will be invoked. If a SI investigation is being undertaken, it is not the expectation that a concurrent complaint investigation will take place if a complaint is received. However, it is important that the SI Investigating Officer is aware of the complainant’s concerns and that these are included in their deliberations and final report. At the end of that investigation, the complainant will be advised on how to receive clarity, if they remain unhappy with the outcome of the investigation and to comply with Regulation, information on how to contact the Parliamentary and Health Service Ombudsman will be given. Where a SI investigation is not deemed appropriate, the formal complaints procedure will be invoked.

2.9 Service Users too Unwell to Receive a Response

If the Consultant or Care Co-ordinator/Key Worker responsible for the service user’s care feels the service user is too unwell to receive a response to a complaint made by them or on their behalf, the following should be undertaken:

Discussion with the clinical team and decisions noted in the service user’s integrated health and social care (clinical) record (RiO).

Clinical team should appoint an advocate and offer support to them if necessary.

Consultant Psychiatrist or Care Co-ordinator/Key Worker should immediately notify Customer Services of complaints addressed to Chief Executive, stating the reasons for this decision and advise if an advocate has been appointed.

Response to be prepared, following investigation.

Where an advocate has been appointed the response will be sent to them on the service user’s behalf.

Where there is no advocate, the Ward/Team Manager or Customer Services will send the written response to the service user’s Consultant/ practitioner in charge of the service

user’s care, who will give it to the service user at a time when they feel the service user is

well enough to receive the response.

The Ward/Team Manager or Customer Services, on behalf of the Chief Executive, will write to the service user advising that this has been done.

Consultant will make a progress note confirming the reasons why it is considered clinically


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inappropriate/detrimental at that time to pass the response to the service user (copy of this to be sent to Customer Services Department).

The response will be passed to the service user at a later date when appropriate.