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Best Care, Highest Standards, Right Place

Report to Trust Board

Date 3 June 2008

Agenda Item P3

Agenda Title Complaints Policy Sponsor Alison Diamond, Associate Medical Director

Prepared by Emma de Carteret, Customer Relations Manager

Presented by Alison Diamond, Associate Medical Director

1 Purpose of this paper

The aim of this policy is to ensure all staff recognise their responsibility within the resolution of formal complaints made to the Trust. The arrangements are accessible and will ensure that complaints are dealt with speedily and efficiently, and that complainants are treated courteously and sympathetically and as far as possible involved in decisions about how their complaints are handled and considered.

Implementation of this policy will ensure that:

• The handling and consideration of complaints is actioned appropriately and in accordance with the regulations in place within the NHS.

• The arrangements in place are accessible; so as to ensure complaints are dealt with speedily and efficiently.

• Complainants are treated courteously and sympathetically and as far as possible involved in decisions relating to the way in which complaints are handled and considered.

• All staff are supported throughout the complaints process and are as far as possible involved in the handling and consideration of complaints.

• There are mechanisms in place to ensure that staff and services are able to demonstrate a process of positive and ‘reflective’ learning with respect to complaints received.

2 Equality and Diversity Implications

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from the policy’s contents.

3 Legal Implications The policy will ensure that the Trust meets nationally recognised best practice for the principles for complaints, including the NHS Litigation Authority’s Risk Management Standards for Acute Trusts and sets out the process for the local implementation of the NHS (Complaints) Regulations, Amendment Regulations 2006, which apply in England and came into force on 1 September 2006.

Complaints Policy (V2.0 Northern Devon Healthcare NHS Trust Trust Board 3 June 2008

4 Patient, Public and Staff Involvement

During the development of the policy, key stakeholders were consulted, which included members of staff and Non-Executive Directors.

5 Controls and Assurances

This policy was given initial approval at the Clinical Governance Committee in March 2008. Final approval was given by the Clinical Services Executive Committee on 15 April 2008.

6 Cost Implications

The cost implications have been considered and openness and honesty can help prevent incidents involving patient from becoming formal complaints and any consequent litigation claims.

7 Potential risk to the organisation

If the policy is not developed and implemented, the Trust is at risk of not meeting good practice guidance and an increased risk of receiving complaints or litigation claims. Risk score 9 (consequence = 3 x Likelihood = 3).

8 Recommendations

The Board is asked to RATIFY the attached Complaints Policy.

Customer Relations Department, January 2008 of 36

Complaints Policy (V2.0 Northern Devon Healthcare NHS Trust Trust Board 3 June 2008

Customer Relations Department, January 2008 of 36

Strategic Objectives Ten strategic objectives were agreed by the Trust Board in May 2007 to support the Trust’s mission statement “Best Care, Highest Standards, Right Place”. The strategic objectives have been developed to ensure there is a shared understanding and common purpose throughout the organisation about the Trust’s strategic direction and what needs to be delivered.

Patient Safety High Quality Services

Efficient & Effective Strategic Partnerships

Listening and responding to the needs of patients X Modern and Effective Infrastructure

Deliver Care in the most appropriate setting Public Health

Integrate Health and Social Care X Robust and Sustainable

Standards for Better Health The Core and Developmental Standards for Better Health have been developed by the Healthcare Commission. Compliance with the Standards throughout the year form a part of the Trust’s Annual Health Check.

C1a Incident Reporting C7e Equality & Diversity C16 Patient Information

C1b Safety Alerts C8a Whistle blowing C17 Patient & Public Involvement

C2 Child Protection C8b Personal Development Programmes C18 Access to Services –

Equality & Choice

C3 NICE – Interventional procedures C9 Records Management C19 Access to Services –

Emergency care

C4a Infection Control C10a Employment Checks C20a Security and Health & Safety

C4b Medical Devices C10b Professional Codes of Conduct C20b Patient Privacy &

Confidentiality

C4c Decontamination C11a Recruitment C21 Hospital Cleanliness

C4d Medicine Management C11b Mandatory Training C22a Public Health – Health inequalities

C4e Waste Management C11c Professional Development C22b Public Health – D of

PH report

C5a NICE – Technology appraisals C12 Research & Development C22c Public Health -

Working with partners

C5b Clinical Supervision & Leadership C13a Dignity & Respect C23 Public Health – Health

promotion

C5c Clinical Professional Development C13b Consent to treatment C24 Major Incident

Planning

C5d Clinical Audit C13c Use of Confidential Information X D1 Patient Safety – Risk

reduction

C6 Healthcare bodies co-operating together X C14a Complaints - Information D2a Clinical Effectiveness –

Best practice

C7a Corporate Governance X C14b Complaints – Non-discrimination D13a Public Health – Health

inequalities

C7b Finance & Probity X C14c Complaints – Service improvements D13b Public Health –

National guidance

X C7c Clinical Governance C15a Patient Food Standards

C7d Performance C15b Patient dietary requirements

Best Care, Highest Standards, Right Place

Document Control Report

Title Complaints Policy Author Emma de Carteret, Customer Relations Manager Version Date

Issued Status Comment

1 Nov 04 Final Approved

1.1 Jan 08 Revision Amendments made to NHSLA Standards 1.2 Apr 08 Revision Amendments approved by Clinical Governance

Committee 1.2 May 08 Final

Revision Presented to Clinical Services Executive Committee for final Approval

1.2 May 08 Final Presented to Trust Board for approval 2.0 May 08 Final Published on Tarkanet

Main Contact Emma de Carteret Customer Relations Manager Customer Relations Department Suite 1 Chichester House North Devon District Hospital Raleigh Park Barnstaple EX31 4JB

Tel: Direct Dial – 01271 311726 Tel: Internal – 3726 Email: Emma.De [email protected]

Lead Director Alison Diamond, Associate Medical Director Document Class Policy

Target Audience All staff Non-Executives

Distribution List Senior Management

Distribution Method TarkaNet

Superseded Documents Complaint Procedure for Northern Devon Healthcare Trust, November 2004 Complaint Procedure for North Devon Primary Care Trust (2006) Issue Date March 2008

Review Date March 2011

Archive Reference Complaints Draft Policy Path G:/Clinical Governance/Clinical Governance 2008/Shared Information/Policies/Complaints Policy Filename Complaints Policy V1.1

Complaints Policy (V2.0) Northern Devon Healthcare NHS Trust Trust Board 3 June 2008

Contents

Section Page

1 Introduction 5

2 Purpose 5

3 Definitions 5

3.1 Complaint 5

3.2 Discrimination 5

3.3 Non-Discrimination 5

4 Responsibilities 6

4.1 Role of the Chief Executive 6

4.2 Role of the Associate Medical Director 6

4.3 Role of the Customer Relations Manager 6

4.4 Role of the Customer Relations Administrator 6

4.5 Role of the Directorate Complaints Leads 6

4.6 Role of All Staff 7

4.7 Role of Specialist Staff 7

5 Who can Complain 7

5.1 Complaints From a Member of Parliament 8

5.2 Independent Complaints Advocacy Service 8

6 Non Discrimination 9

6.1 Systems to prevent discrimination occurring 9

7 Complaint Record Keeping 10

8 Time Limits for Complaints 10

9 The Complaints Policy: Local Resolution 10

9.1 Statutory Timescales (Regulation 7 – Amendment of Regulation 13 of the Principle Regulations) 10

9.2 Process for dealing with complaints 11

9.2.1 Support for Staff 14

9.2.2 Meeting with complainants 14

9.3 Second opinion 14

9.4 Complainant not satisfied with final response 15

9.4.1 Further correspondence from complainant 15

Customer Relations Department, Jan 2008 of 36


Section Page

10 The Healthcare Commission and Independent Review 15

10.1 The Independent Review Process 16

10.2 Initial Review 16

10.3 Decisions Made at Initial Review 16

10.4 Referral Back to The Trust 16

10.5 Full Investigation 17

10.6 Complaint Referred to Panel 18

10.7 Timescales: Independent Stage of The NHS Complaints Procedure 18

11 The Parliamentary and Health Service Ombudsman 19

12 Special Circumstances 19

12.1 Coroner’s Cases 19

12.2 NHS Private Pay Beds 19

12.3 Complaints Involving More Than One Provider 20

12.4 Civil Claims 20

12.5 Habitual or Vexatious Complainants 20

12.6 Disciplinary Action 20

13 Learning, Monitoring and Reporting 21

13.1 Learning 21

13.2 Monitoring 21

13.3 Reporting 21

13.3.1 Monthly Reports 21

13.3.2 Quarterly and Annual Reports 22

14 Development of the Policy 22

14.1 Prioritisation of Work 22

14.2 Document Development Process 22

14.3 Equality Impact Assessment 22

15 Consultation, Approval and Ratification Process 22

15.1 Consultation process 22

15.2 Policy approval process 23

15.3 Ratification process 23




Section Page

16 Review and Revision Arrangements Including Document Control 23

16.1 Process for reviewing the policy 23

16.2 Process for revising the policy 23

16.3 Document control 23

17 Dissemination and Implementation 24

17.1 Dissemination of the policy 24

17.2 Implementation of the policy 24

18 Document Control including Archiving Arrangements 24

18.1 Library of procedural documents 24

18.2 Archiving arrangements 24

18.3 Process for retrieving archived policy 24

19 Monitoring Compliance with and the Effectiveness of Procedural Documents 25

19.1 Process for monitoring compliance and effectiveness 25

19.2 Standards/Key Performance Indicators 25

20 References 25

21 Associated Documentation 26

Appendices

A Habitual or Vexatious Complainants Procedure 27

B Completed Equality Impact Assessment 32

Complaints Policy, (v 2.0) Northern Devon Healthcare NHS Trust 1 Introduction

This policy sets out the process for the local implementation of the NHS (Complaints) Regulations, Amendment Regulations 2006, which apply in England and came into force on 1st September 2006. The regulations are published as SI2006/2084.

Although members of Northern Devon Healthcare Trust strive to provide the best possible care, sometimes causes for concern arise. We aim to respond positively to any comments, suggestions or complaints and use them to improve our services.

These arrangements are accessible and will ensure that complaints are dealt with speedily and efficiently, and that complainants are treated courteously and sympathetically and as far as possible involved in decisions about how their complaints are handled and considered.

2 Purpose

The purpose of this document is to ensure all staff recognise their responsibility within the resolution of formal complaints made to the Trust.

The policy applies to all Trust staff.

Implementation of this policy will ensure that:





• There are mechanisms in place to ensure that staff and services are able to demonstrate a process of positive and ‘reflective’ learning with respect to complaints received.

3 Definitions

3.1 The Citizen’s Charter Complaints Task Force has defined a complaint as:

“An expression of dissatisfaction requiring a response”.

3.2 Discrimination is defined by the English Dictionary as:

• treating people differently through prejudice: unfair treatment of one person or group, usually because of prejudice

3.3 Non-Discrimination is defined by the English Dictionary as:

• The absence of discrimination. • The practice or policy of refraining from discrimination.


Complaints Policy, (v 2.0) Northern Devon Healthcare NHS Trust 4 Responsibilities

4.1 Role of the Chief Executive

In accordance with the NHS (Complaints) Amendment Regulations 2006, the Chief Executive has overall statutory responsibility for complaints.

4.2 Role of the Associate Medical Director

The Associate Medical Director is Executive Lead for Complaints and responsible for overseeing the process and provision of assurance/ exception reports.

4.3 Role of the Customer Relations Manager

The Customer Relations Manager is responsible for:

• Operational management of parts of the complaint process allocated to the complaint department

• Advising, supporting, monitoring and reporting of complaint activity within the Trust

• Ensuring a central record of complaints and performance against national standards is maintained using the IT system Datix.

• Monitoring of Directorate actions around complaints is addressed in the quarterly review process.

• Completing the annual Department of Health Kerner Return

4.4 Role of the Customer Relations Administrator

The Customer Relations Administrator is responsible for:

• In the absence of the Customer Relations Manager, completing all necessary tasks in order that any pending complaints investigations are not delayed.

• Ensuring that all complaints are logged, acknowledged and forwarded to the appropriate Directorate Leads for investigation

• Ensuring that all complaints reports are supplied to the Customer Relations Manager within the statutory timescales for completion of the final response letter.

• Ensuring that all complaints records on the Datix system are kept up to date at all times.

4.5 Role of the Directorate Complaints Leads

Directorate Complaint Leads are responsible for completing complaint investigations, and ensuring action arising out of complaints is: • Recorded systematically • Subject to monitoring • Reported to the Customer Relations Department


Complaints Policy, (v 2.0) Northern Devon Healthcare NHS Trust

4.6 Role of All Staff

All staff are responsible for: • Listening to the concerns of people using the service and if possible,

resolving those concerns • Referring those matters they cannot resolve to a senior or the Patient

Advice Liaison Service • Providing information about how to complain either by issue of the

complaint leaflet, referral to the website or a member of the complaints department

• Fully co-operating with a complaint investigation within the stated timescales, formal process and complaint management workbook

• Learning from complaints and making changes where necessary

4.7 Role of Specialist Staff

Specialist Staff such as the Back Care Adviser, Fire and Safety Adviser must be contacted at the onset of the complaints investigation to provide specialist input as required.

5 Who Can Complain?

Most complaints start as concerns, therefore we try to resolve matters on the spot or informally. If this is not possible the person complaining may choose to use the NHS Complaint Procedure to formalise the matter.

A complaint can be made by any existing and /or former users of the Trust’s services. A complaint can be made by a person acting on behalf of another person if that person: • Has died • Is a child • Is unable to make the complaint themselves • Has requested the representative to act on their behalf In the case of a patient or person affected who has died or who is incapable, the representative must be a relative or other person who, in the opinion of the Customer Relations Manager, had or has a sufficient interest in their welfare and is a suitable person to act as representative. If in any case the Customer Relations Manager is of the opinion that a representative does or did not have a sufficient interest in the person’s welfare or is unsuitable to act as a representative, they must notify that person in writing, stating their reasons. In the case of a child, the representative must be a parent, guardian or other adult person who has care of the child and where the child is in the care of a local authority or a voluntary organisation, the representative must be a person authorised by the local authority or the voluntary organisation. In accordance with the Regulations any reference to a complainant within this procedural guidance includes a reference to their representative.



The Trust needs to establish that the complainant is suitable to represent the service user, paying particular attention to the need to respect the confidentiality of the service user and to any known wishes expressed by the service user that information should not be disclosed to third parties. 5.1 Complaints from a Member of Parliament

When complaints are made by Members of Parliament on behalf of their constituents, if a patient has visited an MP in their surgery, written to them requesting their representation on their behalf in making a complaint, or contacted them by telephone, consent is not required under the current complaints regulations. In most cases the MP encloses a copy of the constituent’s letter. If the MP states they have received their constituent’s permission, the Trust assumes this to be the case and therefore there is no requirement to seek permission Information is only disclosed on a need to know basis. Nothing more than the relevant information pertaining to the complaint is given in the final response to the MP. If an MP is representing a constituent who is acting on behalf of a patient, then permission must be obtained from the patient. Information must never be disclosed without the permission of the patient. If the MP has obtained this permission then they must provide us with the written document. In all of the above situations, under the NHS (Complaints) Amendment Regulations 2006, the final decision about how to proceed rests with the Customer Relations Manager, who if appropriate, seeks guidance and assistance from the Trust’s Information Governance Manager and/or Caldicott Guardian with regards to the Data Protection Act and patient confidentiality. The Customer Relations Manager must be satisfied that the complainant is acting in the patient’s best interest. In certain cases, it may be necessary to seek advice from the Trust Solicitor.

5.2 Independent Complaints Advocacy Service (ICAS)

Independent Complaints Advocacy Service supports patients and their carers wishing to pursue a complaint about their NHS treatment or care. Independent Complaints Advocacy Service empowers clients by providing information, support, and guidance and helping them to articulate their concerns and navigate the complaints system. This may include assistance with constructing a complaint letter or attendance at meetings. Independent Complaints Advocacy Service supports the principle of local resolution and aims to help clients find a solution as close as possible to the point of service that has caused the dissatisfaction.

The Independent Complaints Advocacy Service is mentioned in the Trust’s complaints information leaflet and website. Each complainant will receive a copy of the leaflet with the letter of acknowledgement of their complaint.



6 Non Discrimination

The Trust condemns any discrimination against complainants. Care and treatment of complainants must not be compromised, now or in the future. The Trust has in place systems to ensure that patients, their relatives and carers are not discriminated against when they make a complaint.

The Trust is committed to equality for patients and service users, both during and after the complaints process, no matter what their complaint or concern raises. Staff are aware of the importance of not discriminating against those who have made a formal complaint to the Trust, through the complaints training that the Trust provides.

6.1 Systems to prevent discrimination occurring Any allegations of discrimination are referred to the relevant Executive Director. Trust complaints records are kept separate from health records and not filed in the medical notes unless specifically requested by the patient. If a patient requests that information relating to a complaint be added to their medical record, the Customer Relations Department seeks advice from the Trust’s Information Governance Manager and/or Caldicott Guardian. Computer records of all complaints received are recorded on the hospital’s DATIX database system. Password access is required for this, which is limited to those staff members handling complaints, PALS, incidents or claims, only if access is authorized by the Corporate Governance Department. Information about complaints is NOT recorded on the Patient Administration System. Representatives of the Trust attend a variety of external meetings (such as community and voluntary sector groups, user groups, Independent Complaints Advocacy Service events). This provides an opportunity for gathering feedback, recognising that some complainants may raise their concerns via these methods rather than directly to the Trust. The Trust periodically performs a complainant satisfaction survey which includes questions about possible discrimination. The Trust has developed an Interpreting and Translation Procedure to ensure non-English speakers, patients, carers and family whose first language is not English and deaf people receive the support and information they need to access services. This includes access to a complaints service. The Customer Relations Manager is responsible for: • Recognising that a language need exists • Access and making provision for that need • Recording the requirement for an interpreter Further detailed guidance is provided in the aforementioned Interpreting and Translation Procedure. Arrangements for the provision of information in other formats such as large print, audiotape, symbols etc are described in the Trust’s procedure for Producing Patient Information. The Complaints Leaflet is available on large print and audio tape.



7 Complaint Record Keeping

There must be no reference to any complaint recorded in the patient’s medical records. Complaints records must be kept separate from health records and must not be filed in the medical notes unless specifically requested by the patient. If a patient requests that information relating to a complaint be added to their medical record, the complaints department seeks advice from the Information Governance Manager and or the Caldicott Guardian. Computer records of all complaints received are recorded on the Trust’s DATIX database system and managed in accordance to the IT Security Policy. All complaint records are used, retained, archived and destroyed according to the Trust’s records management framework which addresses the requirement for Data Protection Act. Maintaining confidentiality is given utmost importance.

8 Time Limits for Complaints

Normally a complaint should be made within 6 months of the matter that caused the problem, or within 6 months of the date of discovering the problem. The Trust has the discretion to extend this time limit if:

• There is a valid reason why the complaint was not raised earlier, for example illness of bereavement

• The complaint can still be investigated properly, for example if staff recollect the matter

If the Trust refuses to waive the time limit, the complainant should be told why and that they have a right to an independent review of that decision.

9 The Complaints Policy: Local Resolution

9.1 Statutory Timescales (Regulation 7 – Amendment of Regulation 13 of the Principle Regulations)

The initial complaint letter must be acknowledged by the Trust within 2 working days of its receipt, with details of the complaints process for their information.

The final complaint response must be sent to the complainant within 25 working days beginning on the date on which the complaint was made, unless the complainant agrees to a longer period in which case the response may be sent within that longer period.

The Regulations stipulate that the 25 days deadline can be extended, but only by agreement with the complainant.



In cases where the NHS body concerned considers it appropriate to seek an extension of the time limit, for example because of the complexity of the case, they should contact the complainant to invite their agreement, explaining the reasons for the request.

No pressure must be placed on the complainant to agree the extension but the complaints manager may, in suitable cases, consider it appropriate to explain that a comprehensive response may not be possible to achieve within 25 days.

The key considerations are whether an extension will genuinely enable local resolution of a complaint to be achieved, and that the complainant is involved in the discussion.

Requests for Extension of timescales will be overseen by the Customer Relations Manager in line with Department guidance. The Customer Relations Department will ensure that extension requests are appropriately documented within the Complaints Record.

Lack of response must be escalated through the organisation and actioned upon promptly.

Delays can occur because of the complexity of a complaint or staff absence. If it is obvious from the outset that the time scales cannot be achieved the Customer Relations Manager must contact the complainant to negotiate time scales.

9.2 Process for Dealing with Complaints

All formal complaints, received via letter, telephone, face to face contact or email, however addressed are passed immediately to the Customer Relations Manager for action, according to the process stated in the flow chart (page 13).

The Customer Relations Manager forwards the complaint to the appropriate Directorate Complaint Lead for thorough investigation. The process is supported by completion of the complaint management template which forms appendix A. Further guidance is provided within the complaint management workbook. The Customer Relations Manager is responsible for the preparation of the final letter of response based on the information provided through the Complaints Investigation by the Directorate Complaints Leads. Circulation of the draft final response letter will be in accordance with Customer Relations Department internal procedures. Final response letters will:

• Be clear, accurate, balanced and simple (using plain English with clear explanations of any clinical or medical terminology employed).

• Ensure that all points raised by the complainant are appropriately addressed.

• Acknowledge how the complainant feels or felt in respect of the complaint. • Give an apology where due. • Provide a full and honest explanation of all points raised. • Report any preventative action to be, or already, taken.



• Make clear if further local resolution is still available. • Provide further details in relation to the complainant's ongoing rights

under the NHS Complaints Regulations. State the complainant's right to ask for Independent Review by the Healthcare Commission



9.2.1 Support for Staff

The receipt of a complaint can be an extremely stressful experience for any member of staff. The implication that in some way the care that was provided has been perceived as being anything but of the highest quality can have a considerable impact on a person’s functioning. As a Trust, we are committed to ensuring that all staff are supported during the complaints process: • We always ensure fairness, openness and impartiality during our

complaints investigations. • As a Trust we always accept where something has gone wrong

and apologise for it. • Equally, if we feel that the complaint is unfounded or incorrect we

always fully support both our staff and the service or services questioned.

Managers should discuss with staff options for support (e.g. Ward/Team Manager, clinical supervisor, manager, occupational health). Complaints Handling, Customer Care and Complaints investigation sessions are currently available to all Trust staff through the Trust In-house training prospectus. Further guidance for staff can be found on the Complaints section of TarkaNet.

9.2.2 Meeting with Complainants

At any point in the complaints process, the Customer Relations Manager may consider for the complainant to meet with appropriate staff. This is only offered after discussion with and the agreement of the key respondents concerned. The complainant may bring a family member, a friend or advocate to this meeting. It is confirmed at the meeting whether the complainant requires a final letter summarising the discussions held. If required this is prepared by the Customer Relations Manager in association with the Directorate Complaint Lead, summarising the content of the meeting and the agreement reached. Advice to those wishing to make a complaint is provided in leaflet format that is available in paper and distributed to all areas throughout the hospital. It is also available electronically on the Trust website which includes some additional information.

9.3 Second Opinion

The complainant or Customer Relations Manager may ask for an independent opinion about the quality of service/care provided. A member of the Executive Team or an independent person outside the Trust may be used.



9.4 Complainant not satisfied with final response

9.4.1 Further Correspondence from Complainant

If a complainant remains dissatisfied with the final response they are encouraged to contact the Trust again outlining their further concerns. If a follow up letter is received, the Customer Relations Manager processes this in accordance with the Complaints process. Providing further information to complainants may facilitate final closure of the complaint. There are no statutory timescales for this part of the process, however to ensure that second responses are provided in a timely manner, a response target of 25 working days is set.

10 The Healthcare Commission and Independent Review

If attempts at resolving complaints locally are unsuccessful, the complainant may wish to ask the Healthcare Commission for an independent review of their complaint. This must be done within six months of the date of the final response from the Trust. The request should be sent to The Healthcare Commission, Freepost NAT 18958, Complaints Investigation Team, Manchester M1 9XY. To ensure complainants know their rights, the Trust includes a section at the end of the final response letter advising them about the role of the Healthcare Commission.

This procedure is directly based on the Healthcare Commission guidance on how it will handle Independent Reviews. Further information is contained on their website www.heathcarecommission.org.uk or can be obtained from their helpline 0845 601 3012.

The current complaints procedure stresses that, wherever possible, issues should be addressed and resolved locally. The Department of Health has proposed ways of strengthening this local activity, as outline in the 2003 publication ‘Making things rights’.

The introduction of Patient Advice and Liaison Services (PALS), Independent Complaints Advocacy Services (ICAS), modern matrons and improved training in caring for the needs of patients and carers, should mean that the Healthcare Commission should only receive cases that are either serious in nature or the result of a breakdown in trust between the patient and service.

Upon receipt, the Healthcare Commission reviews the complaint and if necessary seeks advice from clinical advisers, to support them in reaching a decision about how the complaint was handled. The Trust is responsible for:

• Complaints that have been referred back to the Trust by the Healthcare Commission who requires further investigation and action.

• The process as stated above is applied, with the addition of notifying the Executive lead for complaints and the relevant Executives as determined by the issues within the complaint.


http://www.heathcarecommission.org.uk/


• A totally fresh issue analysis is performed to ensure all matters identified by the Healthcare Commission are addressed.

• Strict central monitoring of compliance with timescales are provided by the central Customer Relations Department with exceptions immediately escalated to the appropriate Executive.

• Action plans arising from Healthcare Commission complaints are performance managed by the relevant Executive.

• A monthly position statement inclusive of all Healthcare Commission complaints are provided to the Clinical Governance Committee for governance and onward assurance to Trust Board.

The above actions are co-ordinated by the Customer Relations Manager. The Healthcare Commission has produced a “good practice” guide which is available though the website. 10.1 Independent Review Process

The Commission will appoint a Case Manager who will send a letter of acknowledgement to the complainant. The Case Manager will then ensure that they have all of the information they need to carry out an initial review.

The initial review is just one possible stage of the process used by the Healthcare Commission. When a complaint is received an initial review is carried out to determine whether or not it is possible or appropriate for the complaint to be looked at further by the Healthcare Commission. The other possible stages of the complaints process are an investigation and a panel. Whether a complaint goes through all or any of these stages is dependent on a number of factors e.g. whether a case meets the eligibility criteria for review

10.2 Initial Review

The information needed to carry out an initial review will vary from case to case but will generally include the following:

• A request for a review • The necessary consent forms • The case file from the original investigation of the complaint • Relevant medical records.

The Case Manager will look at all of the information they have received. They may then contact the complainant or the complained against to clarify some details before reaching a decision. They may also take advice from an expert advisor.

The initial review will be completed 10 days after the case manager has received the documentation they request from the healthcare provider.

10.3 Decisions Made at Initial Review

It may be that different aspects of a complaint are dealt with in different ways. The Case Manager will make one of the following decisions about all or each part of a complaint:



• Decide the complaint is not eligible because it does not meet the Healthcare Commission’s criteria

• Take no further action • Refer the complaint back to the healthcare provider or NHS body for

further action • Refer the complaint to another body for further action or investigation

e.g. The General Medical Council or the Health Service Ombudsman • Refer the complaint for action by another section of the Healthcare

Commission • Carry out a full investigation of the complaint • Refer the complaint for a panel hearing

If a complainant is unhappy with the outcome of the initial review they will be able to complain about the Healthcare Commission’s decision to the Health Service Ombudsman.

10.4 Referral Back to the Trust

If a complaint is referred back to the healthcare provider or NHS body then the Healthcare Commission may recommend that the healthcare provider or NHS body do a certain number of things to resolve the complaint including:

• Give more information to the complainant • Carry out further investigation • Take remedial action e.g. Offer treatment that may rectify a problem,

improve procedures, follow disciplinary procedures, arrange for an independent person to mediate between the complainant and the healthcare provider

10.5 Full Investigation

If the Healthcare Commission makes the decision to investigate then the Case Manager will first finalise the matters for investigation - these are called the terms of reference. Both the complainant and complained against will be able to comment on the draft terms of reference. If the Case Manager decides not to investigate certain parts of the complaint, they will explain the reasons why.

They will then ask for independent expert advice depending on the type of complaint. This could include medical or legal advice or advice from someone who can give a patient or public interest perspective.

The Case Manager may also decide to interview people connected with the complaint including the complainant, complained against and witnesses.

When the investigation is completed, a draft report will be prepared and sent out for comment on factual accuracy. The report will summarise the investigation and make recommendations. The report will then be finalised and distributed to following parties:

• the complainant • the patient if they are different from the complainant • those complained against • the Chief Executive of the Trust



• any experts consulted • the strategic health authority • the Healthcare Commission standards committee on the management of

complaints

The recommendations made at the end of an investigation will be similar to those possible at the end of initial review.

An investigation will normally be completed within six months of the date we decide to undertake it.

If a complainant is unhappy with the outcome of an investigation they can ask for a panel hearing to be set up to hear the aspects of the investigation that they are unhappy with. A panel hearing will not consider any aspect of a complaint that has not been investigated by the Healthcare Commission unless it was referred directly to panel as an outcome of the initial review.

If the person or organisation that is complained about are unhappy then they can also ask for a panel hearing to be set up or complain to the Health Service Ombudsman, depending on which stage of the process they are unhappy with.

10.6 Complaint Referred to Panel

If a complaint is referred to a panel the Healthcare Commission will set up a panel of three people – a chair and two panel members. The case manager and chair will agree the terms of reference for the panel following comments from the complainant and the complained against. A panel coordinator will then take over with organising the panel and producing the report of the outcomes. All parties involved with the panel will have a chance to check the draft report for factual accuracy before it is finalised and distributed. The distribution of the panel report is similar to that for the investigation report (see previous section).

The recommendations made by a panel will be similar to those possible at the end of initial review.

The panel process will normally be completed within 4 months of the date of the request. This includes the distribution of the panel report.

If a complainant is unhappy with the outcome of the panel hearing they will be able to complain about our decision to the Health Service Ombudsman.

10.7 Timescales: Independent stage of the NHS Complaints Procedure.

The term ‘days’ refers to ‘working days’ and excludes weekends and bank holidays. Some of the activities could be concurrent.

Action Time Acknowledge complaint. Within two days of receipt. If about a Foundation Trust, copy to OIS. Within two days. Obtain consent forms. Up to five days. Call for papers, including views of organisation complained against in the complaint.

Up to twenty days.



Expert advice identified and received. Up to thirty days. Decision on what will happen to the case. Communicated to all parties.

Up to ten days.

If investigation agreed, terms of reference drafted. Two days. Comments from parties. Up to ten days. Identify and secure experts. Up to twenty days. Arrange interviews, call for further papers, write reports, quality assurance.

Must be completed within ninety days of decision to investigate unless there is a valid reason.

Request for a hearing by panel from complainant or organisation complained against.

Within 40 days of the report issue date.

Panel established. Within 48 days of the receipt of the request. Draft report for checking by parties for factual accuracy.

Within 10 days of panel.

Receipt of comments and checks for quality. Within 10 days of the deadline for comments. Issue Report

11 The Parliamentary & Health Service Ombudsman

The Health Service Ombudsman investigates complaints about the National Health Service. Complaints should first be taken up locally with the local provider; if the complaint is not dealt with satisfactorily locally or by the Healthcare Commission then a complaint can be made to the Ombudsman. The Ombudsman is completely independent from the NHS and Government. There is no charge for the Ombudsman's service.

12 Special Circumstances

12.1 Coroner’s Cases

In the event of a death being referred to H M Coroner, consideration is given to which aspects of the complaint can still be investigated. Consultation between the Coroner and complainant are vital to ensure appropriate investigations are commenced. The Trust Solicitor supports this liaison.

12.2 NHS Private Pay Beds

This procedure covers any complaint made about the Trust's staff relating to care in the Trust's private pay beds/service areas, but not to the private medical care provided by the consultant outside his/her NHS contract. Complaints relating to medical care provided under private arrangements must be pursued with the practitioner concerned. In these circumstances the complaint is sent to the clinician concerned for their direct response and informing the complainant in writing. (Further guidance is available from the Department of Social Security Circular HC(86)4 handbook 'Management of Private Practice in Health Service Hospitals in England & Wales').



12.3 Complaints involving more than one provider

If a complaint involves more that one NHS provider or other bodies such as local authority, the Customer Relations Manager must ensure appropriate communication and co-operation occurs to refer non-Trust issues to the relevant body for investigation under their local complaint procedure. All actions should be communicated to the complainant in writing. Complaints that are solely concerned with another provider's care must be discussed with the complainant and referred to the appropriate body.

12.4 Civil Claims

If a complaint reveals a prima facie case of negligence, or the likelihood of legal action, the Customer Relations Manager must liaise with the Trust’s claims staff. The complaints should not be dealt with in a defensive manner as this may encourage the complainant to claim. Prima facie evidence of negligence should not delay a full explanation of event and, if appropriate an apology: an apology is not an admission of liability. Fuller information is provided in the NHSLA’s circular no:02/02, Apologies and Explanations. If the complainant has instigated formal legal action, or notified the Trust in writing that he or she intends to do so, the complaint procedure should be stopped and written notification given to the complainant.

12.5 Habitual or vexatious complainants

Whilst complainants are encouraged to contact us if they remain dissatisfied, infrequently there are some complainants that remain dissatisfied with the Trust response, despite our best efforts to address their concerns. The Trust endeavours to take a balanced approach at this point, to ensure that complainants are not discriminated against. To ensure the decision-making is as open, fair, and transparent as possible, there is a separate procedure providing further guidance for use when considering taking action against any complainant that may be considered to be vexatious, or seeking to prolong the complaints process unnecessarily. See Appendix A.

12.6 Disciplinary Action The complaint procedure must not be used to investigate disciplinary matters. However some complaints may identify information about serious matters and the Trust may consider disciplinary action is warranted. Information gathered as part of the complaint investigation may be made available in accordance with the relevant human resources process. If it is decided to take disciplinary action regarding the matter of the complaint before the complaint investigation has been completed the complainant must be notified that the matter is being investigated through the human resources process. Disclosure of the nature of the investigation and outcome must not be made without advice from the human resources department. The complainant must be informed of progress. When the process is complete a further response should be sent to the complainant, outlining the outcome



and any actions to be taken. Care must be taken about patient and staff confidentiality.

NHS staff may complain about the way they have been dealt with under the complaint procedure and may take such a complaint to the Ombudsman. In the first instance staff must raise their concern through the Trust grievance procedure only. In exceptional cases the Ombudsman would consider cases that have not exhausted this route.

13 Learning, Monitoring & Reporting

13.1 Learning

The Customer Relations Manager is responsible for monitoring all action plans related to complaints centrally, using the Datix module. This will facilitate Directorate Complaints Leads to ensure that all specific actions occur in the timeframe stated.

Each month the Customer Relations Manager will forward each Directorate Complaints Lead a list of actions due or outstanding, for these to be carried out by the deadlines set out during the original investigation process.

To ensure organisational learning is shared across the Trust, the quarterly and annual reports will be posted on Tarkanet, the Trust intranet, and reported through the Chief Executive Bulletin.

All line managers are responsible for monitoring and ensuring that individual staff members involved in a concern or complaints investigation reflect on this and change/improve their practice as a result where appropriate.

13.2 Monitoring

The Complaints, Litigation, Incidents & Patient Advice and Liaison Service Group (CLIP), a specialist advisory group of the Clinical Governance Committee, will monitor progress against the action plans, and the implementation of recommendations following investigations into incidents, complaints or claims. Exceptions will be reported to the relevant trust committee.

Actions required and learning needs identified through investigations into complaints should be reflected in the Directorate Service Plans and Clinical Governance Development Plan (where Trust wide).

13.3 Reporting

13.3.1 Monthly Reports

The Customer Relations Manager produces monthly complaint performance reports to the Clinical Services Executive Committee (CSEC), Finance and Performance Sub-Committee and the Executive Team. This ensures complaint information around time scales and learning points can be identified.



13.3.2 Quarterly and Annual Reports

The Customer Relations Manager produces quarterly complaint reports for the Clinical Services Executive Committee (CSEC), Clinical Governance Committee and the Executive Team. Once approved, these are sent to the Trust Board for formal discussion and ratification/approval. The Trust Quarterly Complaints Report provides information about the achievement of performance targets, the range and type of complaints, the Trusts’ ability to satisfy complainants and the action that has been taken as a result of complaints. The Trust Quarterly & Annual Complaints Reports include: • Numbers of complaints received. • Complaints by Directorate/Service Type. • Performance against statutory timescales including response

times. • Information about the complaint process during the quarter/year. • Information provided by the Directorate Complaints Leads

regarding lessons learnt and remedial actions taken. • The Customer Relations Manager is responsible for completing

the annual DOH Kerner return.

14 The Development of the Policy

14.1 Prioritisation of Work

Following vertical integration of the community services from the North Devon Primary Care Trust with the acute services, a requirement was identified to harmonise the two organisations’ policies for complaints management.

14.2 Document Development Process

As the author, the Customer Relations Manager is responsible for developing the policy and for ensuring stakeholders were consulted with.

Draft copies were circulated for comment before approval was sought from the relevant committees.

14.3 Equality Impact Assessment

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. An Equality Impact Assessment Screening has been undertaken and there are no adverse or positive impacts (Appendix B).

15 Consultation, Approval and Ratification Process

15.1 Consultation Process



The author consulted widely with stakeholders, including:

• Executive Directors • Clinical Governance Committee • Complaints, Litigation, Incidents and Patient Advice and Liaison

Service group (CLIP)

Consultation took the form of a request for comments and feedback via email. Hard copies were available on request.

15.2 Policy Approval Process

Initial approval of the policy will be sought from the Clinical Governance Committee.

Final approval will be sought from the Clinical Services Executive Committee.

15.3 Ratification Process

The policy will be ratified by the Trust Board.

16 Review and Revision Arrangements including Document Control

16.1 Process for Reviewing the Policy

The policy will be reviewed every three years. The author will be sent a reminder by the Tarkanet Support Officer four months before the due review date. The author will be responsible for ensuring the policy is reviewed in a timely manner and that the reviewed policy is initially approved by the CLIP group and then given final approval by the Clinical Services Executive Committee and ratified by the Trust Board.

All reviews will be recorded by the author in the document control report.

16.2 Process for Revising the Policy

In order to ensure the policy is up-to-date, the author may be required to make a number of revisions, e.g. committee changes or amendments to individuals’ responsibilities. Where the revisions are minor and do not change the overall policy, the author will present the revised version to the CLIP group for approval.

Significant revisions will require final approval by the Clinical Services Executive Committee and ratification by the Board.

All revisions will be recorded by the author in the document control report.

16.3 Document Control

The author will comply with the Trust’s agreed version control process, as described in the organisation-wide Guidance for Document Control.



17 Dissemination and Implementation

17.1 Dissemination of the Policy

After ratification by the Trust Board, the author will provide a copy of the policy to the Tarkanet Support Officer to have it placed on the Trust’s intranet. The policy will be referenced on the home page as a latest news release.

Information will also be included in the weekly Chief Executive’s Bulletin which is circulated electronically to all staff.

An email will be sent to senior management to make them aware of the policy and they will be responsible for cascading the information to their staff.

In addition, staff will be informed that this policy replaces any previous versions.

17.2 Implementation of the Policy

Line managers are responsible for ensuring this policy is implemented across their area of work.

Support for the implementation of this policy will be provided by the Customer Relations Department

At Trust Induction, all staff employed by the Trust will be given basic information on the complaints policy and the local arrangements for complaints management and resolution.

An in-house Customer Care and Complaints training is mandatory for all staff employed by the Trust.

18 Document Control including Archiving Arrangements

18.1 Library of Procedural Documents

The author is responsible for recording, storing and controlling this policy.

Once the final version has been ratified, the author will provide a copy of the current policy to the Tarkanet Support Officer so that it can be placed on Tarkanet. Any future revised copies will be provided to ensure the most up-to-date version is available on Tarkanet.

18.2 Archiving Arrangements

All versions of this policy will be archived in electronic format within the Customer Relations policy archive. Archiving will take place by the Customer Relations Manager once the final version of the policy has been issued.

Revisions to the final document will be recorded on the document control report. Revised versions will be added to the policy archive held by the Customer Relations team.

18.3 Process for Retrieving Archived Policy



To obtain a copy of the archived policy, contact should be made with the Customer Relations Manager.

19 Monitoring Compliance With and the Effectiveness of the Policy

19.1 Process for Monitoring Compliance and Effectiveness

Monitoring compliance with this policy will be the responsibility of the Customer Relations Team. This will be undertaken by audit of the complaints process.

Where non-compliance is identified, support and advice will be provided to improve practice.

19.2 Standards/Key Performance Indicators

Key performance indicators comprise:

• At least 80% of staff trained in Complaints Management. • A decrease in the number of complaints re-opened. • A decrease in the number of complaints referred to the Healthcare

Commission.

20 References

• Department of Health (2005). Handling Complaints in the NHS – Good Practice Toolkit for Local Resolution. London. Available at www.doh.gov.uk

• Department of Health (2007). Making Experiences Count: A New Approach to

Responding to Complaints. London. Available at www.doh.gov.uk

• Department of Health (2006). Supporting Staff, Improving Services – Guidance to Support Implementation of the National Health Service (Complaints) Amendment Regulations 2006. London. Available at www.doh.gov.uk

• National Patient Safety Agency (2005). Patient Briefing – Saying Sorry When

Things Go Wrong. London

• National Patient Safety Agency (2005). Being Open Communicating Patient Safety Incidents with Patients and Their Carers. London

• NHS (2004). The National Health Service (Complaints) Regulations. Available

at www.doh.gov.uk

• NHS (2006). The National Health Service (Complaints) Amendment Regulations. Available at www.doh.gov.uk

• The Data Protection Act 1998. London

• Freedom of Information Act 2000. London


http://www.doh.gov.uk/






• www.healthcarecommission.org.uk

21 Associated Documentation

Claims Policy for Northern Devon Healthcare Trust Incident Reporting Policy for Northern Devon Healthcare Trust

Investigations Policy for Northern Devon Healthcare Trust Raising Concerns Policy for Northern Devon Healthcare Trust

Supporting Staff Involved in an Incident, Complaint or Claim Policy for Northern Devon Healthcare Trust Whistle blowing policy for Northern Devon Healthcare Trust


http://www.healthcarecommission.org.uk/


Appendix A – Habitual or Vexatious Complainants Procedure Introduction Habitual and/or vexatious complainants can be a problem for NHS staff. Handling such complainants can place a strain on time and resources and cause unacceptable stress for staff who may need support in difficult situations. NHS staff are trained to respond professionally and with patience and understanding to the needs of all complainants, but there are times when there is nothing further that can reasonably be done to assist them in achieving the local resolution of their complaint. In determining arrangements for handling such complainants, Trust staff are presented with two key considerations:

• To ensure that the NHS complaints procedure and Trust’s complaints policy have been correctly implemented and that no aspect of a complaint has been overlooked or inadequately addressed. In doing so it should be appreciated that even habitual or vexatious complainants may raise substantive concerns and issues. The need to ensure an equitable approach is, therefore, paramount; • To be able to identify the point at which a complainant has become habitual or vexatious.

Purpose of this Procedure Complaints about the staff and services of the Northern Devon Healthcare NHS Trust are processed in accordance with NHS (Complaints) Amendment Regulations 2006 (a statutory instrument). During this process, staff may have contact with a small number of complainants who take up an unwarranted amount of NHS resource. The aim of this procedure is to identify situations where the complainant could be considered habitual or vexatious and to suggest ways of responding to such situations. This procedure should only be used after all reasonable measures have been taken to try to resolve complaints following the NHS Complaints Procedure. Definition of a Habitual or Vexatious Complainant Complainants (and/or anyone acting on their behalf) may be deemed to be habitual or vexatious where current or previous contact with them shows that they have met two or more (or are in serious breach of one) of the following criteria:

• Persisting in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted. For example, where investigation is deemed to be ‘out of time’ or where the Healthcare Commission has declined a request for independent review; • The substance of a complaint is changed or new issues are raised persistently or complainants seek to prolong contact by unreasonably raising further concerns or questions upon receipt of a response whilst the complaint is being dealt with. Care must be taken not to disregard new issues which differ significantly from the original complaint – these may need to be addressed as separate complaints; • Complainants are unwilling to accept documented evidence of treatment given as being factual (e.g. drug records, manual or computer records, nursing records) or deny receipt



of an adequate response despite correspondence specifically answering their questions/concerns. This could also extend to complainants who do not accept that facts can sometimes be difficult to verify after a long period of time has elapsed; • Complainants do not identify clearly the precise issues they wish to be investigated despite reasonable efforts to help them do so by Trust staff and, where appropriate, the Independent Complaints Advisory Service (ICAS); • Where the concerns identified are not within the jurisdiction of the Trust to investigate; • Complainants focus on a peripheral matter to an extent that is out of proportion to its significance and continue to focus on this point. It should be recognised that determining what is peripheral can be subjective and careful judgement must be used in applying the criterion; • Physical violence has been used or threatened towards staff or their families/associates at any time. This will in itself cause personal contact with the complainant and/or their representatives to be discontinued and the complaint will, thereafter, only be pursued through written communication. All such incidents should be documented and reported, as appropriate, to the Trust’s security manager, the police and noted on DATIX; • Complainants have, in the course of pursuing a registered complaint, had an excessive number of contacts (or unreasonably made multiple complaints) with the Trust placing unreasonable demands on staff. Such contacts may be in person, by telephone, letter, fax or electronically. Discretion must be exercised in deciding how many contacts are required to qualify as excessive, using judgement based on the instances of each individual case; • Complainants have harassed or been abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint – directly or indirectly – or their families and/or associates. If the nature of the harassment or aggressive behaviour is sufficiently serious, this could, in itself, be sufficient reason for classifying the complainant as vexatious. It must be recognised that complainants may sometimes act out of character at times of stress, anxiety or distress and reasonable allowances should be made for this. All incidents of harassment or aggression must be documented and dated and recorded on DATIX; • Complainants are known to have electronically recorded meetings or conversations without the prior knowledge and consent of the other parties involved. It may be necessary to explain to a complainant at the outset of any investigation into their complaint(s) that such behaviour is unacceptable and can, in some circumstances, be illegal; • Complainants display unreasonable demands or expectations and fail to accept that these may be unreasonable after a clear explanation has been provided as to what constitutes an unreasonable demand (for example insisting on responses to complaints or enquiries being provided more urgently than is reasonable or recognised practice).

Options For Dealing With Habitual Or Vexatious Complainants Careful judgement and discretion must be used in applying the above criteria to identify habitual or vexatious complainants and in deciding what action to take in specific cases. This procedure should only be implemented following careful consideration by, and with authorisation of, the Chief Executive.



However, the Chief Executive may decide to delegate this responsibility to their deputy or representative. After authorisation from the Chief Executive or delegated deputy or representative, a meeting will be coordinated by the Patient Liaison Services Manager, which will include the Complaints Lead and any clinical or other staff as necessary in order to determine the terms of reference for dealing with the complainant in an appropriate manner. The outcome of the meeting will be reported immediately to the Chief Executive or delegated deputy or representative.

The Chief Executive (or delegated deputy/representative) will decide what action to take on receiving the outcome of the meeting and agreed terms of reference. The Chief Executive (or delegated deputy/representative) will implement such action and notify complainants promptly and in writing, of the reasons why they have been classified as habitual or vexatious and the action to be taken.

This notification must be copied for the information of others already involved in the complaint such as advocates and members of parliament. A record must be kept, for future reference, of the reasons why a complainant has been classified as habitual or vexatious and the action taken.

The Chief Executive (or delegated deputy/representative) may decide to deal with habitual or vexatious complainants in one or more of the following ways:

• Once it is clear that complainants meet any one of the criteria of the

Trust’s Procedure for Dealing with Habitual and Vexatious Complainants, it may be appropriate to inform them in writing that they are at risk of being classified as habitual or vexatious. A copy of this procedure should be sent to them and they should be advised to take account of the criteria in any future dealings with the Trust and its staff. In some cases it may be appropriate at this point to copy this notification to others involved in the complaint and suggest that complainants seek advice in taking their complaint further;

• Try to resolve matters before invoking this procedure, and/or the sanctions detailed within it. If the Trust is to continue dealing with the complaint, it may be appropriate to draw up a signed agreement that establishes a code of behaviour for the parties involved. If this agreement is breached consideration would then be given to implementing other actions as outlined below;

• Decline further contact with the complainant either in person, by telephone, fax, letter or electronically – or any combination of these – whilst ensuring that one form of contact is maintained. Alternatively, further contact could be restricted to liaison through a third party. A suggested statement has been prepared for use if staff are to withdraw from a telephone conversation with a complainant. (See below).

• Notify complainants in writing that the Chief Executive (or delegated deputy/representative) has responded fully to the points raised and has tried to resolve the complaint but there is nothing more to add and continuing contact on the matter will serve no useful purpose. Complainants should be notified that correspondence is at an end and that further communications will be acknowledged but not answered;

• Inform complainants that in extreme circumstances the Trust reserves the right to refer unreasonable or vexatious complaints to solicitors and, if appropriate, the police; temporarily suspend all contact with the complainant(s), or investigation of a complaint, whilst seeking legal advice



or guidance from the NHS Executive, Department of Health or other relevant agencies;

• In exceptional circumstances, consideration can be given to the possibility of referring the matter to the Health Services Ombudsman under Section 10 of the Health Service Commissioners Act 1993.

If this procedure is to be implemented, it should be remembered and explained to the complainant(s) that any course of action taken as a result only relates to contact with the Trust over their specific complaint(s). It does not, and is not intended to, have any impact on any other dealings between the Trust and the complainant(s) on other, unrelated issues. It is also important to reassure the complainant(s) that implementation of this procedure will not compromise any current and/or future care or treatment. If complainants feel that this has occurred, or they feel that they have been discriminated against in any other way, they should be advised to report this to the Chief Executive’s office.

Withdrawing Habitual or Vexatious Status Once complainants have been classified as habitual or vexatious, such status will continue to apply for a period of twelve months, at the end of which period habitual or vexatious status will automatically be withdrawn. However, there also needs to be a mechanism for withdrawing this status earlier if, for example, complainants subsequently demonstrate a more reasonable approach. If they submit a further complaint, relating to a new matter(s), the normal complaints procedures would apply. Staff should have already used careful judgement and discretion in recommending or confirming habitual or vexatious status and similar judgement/discretion will be necessary when recommending that such status should be withdrawn. Where this appears to be the case, discussions will be held with the Chief Executive (or their delegated deputy/representative) and, subject to their approval, normal contact with complainants and application of the national NHS Complaints Procedures will be resumed. In any event, the status of a complainant(s) as habitual or vexatious will automatically be reviewed at the end of the twelve-month period. If it is decided that habitual or vexatious status will be re-imposed for a further period of twelve months, all relevant parties involved will be informed of this decision. It is the responsibility of the Customer Relations Manager to monitor/review the status of a complainant(s) as habitual or vexatious.

Staff Operational Guidance for Handling Habitual or Vexatious Complainants

The following form of words – or a very close approximation – should be used by any member of Trust staff who intends to withdraw from a telephone conversation with a complainant. Grounds for doing so could be that the complainant has become unreasonably aggressive, abusive, insulting or threatening to the individual dealing with the call or in respect of other NHS personnel. It should not be used to avoid dealing with a complainant’s legitimate questions/concerns that can sometimes be expressed extremely strongly. Careful judgement and discretion must be used in determining whether or not a complainant’s approach has become unreasonable.



Form of Words:

“I am sorry but I have to inform you that we have reached a point where your manner has become unreasonable and I have no alternative but to discontinue

this conversation. Your complaint(s) will still be dealt with by the Trust in accordance with the

NHS Complaints Procedure. I am now going to end this conversation but would like to assure you that the situation will be confirmed to you in writing.“

Follow-up Action: The incident should immediately be reported to the Customer Relations Manager. The member of staff must also complete an incident report and the conversation noted on DATIX.


Complaints Policy, (v 2.0) Northern Devon Healthcare NHS Trust APPENDIX B – Completed Equality Impact Assessment Screening

Equality Impact Assessment Screening Form

Title Complaints Policy

Author Emma DeCartaret, Customer Relations Manager

Directorate Clinical Services

Team/ Dept. Customer Relations Department

Document Class Policy

Document Status Review

Issue Date March 2008

Review Date March 2011

1 What are the aims of the document? This policy sets out the process for the local implementation of the NHS (Complaints) Regulations, Amendment Regulations 2006, which apply in England and came into force on 1st September 2006. The regulations are published as SI2006/2084.

2 What are the objectives of the document?

The purpose of this document is to ensure all staff recognise their responsibility within the resolution of formal complaints made to the Trust.

3 How will the document be implemented? Implementation of this policy will ensure that:





• There are mechanisms in place to ensure that staff and services are able to demonstrate a process of positive and ‘reflective’ learning with respect to complaints received

4 How will the effectiveness of the document be monitored? • At least 80% of staff trained in Complaints Management. • A decrease in the number of complaints re-opened. • A decrease in the number of complaints referred to the Healthcare

Commission. 5 Who is the target audience of the document?

• All Staff 6 Is consultation required with stakeholders, e.g. Trust committees and equality groups?

Yes

7 Which stakeholders have been consulted with? • Executive Directors • Clinical Governance Committee • Complaints, Litigation, Incidents and Patient Advice and

Liaison Service group (CLIP) 8 Equality Impact Assessment

Please complete the following table using a cross, i.e. X. Please refer to the document “A Practical Guide to Equality Impact Assessment”, Appendix 3, on Tarkanet for areas of




possible impact. • Where you think that the policy could have a positive impact on any of the equality

group(s) like promoting equality and equal opportunities or improving relations within equality groups, cross the ‘Positive impact’ box.

• Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, cross the ‘Negative impact’ box.

• Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, cross the ‘No impact’ box.

Equality Group

Positive Impact

Negative Impact

No Impact Comments

Age x

Disability X

Gender X Race / Ethnic Origins

X

Religion or Belief

X

Sexual Orientation

X

If you have identified a negative discriminatory impact of this procedural document, ensure you detail the action taken to avoid/reduce this impact in the Comments column. If you have identified a high negative impact, you will need to do a Full Equality Impact Assessment, please refer to the document “A Practical Guide to Equality Impact Assessments”, Appendix 3, on Tarkanet. For advice in respect of answering the above questions, please contact the Equality and Diversity Lead.

9 If there is no evidence that the document promotes equality, equal opportunities or improved relations, could it be adapted so that it does? If so, how?

Completed by:

Name Emma de Carteret Designation Customer Relations Department Trust Northern Devon Healthcare NHS Trust Date 31 January 2008