How we use complaints to improve patient experience and safety

Main issues raised and action taken:

• Patient complained to the Trust they were not receiving correspondence in an accessible format.

  All correspondence will be issued using encrypted emails which will enable viewing of letters using specialist software.

• Patient attended clinic appointment and was unhappy that the results of their imaging were not available.

  The Imaging Department is to discuss processes on feeding back changes to the priority of scans to the requesting clinician.

   

• Interpreter was not available for a patient’s appointment

  Department systems have been flagged to indicate patient requires BSL interpreter at every appointment

   

• Patient’s arm became trapped behind the bed during imaging procedure.

  Clinician has been asked to reflect on their practice.

   

• Patient with cardiac problems was made to walk to the Cardiac Unit.

  Staff have been instructed that all patients with cardiac symptoms/conditions should be taken to the unit by wheelchair.

   

• Poor communication regarding giving patients potential dates for surgery

  It has been acknowledged the importance of communicating effectively with the patients not offering a provisional date for surgery until it has been confirmed

   

• Poor experience in department, poor communication and lack of appropriate support regarding issues after surgery.

  Informed consent to be discussed at outpatients appointment, complaint shared with Day Ward staff to ensure improved communication and improvement in pain management.

   

• During an inpatient stay, patient requested to be treated by a different consultant and was told it was not possible.

  Review of process to make it possible for inpatients to change their consultant team or seek a second opinion.

   

• Poor experience on ward, patient not happy with clinician’s approach and miscommunication.

  Clinician has reflected on their practice, apologised if patient did not like their style of communication.

   

• Issues around discharge, poor communication and patient sent home with incorrect medication.

  Apology given, member of staff has reflected on complaint and training provided regarding medicine management.

   

• Breakdown in communication during clinic consultation.

  Apology given and clinician been made aware of patient’s experience in order to learn from it and manage future consultations differently.

   

• Family of patient was appalled at the manner patient was spoken to by the clinician.

  Clinician has reflected on how they were perceived by the patient’s family and will modify their approach with regards providing serious information in a short time frame.

   

• Pre-operative assessment documentation was ambiguous and reported inconsistent instructions, patient surgery postponed.

  Pre-operative Nurse who assessed patient in clinic has reflected on their documentation

Main issues raised and action taken:

• Patients concerns were not listened to when required pain killers such as Morphine to relieve abdominal pain.

  Patient had previous abdominal surgery and presented to the hospital with symptoms of obstruction (such as colicky abdominal pain associated with vomiting), consideration should have been given for a diagnosis of adhesion small bowel obstruction and investigations should be tailored to this.

  Patients on morphine will receive careful reassessment, preferably with the input of a more senior doctor e.g Registrar.

  It was recognised plain abdominal film and consideration of cross sectional imaging, where appropriate, should be considered.
  

• Following attendance in primary care clinic, patient’s follow up appointment with a clinician was lost in the system

  A protocol established for failsafe of primary care cases sent for doctor review.

• Due to administration error, patient was sent incorrect letter

  Protocol reviewed with additional checks introduced to ensure any requests for additional surveillance imaging had been acted on.

• Patient’s family was unhappy with the communication from a Consultant and the prescribing of medications which were contraindicated.

  The Consultant has reflected on their communication with patients and practice in prescribing medications.

• Family of patient complained about arrangements for parent’s discharge from the hospital.

  It has been highlighted to staff the importance of completing the discharge checklist.

  Further education is to be provided to staff in relation to discharge planning.

  It is recognised there needs to be improved communication between teams in relation to discharge planning.

• Due to staffing vacancies, waiting times for physiotherapy have increased, with patients experiencing delays in referral, triage and commencing routine physiotherapy treatment.

  Vacancies have now been recruited to, with new staff started in September and October 2019. It is anticipated waiting times will improve.

• The attending doctor was falsely reassured by the normal nature of the patients’ blood tests.

  Clinicians have emphasised the need of clinical assessment in terms of history and examination. Learning is required.