
Below is an archive of the complaints and concern we have received and acted upon and their outcomes...
See below for complaints data for Q1 to Q4 of 2018/19.
Number of complaints upheld: 27
Number of complaints partially upheld: 11
Number of complaints not upheld: 31
Top trends for upheld or partially upheld complaints:
Our top 3 causes for complaints this quarter were in relation to:
These account for 64% of our complaints
Main issues raised and action taken:
Family felt patient’s INR target range was incorrect
Discussion with team members regarding target range and INR
Poor communication regarding treatment pathway
Complaint shared with the team to ensure learning
Patient’s pain was not managed
Education to staff and reiterate the importance of repeat pain scores being documented 1 hour after administration of pain relief.
Family unhappy neurological observations not carried out
Education to be provided to nursing staff around head injuries and neurological observations
Family not happy at how long patient left in soiled clothes and pressure areas not checked
Education to nursing staff around tissue viability. Also reiterated to staff patients to be identified at triage if there are personal hygiene needs
Family unhappy patient suffered fall
Staff education regarding Falls and assessment, monthly audit to be carried out regarding assessments and documentation
Fractures not identified initially which led to delay in referring to appropriate services
Complaint shared with the team involved in order to learn lessons.
Patient unhappy with how they were triaged when attending emergency department
Manchester Triage training provided for Emergency department staff
Family unhappy with a number of issues including end of life care
Issues addressed by ward manager and palliative care team provided training to educate staff
Issues raised around pressure area care and medications
Training provided by Tissue Viability team and Pharmacy
Behaviour of Doctor and local anaesthetic not considered for procedure
Doctor reflection regarding care provided. Availability of local anaesthetic in department checked
Family not happy about a number of issues during patient’s journey
Action plan developed to address each issue in the different areas
Poor communication and poor nursing care
Action plan and staff reflection to address the issues
Family raised issues around medication, care of tracheostomy and oxygen administration
Training/education arranged for each issue.
Family unhappy with the poor communication at the end of life
Palliative care team to work with staff in area care was provided
Patient’s surgery cancelled on day as had not been advised to stop medication
Refresher training and reflective practice carried out with the member of staff
Patient’s surgery cancelled and new date not provided
Increased provision at Broadgreen Hospital
Patient given incorrect diagnosis
Clinical supervisor to reiterate to Doctor on carefully listening to patients when taking medical history
Poor communication by doctor
Clinician reflected on the outcome of the complaint in order to identify changes in practice
Delay in pain being managed
Share complaint with ward staff ensure all staff are aware of the importance of managing patient’s pain and to give clear explanations to patients on their pain management.
Patient’s blood sugars not check prior to surgery
Staff member will be re-educated regarding the management of diabetic patients
Patient not referred to the District Nurses
implications of delays in discharge planning and referring to other teams
24 hour blood monitor caused red and blistering on arm
The cleaning processes for the cuffs was re assessed in conjunction with the infection control team regarding best practice.
Number of issues raised regarding care, including communication
Complaint shared with staff and emphasis on effective handover of doctors to nurses
Damage to nerves during surgery
Reflection by surgeon as to whether it could have been avoided
Delay in patient being reviewed in clinic following investigations
Staff reminded all diagnostic results should be reviewed in a timely manner
Number of Complaints Upheld: 34
Number of Complaints Partially Upheld: 15
Number of Complaints Not Upheld: 31
Top Trends for Upheld or Partially Upheld Complaints:
Our top 3 causes for complaints this quarter were in relation to:
These account for 62% of our complaints
Main issues raised and action taken:
Faulty nurse call buzzers on ward
All patients within the ward will have a nurse call buzzer that is fully functional. The nurse inn charge is to escalate if equipment has not been repaired.
Vulnerable patient not placed near to the nurse’s station
Vulnerable or elderly patients will be placed as near to the nurse’s station as possible. The nurse in charge will ascertain the patient’s needs prior to ward admission
Lack of communication regarding discharge to relatives
Staff to reflect on experience and understand the importance of good communication when discharging patients
Appropriate feeding tubes not available in department
Email to staff to highlight where appropriate pumps can be sourced from. Training arranged for staff on how to set up feeding pumps.
Missed diagnosis
Clinician has been asked to reflect on their practice
Vulnerable patient left with bed rails down while awaiting to be assessed
All patients will be assessed at triage so that those at risk can be identified. Patient to be made aware of the need for cot sides being up
Delay in critical medications on admission
Critical medications to be identified at triage. Any delays with prescribing/administration should be fully explained to the patient.
Relatives were not informed of therapy input for patient
Ward staff were asked to reflect on their communication with patients and their relatives
Oxygen port on ward not working
Highlighted to staff that condemned oxygen ports are replaced in a timely manner and any delays are escalated to the Ward Manager and Estates Department
Medication delays in assessment unit
Electronic prescribing has now been introduced in the department to ensure real time prescribing and no delays in administration of medications
Attitude of Consultant in meeting with family
Consultant asked to reflect on his practice
Delay in patient being referred to Infectious Disease team
This will be addressed in Junior Doctor teaching
Patient experienced delay in having ECG in Emergency Department
Once an ECG has been requested, staff in the designated area are to check if this undertaken in a timely manner. Delays with ECGs are to be escalated to the nurse in charge. The department is to explore 24 hour ECG cover
Patient discharged from hospital without any footwear resulting in an injury to their foot
Matron has discussed the incident with nursing staff and suggested patients with no footwear should be supplied with slipper socks
Patient complained about attitude of Consultant in clinic.
Consultant has reflected on their practice and the complaint will be discussed in yearly appraisal
Relatives complained about the attitude of nurse on the ward.
Nurse has reflected on their practice and the complaint will be discussed in their yearly appraisal.
Lack of follow up to fax referral
Referral process has been changed to ensure a telephone call is made to confirm receipt of the referral
Patient’s complaint recorded in patient’s records and shared with GP
Reference to patient’s complaint removed from patient’s record and letter of apology sent
Delay in diagnosis
Discussion of the case to ensure learning from the team
Pain not managed following procedure
Change in practice to ensure medications are prescribed. Discussion of the case to ensure learning from the team
Patient unhappy with attitude and behaviour of Consultant
Clinician has reviewed complaint and reflect on lessons learned
Delay in on-call Doctor attending and attitude
Clinician reflected on how they were perceived by the patient
Investigations not requested and patient not updated with outcomes
Staff reminded of importance of ensuring referrals for investigations are made and good communication with patient
Patient unhappy at how many times member of staff tried to insert cannula
Staff member attended training refresher
Patients surgery cancelled as they had not been advised to stop medication
Reflective practice by clinician regarding omissions in practice
Patient was missed from follow up investigation
Refresher training for administrative staff and audit to ensure other patients have not been missed
Missed diagnosis
Clinician reflected on patient care to see if could have done differently
Family complained about lack of nursing care
The issues were addressed with the ward staff and monitored
Patient complained about cancelled appointments
Care group reviewing processes
Patient complained about lack of availability of specialised appointments
Care group reviewing processes
Patient’s complaint recorded in patient’s records and shared with GP
Reference to patients complaint removed from patients record and letter of apology sent
Delay in diagnosis
Discussion of the case to ensure learning from the team
Pain not managed following procedure
Change in practice to ensure medications are prescribed. Discussion of the case to ensure learning from the team
Patient unhappy at how many times member of staff tried to insert cannula
Staff member attended training refresher
Q3 (October – December 2018) 98 Complaints, 7 Withdrawn.
Number of Complaints Upheld: 26
Number of Complaints Partially Upheld: 21
Number of Complaints Not Upheld: 44
Top Trends for Upheld or Partially Upheld Complaints:
Our top 3 causes for complaints this quarter were in relation to:
These account for 70% of our complaints
Doctor has been asked to reflect on their practice and consider a lower threshold for requesting blood tests in future.
Patient’s experience was highlighted to staff to ensure all electronic referrals are followed up with telephone confirmation.
Clinician has reflected on their practice and will consider a lower threshold for requesting X-rays in future.
Patient’s experience was shared with ward staff who have been asked to reflect on their practice.
Patient experience highlighted to staff who have been asked to be aware of both their verbal and non-verbal communication.
Reflection by Doctor and will be discussed at appraisal.
The importance of adequate clothing on discharge has been highlighted to staff responsible for discharge.
Clinician asked to reflect on their practice
Staff will ensure pain score is taken at triage and appropriate pain relief is given in a timely manner
Doctor will reflect on their practice in future cases.
Concerns discussed with ward team, catering staff and cleaning contractor
Staff to ensure patients have nurse call system to hand at all times.
Review of process and improved equipment.
Consideration of changing to electronic method of referral In order to improve the system.
Manager has supported nurse with professional development and reflection
Doctor reflected on their method of communication.
Manager apologised and will ensure in future to respond in a timely manner
Review of services
Review and change of processes to prevent patients being missed from the procedure list
Acceptance criteria reviewed by clinician to ensure understanding
Complaint discussed with staff to ensure it does not happen again
Process reviewed with clinicians involved
Training provided for nursing staff by Infection Control Link Nurses.
Care group reviewed processes
Clinician reflected on error
Nurse supported in learning and reflected on incident
Number of Complaints Upheld: 19
Number of Complaints Partially Upheld: 23
Number of Complaints Not Upheld: 29
Number of Complaints Withdrawn: 3
Top Trends for Upheld or Partially Upheld Complaints:
Our top 3 causes for complaints this quarter were in relation to:
These account for 50% of our complaints
See below for complaints data for Q1 to Q4 of 2017/18.
Number of complaints Upheld: 37
Number of Complaints Partially Upheld: 13
Number of Complaints Not Upheld: 35
Top Trends for Upheld or Partially Upheld Complaints:
Our top 3 causes for complaints this quarter were in relation to:
These account for 48% of our complaints
Main issue raised and
Actions taken
Lack of communication between teams regarding patient’s warfarin, which led to procedure being cancelled
Staff to ensure they check with patients regarding their medications. If the patient is on any anti-coagulation medication then the consultant will liaise with nursing staff to determine an appropriate course of action for the patient prior to their procedure
Patient unhappy with lack of communication regarding their medication and discharge from clinic
Manager to emphasis to staff that they should always:
Patient did not receive his eye drops following his surgery while he was on the ward as they were not prescribed
Medical staff attended training on prescribing medications
Family unhappy with the way it was discussed with them about whether resuscitation was appropriate.
Also they were given the news about a stroke by the specialist nurse not a doctor.
Staff were going to give patient a meal when they were nil by mouth.
Lack of communication skills and unprofessional behaviour of nursing staff
Clinical director apologised for lack of sensitivity and discussed with staff regarding how the family were made to feel.
Consultant acknowledged may have been helpful for the information to have been given by someone the family were familiar with and this has been discussed with her team.
Ward Manager discussed with staff the importance of checking signage above the patient’s bed.
The Matron and Ward Manager have addressed shortcomings with the staff.
Patient in confused state left to take his own medication, lack of communication between teams, lack of communication with relatives, Confused patient allowed to leave ward
Families of patients with confusion or dementia are spoken to by a member of staff during admission phase to reassure them and to obtain any information to assist the patient’s care whilst in hospital
Patients requiring dementia care input will receive prompt referral to the dementia specialist nurse as required.
All families of patients with dementia will be provided with a dementia information pack as soon as possible following their admission
Patients with confusion or dementia will receive assistance during medication rounds or when receiving medication as required to ensure that they safely take their medication
Delays in arranging appointment with Therapies
Change in process and new referrals to be sent electronically in line with Trust policy
Delay in arranging appointment following discharge from hospital
It was discussed with junior doctors and consultants that at discharge, all patients to be reviewed for discharge follow up and if an appointment is necessary for the time frame for follow up to be reasonable.
Delays in pain relief and treatment
Staff made aware of complaint through staff meeting and department magazine.
Pain score to be noted at triage and updated hourly and acted upon accordingly. Effectiveness of administration of analgesia to be documented and acted upon.
Poor Communication regarding numerous falls on ward and family not kept updated regarding outcome of investigation into falls
Complaint discussed with staff to emphasise importance of improved communication with patient and relatives. Staff to ensure patients who are at risk of falling are appropriately monitored, all preventative measures and all alert systems are in place
All staff to adhere to the policies and guidelines, regarding incidents.
Staff will ensure family are notified where appropriate of any incidents that have occurred to their relatives in a timely manner.
Lack of communication to nursing home regarding nutritional needs on discharge
Matron made staff aware of the importance of ensuring all take home medications, including food supplements, are with the patient when they leave.
Lack of communication regarding delay on day of discharge
Discussed complaint with staff at Ward Meeting and emphasised the importance of keeping patient and relatives updated regarding any delays in discharge.
Breach of confidentiality and support for patient
Reflective practice undertaken by the staff member
Patient not given pureed food, patient given Ensure food supplement when not appropriate
Training given to ward staff to ensure knowledge of the consistency of supplementary drinks and action to take if incorrect supplements are prescribed
Patient story shared with staff in the department through departmental meetings with minutes and attendance obtained
Blood sugar testing not carried out during the night
Lack of pain relief
All staff in the unit to read the Trust policy regarding the policy for administration of intravenous insulin and undertake online training.
Complaint shared with staff involved so they can undertake reflective practice
Patient missed to follow up
Recommendation that an IT solution for the management of endoscopic surveillance databases to be developed
Improving the administrative support for UGI specialist nurses
Implementation of Endoscopy Clinical SOP (Standard Operating Procedure) and Guidelines and Trust Electronic Access Policy
Attitude of doctor
Written reflection to form part of electronic portfolio and to be discussed with Educational Supervisor
Concern regarding lack of infection control measures and cancelled appointment
Nurse reminded of infection control policy.
Clerical staff reminded to ensure patients are informed of cancelled appointments
Attitude of nursing staff
Staff to attend Education and Customer Service Training
Patient had poor experience
Lack of clarity around appointment for removal of catheter
Family not informed of discharge, medications and follow up plan
Complaint discussed with staff in order they can reflect
Patient information leaflet to be produced regarding removal of catheter.
Complaint discussed at monthly governance meetings regarding communication with families
Attitude of nurse practitioner
A reflective meeting with the practitioner- coaching to be utilised to support this
Poor patient experience
Complaint discussed with staff, change in the nurse handover process
Attitude of consultant
Written reflection to form part of electronic portfolio and to be discussed with Educational Supervisor
Delay in follow up appointment
Capacity and Demand review for this service
Patient transferred to incorrect address on discharge
Review of transfer and discharge process, and change to electronic discharge forms
Inappropriate breaking of bad news to the patient over the telephone
Department reviewed process of communicating cancer diagnosis over the telephone
Poor communication regarding procedure, infection control issues on ward, lack of dignity when catheter inserted
Complaint discussed with ward staff so they could reflect on care provided, individual nurse spoken to regarding dignity.
Difficulty for patient with mental health issues to access department
Change in process to ensure that high risk patients will be streamed immediately on booking in, Triaged as a priority and Mental Health referral made ASAP.
Joint triage with Mental Health Team to commence and triage training in mental health conditions to be arranged with mental health team and education team for ED.
Laboratory test carried out that patient had not given consent for
Update cytology specimen reception Standard operating procedure to incorporate the new NHSCSP national acceptance policy (NAP). Update will also include reference to the ‘clinical details section and Non-consent’
Venous thromboembolism assessment (VTE) not carried out correctly and advice not followed
Communication to all staff regarding adequate VTE assessment and that corrective action needs to be taken on admission
Noise level on ward at night, attitude of nurse and not following infection control practices
Area monitored regarding noise at night. Nurse to undertake reflected practice. Peer review carried out on their infection control practices.
Poor experience and attitude of nurses
Complaint shared and discussed with staff in department in order they can reflect on care provided
Delay in treatment as referral not sent
Doctor reflected on how this happened in order to prevent it happening again
Delay in treatment and transferred twice to incorrect wards
Complaint discussed with GP unit in the Emergency Department to ensure their staff are aware of correct process of referral
Patient had poor experience due to lack of communication between teams and lack of specialist knowledge by nurses who do not usually care for patient following procedures in gastroenterology
Lack of detail in handover to staff addressed through gastroenterology governance meetings
Lack of knowledge addressed through nurse training for that area
Incorrect details recorded on booking in to Emergency department and lack of follow up arranged
Details are now checked on rapid assessment. Discharge arrangements including providing patient with copy of discharge letter, emphasised in junior doctors training.
Failure to follow SOP for post mortem materials
Complete review of all standard operating procedures including roles and responsibilities
Number of complaints Upheld: 28
Number of Complaints Partially Upheld: 21
Number of Complaints Not Upheld: 32
Top Trends for Upheld or Partially Upheld Complaints:
Our top 3 causes for complaints this quarter were in relation to:
These account for 59% of our complaints
Main issue raised and
Actions taken
Inappropriate discharge from Emergency Department. Conflicting information on discharge. Delay in colorectal treatment
Low haemoglobin levels should have been addressed before discharge. Patient’s experience will be discussed with the wider team as a learning tool.
Dementia patient who’s first language was not English was distressed by gastroenterology procedure.
The Gastroenterology Unit have made sure reasonable adjustments are made for patients who require any special requirements.
Patient experience has been shared at Clinical Governance meeting to minimise the risk of this happening again.
Delay in treatment (nebulisers) and treatment by doctor.
Patient experience will be shared with the staff.
Nurse responsible for the patient has been asked to reflect on his practice.
Delay in clinic appointment
Extra consultant being recruited to address demands on the clinic (capacity issues).
Inappropriate management of back and leg pain by Therapies team.
Ensure that all assessment documentation addresses any questions or concerns raised on the referral.
Ensure that MCAS letters clearly evidence reasoning and discussion of options within clinic.
Ensure that all patients have the opportunity to individually raise concerns.
Delay in surgery
Utilisation of new electronic listing for surgery to highlight patients in line with clinical priority
Poor communication with patient
Faulty screw used during surgery
The full details of an incident will be available for reporting and learning processes; and to refer to in the case of patient complaints.
Surgeons will liaise with Medical Devices representative when concerns are highlighted. An investigation report from the equipment supplier which should lead to improvements in quality.
Breach of patient confidentiality. (Patient received a copy of another patient’s clinic letter).
Information Governance refresher training
Clinical and clerical staff to scrutinise letters more thoroughly before issuing through electronic systems
Delay in results from mastectomy due to backlog in Pathology department.
The co-ordinator for pathology will inform the multi-disciplinary team and the Breast Unit of any delays.
One further Pathologist has been recruited and a business case has been put forward for further recruitment.
Delays in test results being acted upon, resulting in further kidney damage.
A new flag is to be introduced on our electronic systems which would highlight the increase in Creatinine levels and alert the Consultant.
Delay/cancellation of Nephrology appointments.
Delays were due to relocation of services. Apology was offered for the cancellations.
Cancelled surgery (Due to capacity issues)/lack of communication
Digestive Diseases department will review the process of how patients care is transferred from the Gastroenterology team to the Surgical team.
The Surgical team will review how they utilise the emergency list versus an elective list and they prepare patients for surgery so operations take place as planned.
Clinic appointments cancelled although patient was receiving texts reminding him of appointment
Issue raised with external supplier in relation to text messages.
Blood samples in Emergency Department will be correctly labelled
All patients will have a pain assessment in Emergency Department
Correct assessment and appropriate prioritisation of patients in Emergency Department.
Audit of compliance in department
Nursing staff to use patient safety checklist for pain score and the score is to be recorded on the department whiteboard. This will be audited.
The Education Team will undertake Manchester Triage education with all staff in the department. Senior nurses are now allocated to Triage to cover 24 hours and to ensure correct triage and prioritisation. All nursing staff are to undertake ENEWS training and this will be audited on a monthly basis.
Patient was unhappy how she was spoken to by the anaesthetist prior to her surgery.
Doctor has been asked to reflect on his practice and review his methods of communication following advice from his education supervisor.
Patient raised concerns about hygiene in the bathroom on the ward.
Patient was concerned about staffing levels on the ward and attitude of one particular Healthcare Assistant.
Issues were raised by the Ward Manager with housekeeper for the ward.
Concerns were highlighted with agency and it was agreed that if particular bank staff consistently failed to attend, they would no longer be used. Healthcare Assistant was asked to reflect on her practice. Patient experience was highlighted with all staff in the ward meeting.
Patient was unhappy with the manner of the doctor in clinic.
The doctor has agreed to let a lead nurse sit in with future consultations in order to provide feedback on his interactions with patients. The incident has also been highlighted to his clinical and educational supervisor for future monitoring and training purposes.
Inappropriate physiotherapy treatment following surgery resulting in further injury and surgery.
Protocol has been reviewed and is clear to all staff about treatment progression. We will ensure all staff have had suitable training on common procedures and clinical protocols. We will ensure that all patients in class environments have the opportunity to individually raise concerns. We will ensure that all adverse clinical incidents are reported on the Trust incident reporting system.
Ultrasound scan not requested in Emergency Department resulting in delay in treatment for deep vein thrombosis.
Doctor has been asked to reflect on his practice and the future management of patients with similar presentations.
Delay in pain relief in Emergency Department
Patient not supplied with pillow in Emergency Department
Education for all staff on the newly introduced patient safety checklist. Pain score on admission is to be recorded and on the department whiteboard and on the ENEWS system. Nursing staff are to ensure regular pain relief is prescribed by a doctor if the patient if the patient is being admitted to the hospital.
Housekeepers are to ensure an adequate stock of pillows is maintained in the Emergency Department 24 hours a day.
A breakdown in clinical communication was identified between a junior doctor and a Consultant.
The Consultant was asked to reflect on how best to relay clinical instructions and information to junior staff.
Patient attended for appointment which had been cancelled although he had not been notified. Cancellation letter had not been generated.
Staff will undergo further training. It has been agreed that if a patient arrives in clinic to find they have been cancelled, staff must escalate this to the senior nurse in order the patient can be appropriately assessed and advise the patients/carers appropriately.
Patient’ surgery was cancelled at short notice although she had been informed she was first on the list by ward staff.
Complaint has been discussed with the nursing staff to ensure there is clear communication with patients regarding where they are on the theatre list.
Delays in appointments due to capacity issues.
Extra clinics factored in on Saturdays and audit of clinic cancellation reasons.
Cancellation of surgical procedure, owing to blood samples not being correctly labelled.
Service lead will address complaint with phlebotomist to ensure their training is up to date and competency is re-assessed . Complaint will be shared with the phlebotomy team at team meeting to ensure there is learning from this incident.
Patient was unhappy with the outcome of her surgery.
Consultant has reflected on an error of judgement in the procedure he carried out. He has since met with the patient and personally apologised.
No clear communication from ward staff to relatives
Complaint shared with ward staff to highlight poor communication
Number of complaints Upheld: 28
Number of Complaints Partially Upheld: 12
Number of Complaints Not Upheld: 27
Top Trends:
Our top 3 causes for complaints this quarter were in relation to:
These account for 70% of our complaints
Upheld complaints outcomes (28)
Main issue raised and
Actions taken
Patient had poor experience including confusion around appointments, cancelled appointments and being given leaflet with someone else’s details
Reiterated to clerical staff the administration processes when cancelling appointments and booking appointments
Patients’ surgery can only be cancelled once due to non-clinical reasons
Reiterated to nursing staff the discharge process and checking post-operative medication and ID check
Attitude and behaviour of nurse
Temporary staffing team contacted to ensure nurse not employed in specific area again and issue will be addressed by them with nurse
Lost to follow up despite being suspected cancer
A change in practice regarding how follow up appointments are requested and monitoring that they have been arranged
Poor experience, lack of pain relief, patient being told not to drink as there was not enough nurse to take him to the toilet,
Importance of assessing pain score, documenting this and providing appropriate pain relief, discussed at team meeting.
Discussed with staff comments regarding staffing levels unprofessional and inappropriate
Lack of information provided to relative regarding further medication sent to patient
Complaint discussed with ward staff in order they can reflect on care provided and importance of clear communication
Patient’s diabetic medication not prescribed or given
Care group to review and ensure patients clerked in when admitted to the ward and all medications prescribed
Lack of trained nursing staff on ward, Staff not monitoring urine output of patient
In future it will be ensured there is appropriate ENT, urology and orthopaedic cover for ward. Appropriate clinical leads to be informed of ward closures and transfer of their patients.
Training regarding post removal of catheters and post-operative retention to be provided to ward staff.
Attitude of nurse
Complaint shared with staff in order they can reflect on care provided and individual nurse will be spoken to.
Patient discharged in her night wear
Patients experience to be used as a learning exercise in the importance of preparing a patient for discharge
Lack of discharge letter, so GP and patient unaware of ongoing treatment
Electronic discharge summaries are monitored on each ward to ensure they are sent in timely manner
Breach of confidentiality
Discussed at divisional governance meeting to ensure trust wide learning
Inappropriate therapies treatment – did not receive appropriate intensive therapy initially post-operatively
Issues around communication to be addressed with teams involved.
Lack of communication with family members, Delay in antibiotic treatment
Consultants have discussed the importance of keeping families updated. Review of sepsis protocol for patients with severe renal failure
Unacceptable delay in consultation
Capacity and demand issues being addressed, to recruit more clinical staff.
Patient suffered severe throat problem following procedure
Doctor to review his process with clinical director to see if can improve way procedure performed
Cancelled appointment
Ensure consultant post are filled as soon as possible to prevent clinics being cancelled
Patient left in wet clothes
Complaint discussed with staff in order they can reflect on care provided and communication with patients
Poor communication regarding discharge and patient not given his diabetes medication
Incident has been highlighted to staff on appropriate wards.
Appointment not on the system so the patient was turned away without being reviewed
Training put in place with staff to deal with issues regarding electronic referrals
Patient details passed to Stroke Association without her permission
Change in process and patients provided with stroke association leaflets and informed stroke association may contact them to provide support
Lack of communication with parents in department / patient moved while still attached to oxygen/Allegation that picture was taken of patient and family by member of staff using an i-pad
Staff informed of importance of accurate communication to be provided to patients and relative around use of digital tablets for documentation within department and also around transferring of patients to other areas in the department. Also emphasised that oxygen to be removed appropriately prior to transferring of patient on bed from cubicle to another area in department
Lack of communication when patient transferred to BGH
Registered nurse will communicate with the next of kin to inform of transfer to other ward areas or upon discharge
Lack of pain relief on discharge
Complaint will be used as an education tool with staff on ward
Attitude of staff
Nurse asked to provide written reflection on how he managed situation
Incorrect documentation regarding a faint
Complaint shared with staff in order to learn from episode.
Attitude of staff towards patient who had stayed overnight on ward
Complaint discussed with staff to ensure all consultants and junior medics are aware of patients who need to stay overnight following surgery for what is routinely a ‘day case’ procedure
Poor experience, lack of pain relief, unprofessional comment by nurse, delay in responding to concern regarding cannula
Complaint discussed with staff to emphasise the importance of prompt review of pain score and providing pain relief. Also in attending to concerns about cannulas
Delay in diagnosis
To ensure that full patient reviews take place on the ward on a daily basis, 2 nurse practitioners have been appointed.
Scan appointment cancelled at short notice due to sickness
Apology to patient, unable to meet appointment due to unpredicted staffing issues on day.
Patient left waiting on a trolley for number of hours. Confusion around discharge
Complaint discussed with staff to ensure patients requiring admission to hospital to be placed on a bed within the Emergency Department within 8hours of admission, or once investigations are complete.
Patient and relatives to be involved in discussion around discharge/admission at all times.
Staff will understand the importance of effective communication and that ensuring that it is consistent
Patients will have a discharge checklist completed
Number of complaints Upheld: 19
Number of Complaints Partially Upheld: 21
Number of Complaints Not Upheld: 30
Top Trends:
Our top 3 causes for complaints this quarter were in relation to:
These account for 60% of our complaints
Main issues raised and action taken
Pain during procedure and incorrect information on discharge letter
Gastroenterology manager remind all staff the importance of checking correct information on letters
Staff forget to give 2 injections prior to treatment & Incorrect medications prescribed
Ward sister to order large stamp stating ‘pre-meds’ to stamp on infusion charts if they are required. Doctor apologised for error
Family had requested to be with patient just prior to going for procedure, but this was not arranged
Staff will discuss any family requests in their morning meeting and will accommodate if they can
Medications left on table, lack of communication regarding treatment plan, patient not assisted with eating and drinking
Ward manager arranged for Medication Safety Nurse to provide education to the staff to remind them of roles and responsibilities with regards medications.
Staff arranging a daily time slot when relatives can speak to the consultants
Ward hand over improved so all staff aware which patients require assistance
Discharged with outstanding laboratory test results, medication prescribed in error
Highlighted to medical staff that outstanding investigations should be followed up, prior to discharge recommendation that the reason for stopping/suspending the medication will be clearly documented in electronic prescribing and medicine administration (EPMA) system.
Patient unhappy with the way risks of surgery explained just prior to operation
Consultant to reflect on communication
Waiting time for appointment, attitude of call centre staff
Department looking at ways to reduce capacity issues, including utilising community ophthalmic services
Regular training sessions, team meetings and updates
Communication from doctor
Doctor to reflect on consultation
Incorrect information from Breast screening
Review of system and protocols, changes in where patients are screened
Attitude of nurse on the ward. Shouting at patient and did not offer any assistance.
Nurse in question was an agency nurse. Temporary Staffing Team confirm the nurse will not be booked for any future shifts and the agency was asked to share the patient’s wife’s concerns with her and highlight that her behaviour was not acceptable.
Patient feels she was discharged from hospital too soon, resulting in a readmission within a matter of hours.
Medical team acknowledged that the patient’s issues with her diabetes had been under estimated and the effect of antibiotic medication on her condition.
Customer insight survey sent to patient following her death resulting in distress to husband.
Records to be checked more thoroughly before any future surveys are sent.
Delay in patient receiving Parkinson’s medication.
This issue was highlighted in the doctors’ medicine management training. Ward manager has also arranged for her staff to receive further education in relation to Parkinson’s disease from the Parkinson’s specialist nurses.
Patients’ conditions being discussed in corridor areas of the Emergency Department. Vending machines in the department were empty.
Issues in relation to patient confidentiality were discussed with the doctor concerned who was advised confidential discussions should only take place in cubicle areas.
If patients or their relatives have immediate need for food or beverages due to medical needs, additional drinks or sandwiches can be requested by the nursing staff through Hotel Services.
Therapies letter incorrectly stated that the patient had taken their own discharge from the hospital.
Issue was discussed with therapist who apologised for their incorrect assumption.
Nurse call buzzer not available/ bed brake not applied/ another patient’s charts left on bed
The importance of regular checks has been raised with all staff at the ward meeting. In relation to patient charts this will be addressed in our on-going staff education programme and there are steps in place to minimise the risk of this happening again.
Delay in patient being seen after being asked to attend the hospital after abnormal blood results.
Patients attending ED with abnormal blood results will be diverted to ambulatory care on AMU. Laboratories should contact ED before asking a patient to attend.
Inappropriate behaviour from member of nursing staff towards an elderly patient and her relatives.
Internal investigation - Trust’s Disciplinary Policies and Procedures
Shortcomings in discharge arrangements resulting in patient being left without food/hydration.
Ward Manager to ensure that the nurse in charge of a patient discharge will ensure all correct paperwork is completed and faxed over to the relevant teams before discharge occurs.
Inappropriate pain relief on discharge from ward.
Patient’s experience highlighted as an education tool with all ward staff.
Unclear information given to patient’s family regarding fluid requirements.
Drinks were given un-thickened when patient was nil by mouth.
Dietician was asked to reflect on her communication to family members.
The Nutrition Team will carry out education sessions on the ward. A nutrition manual has been produced which will be expected to provide appropriate information and will be used as a support document for staff in relation to thickened fluids.
Patient with learning disabilities – Lack of communication with parents in Emergency Department. Department environment was not appropriate for patient.
Experience of patient to be used as an education tool in the department.
Location of patient not communicated to wife following several moves in the hospital. Delay in patient’s insulin being administered.
Patient’s experience was highlighted to staff as an education tool to minimise the risk of this occurring again.
Needs of patient with learning disabilities not addressed whilst a patient by the Learning Disability Team.
Assistant Chief Nurse for Safeguarding met with relatives, apologising for their experience and agreeing to share their experience with her team in order that they could reflect on their practice and communication methods.
Patient found in soiled clothing. Patient had a fall on the Acute Medical Unit. It transpires no falls risk assessment had been completed on admission.
Highlighted to staff on the unit as an education tool.
1.Patient’s hygiene needs were not met.
2. Nurse call buzzer not available
3. Fluid balance not monitored when patient had catheter.
1. Staff to be aware of need to ensure patients are clean at all times.
Doctors to communicate effectively with nursing staff around wet linen post procedures.
2. Daily checks are to be completed by Quality Matrons.
3. Monthly Matron’s audit to be carried out.
Poor communication from multi-disciplinary team in relation to patient’s discharge from hospital.
It was acknowledged that communication with family members had been poor. Family’s experience was shared with the wider multi-disciplinary team as a learning tool.
Patient not given assistance with feeding.
Communication regarding end of life care.
Delay in patient receiving pain relief.
Patient experience will be shared with the ward staff, stressing the importance of assisting patients with their nutritional needs.
Consultant reflected on his practice in relation to the communication relating to end of life care.
Experience in relation to pain relief will be shared with all staff as an education tool.