Complaints and concern outcomes archive

Main issues raised and action taken:

• Family unhappy with behaviour of doctor
  
  Doctor reflection supported by Clinical Director
  
  

• 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

   

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

   

• Missed diagnosis by medical team

Doctor has been asked to reflect on their practice and consider a lower threshold for requesting blood tests in future.

• Referral to another speciality was not made.

Patient’s experience was highlighted to staff to ensure all electronic referrals are followed up with telephone confirmation.

• Fracture was missed in Emergency Department

Clinician has reflected on their practice and will consider a lower threshold for requesting X-rays in future.

• Patient was unhappy with toilet facilities and menu options on ward

Patient’s experience was shared with ward staff who have been asked to reflect on their practice.

• Poor communication from nursing staff

Patient experience highlighted to staff who have been asked to be aware of both their verbal and non-verbal communication.

• Patient unhappy with manner bad news was delivered to patient

Reflection by Doctor and will be discussed at appraisal.

• Patient discharged in appropriate attire

The importance of adequate clothing on discharge has been highlighted to staff responsible for discharge.

• Fracture not identified

Clinician asked to reflect on their practice

• Patient complained of delay in pain relief

Staff will ensure pain score is taken at triage and appropriate pain relief is given in a timely manner

• Missed diagnosis

Doctor will reflect on their practice in future cases.

• Issues raised regarding meal delivery and cleanliness on the ward

Concerns discussed with ward team, catering staff and cleaning contractor

• Lack of assistance to use the commode

Staff to ensure patients have nurse call system to hand at all times. 

• Delay in investigation results being sent to GP

Review of process and improved equipment.

• Patient was not assessed in clinic as did not have the appropriate paperwork from GP

Consideration of changing to electronic method of referral In order to improve the system.

• Patient felt nurse was unprofessional in their communication

Manager has supported nurse with professional development and reflection

• Patient unhappy with the way they were spoken to in clinic

Doctor reflected on their method of communication.

• Relative unhappy manager did not respond to their concerns

Manager apologised and will ensure in future to respond in a timely manner

• Wait for surgery

Review of services

• Repeated cancellations of procedure

Review and change of processes to prevent patients being missed from the procedure list

• Patient told they did not meet the criteria for treatment

Acceptance criteria reviewed by clinician to ensure understanding

• Poor nursing care

Complaint discussed with staff to ensure it does not happen again

• Failure in communication and failure in administrative processes regarding ordering of lens

Process reviewed with clinicians involved

• Staff not following hand hygiene practices

Training provided for nursing staff by Infection Control Link Nurses.

• Repeated cancellations of surgery

Care group reviewed processes

• Patient given too much medication

Clinician reflected on error

• Lack of follow through from preoperative assessment

Nurse supported in learning and reflected on incident

• A patient contacted the Trust regarding delays in outpatient appointments being arranged and how this was communicated.
  
  
  Training workshops were delivered to all administration staff to highlight the benefits of good communication and ensure letters are reviewed and sent to patients in a timely manner.
• Family complained to the Trust in relation to their deceased relative’s appearance following death. It was also identified incorrect details had been recorded in relation to the time of death.
  
  The family’s experience was shared with all medical and nursing staff to ensure the correct details are entered on the Report of Death form and to ensure the condition of a deceased patient is clearly communicated to family members before they see the body.
  
  
• Missed diagnosis in Emergency Department – tendon injury.
  
  The doctor who saw the patient has reflected on the patient’s experience and as a result, has changed their practice.
  
  
• A patient’s family highlighted the poor communication between doctors involved in patient’s care
  
  The department now has a handbook for Junior Doctors which outlines their responsibility in relation to patient handover and how to file results.
  
  
• Patient was unhappy about the length of time had to wait for prescription to be dispensed.
  
  Staff have been reminded of the importance of notifying patients if there is going to be a significant delay in the processing of prescriptions.
  
  
  
• Failed discharge from hospital resulting in readmission.
  
  Patient’s experience has been shared with staff to minimise the risk of this happening again and to ensure patients are adequately assessed in relation to their mobility.
  
  
  
• Patient contacted the Trust regarding delays in their surgical procedure and the lack of communication in respect of this.
  
  Patient’s experience was shared with team in order they could reflect on this experience.
  
  
  
• A patient’s family contacted the Trust regarding discharge from the hospital. Felt inadequate support had been arranged prior to discharge.
  
  The Matron responsible for the ward has discussed with staff the need to check for any outstanding care plans prior to a patient’s discharge.
  
  
• Patient contacted the Trust in relation to a series of cancelled appointments.
  
  
  It was acknowledged there was a disjointed process for co-ordinating clinical tests to coincide with follow up appointments. There was also a lack of information available to clerical staff in order to assist in booking appropriate appointments for patients within the correct timescales. In order to address this, departments are to explore processes for ensuring diagnostic tests are completed and follow up appointments are made based on the availability of test results. There is to be a review of clinic templates to ensure clinic appointments reflect theatre scheduled. There is also to be a review of the information provided to clinic clerks/medical secretaries when booking follow up appointments.
  
  
• Relatives contacted the Trust regarding the attitude of a Junior Doctor on the ward.
  
  The Junior Doctor has been spoken to regarding the family’s experience and has been asked to reflect on their practice.
  
  
• Poor communication and patient felt pain during surgery.
  
  Apology given and discussion with patient regarding their pain, acknowledgement in future patient would require sedation.
  
  
• Urgent appointment was made as routine by GP but this was not changed when reviewed by clinician.
  
  Guidance has been provided for medical staff responsible for reviewing referrals and guidance has been given on bringing appointments forward where appropriate.
  
  
• Poor communication regarding risks of surgery
  
  Doctor has reflected on the impact of the information they discuss with their patients.
  
  
• Poor experience in department, poor communication and lack of appropriate support regarding issues after surgery.
  
  Ensured informed consent discussed at outpatients appoint, complaint shared with Day Ward staff to ensure improved communication and improvement in pain management.
  
  
• Error in coding of investigations requested, therefore results send to wrong clinician, leading to a delay in being reviewed and discussed.
  
  Correct processes reiterated to the team to ensure it does not  happen again.
  
  
• X-ray incorrectly reported
  
  
  Clinician has reflected on their practice and has been provided with appropriate training.
  
  
• 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.
  
  
• Poor experience and poor communication on the ward.
  
  
  Apology given and staff been made aware of patient’s experience in order to learn from it.
  
  
• Inter-hospital delay.
  
  
  Care group are working on a process to prevent delays.

Main issue raised and
Actions taken

• Patient given incorrect medication to take home
  Staff made aware of the incident in order to prevent it happening again

• 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:

  • Introduce themselves to patients with their name and job title
  • Have a clear understanding of  patient’s history and why they are attending
  • They should check patient’s understanding and give them the opportunity to ask relevant questions

   

• 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

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

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

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.