Learning from Complaints

Bradwell Hospital – North Integrated MSK service NIMS

Quarter 1 2024/25

Concern:

Service user said he had an appointment at Bradwell Hospital at 8:30am on 22 May 2024; however, when he arrived nobody was available on reception and although he asked one of the nursing staff, he was told to sit in the waiting area, and somebody would probably call his name.  He sat there until 15 mins past his appointment.  By then the main reception was being manned so he went to reception and was told he was sat in the wrong part of the hospital.  He was redirected to where he needed to be.  The person he was supposed to see eventually came and gave him a ticket to rebook an appointment and said he was sorry that he couldn't see him, as he had another patient due to be seen.

He also complained that he had to leave a message, having rung the Customer Service number seven times because he wanted to talk to someone, didn't want to leave a message and it just went onto the same message loop.

Response:

The Deputy Head of Facilities wishes to share her sincere apologies that your experience was not of the required standard of the one we try to uphold as a Trust and hopes to reassure you that by sharing the plan of improvements and learning with you, it demonstrates our desire to ensure all patients' feedback is listened to and acted on.

The Operational Lead for NIMS has reviewed the letter sent to you specifying the details of your appointment. Upon review she has noted that on the letter there is no department listed. This will be an ongoing improvement, and she is hopeful the resulting change will minimise issues with patients not being informed of where to go.

We wish to again share our apologies that your experience at Bradwell Hospital was not of the standard required. We hope by using patient's experiences, that we can improve and deliver better care and treatment to the people using our services.

The Customer Service telephone service operates from 09:30 until 4pm Monday to Friday. If the telephone lines are busy, there is a voicemail in operation and the team will aim to respond within 24 hours. I am sorry that a member of our team was not available to answer your incoming call.

The actions following this are as follows:

• The Facilities Manager is preparing a 'Way Finding' map. The map is currently under review to ensure that the information is user friendly.
• The NIMS service is working with IT to include the department information on their appointment letters, for the Bradwell Site.
• The Operational Lead will also be providing feedback to clinicians to look in other waiting areas if a patient is not present in the department waiting area.
• Customer Service and Experience Staff have been reminded of the importance of answering telephone calls in a timely manner within the opening hours.

Children & Family Care Group, Paediatric SaLT East

Quarter 1 2024/25

Concern:

The parent is unhappy with the lack of communication following her daughter’s review appointment in August 2023.

Response:

Team Lead reviewed the health records and noted that there had been a lack of communication and a return of calls from the therapist. The team has since sent out an appointment.

Mum has been asked to provide some additional information to discuss further, including the forthcoming appointment, plans to apply for the EHCP and the team process for supporting the application.

Learning:

Team Lead to discuss with the therapist and the wider team the importance of timely communication.

Community Paediatrics (Staffs)

Quarter 4 2023/24

Concern:
Parent asking why Community Paediatrics have not made a referral to CYP Autism and how the service plan to rectify the situation and ensure that her son will not be prejudiced by this error.

Response:
CYP Autism Lead spoke with mum to confirm that there was misunderstanding with the Doctor who has come from a different area, and he thought he had submitted the referral but had not sent it.  CYP Autism have linked in with the paediatric service and the referral has now been received along with a teacher liaison form.  The referral has been triaged immediately and accepted for assessment; the referral has also been backdated to October.  Mum has been informed that the team are looking at about 18 months to commence the assessment.  In the interim, mum has been provided with resources to support whilst they await their appointment.

Learning:
Learning for paediatrics - to ensure any new Doctors coming into the service are aware of the process for making a referral.  This will be included as part of paediatrics local induction and training planning.

CRHT Shropshire

2023-2024 Q4
 

Concern:
Complainant contacted PALS to advise after speaking with the team they felt the staff member was unhelpful and unsympathetic, causing them to feel worse about their condition. Complainant felt disheartened by the lack of empathy and personalised care provided by mental health services. And highlighted how they felt like a statistic rather than a person in need of assistance.

Response: It was acknowledged that callers to the service should feel heard and not made to feel that the practitioner is unhelpful or unsympathetic towards them. Team leader spent time advising changes to procedure over the past two years and complainant was thankful to have clarification on which service to call out of hours and the potential process of support following this, i.e. signposting to services such as the sanctuary or the access team requesting support from their designated clinician, who would then refer to CRHT for follow up if appropriate.  

Learning:
Concern was raised in the next CRHT team meeting and in supervision with staff members. This was used as a learning opportunity to improve practice within the team and prevent similar situations arising in the future.

Crisis Team South Staffordshire East 

Q4 2023/24

 
Concern:
A concern was raised by a family member regarding the care their mother received when contacting the Crisis team for support. The family member was unhappy that they overheard a conversation between staff members during the telephone call. This comment had caused the service user distress and that she felt she was unable to contact the service for support.

Response:
The service manager spoke with the service user directly to discuss the concerns raised and provided their sincere apologies from the team. The service user had stated she had no concerns relating to the care and treatment from the team other than the comment made when contacting for help. The service user was assured that it would be raised with the wider team to ensure that staff members are not sharing information or comments with other staff.

Learning:
All staff are to be reminded of the Trust’s values and behaviours when supporting our service users and carers and to treat all people with the upmost dignity and respect.

Grange Ward

Q4 2023/24

Concern:
Complainant contacted PALS to advise that during their inpatient stay, prescription charts were not kept up to date and there were delays with medication due to low stock on the ward, which resulted in delayed pain relief.

Response:
The ward manager confirmed that prescription charts last 28 days and should be rewritten on the 27th or 28th day. The ward manager provided their apologies to the service user that it was not identified the prescription chart was not updated in a timely manner.

In regard to medication, it was confirmed that liquid paracetamol is not a medication which the ward stock and is only dispensed on request. The ward manager provided assurance to the service user that staff would be reminded to check medication stock and ensure the required medications are ordered more promptly.

Learning:
All staff were reminded during a team meeting on 27 March 2024 that prescription charts should be rewritten on 27th or 28th day.

All staff were reminded during a team meeting on 27 March 2024, to check medication stock regularly and order required medication in advance.

Willow Ward - Low Secure Unit (LSU)

Quarter 4 2023/24

 
Concern:
Service user wrote to complain about the repeated mistakes that are happening with the prescribed Nicotine Replacement Therapy (NRT) on numerous occasions; staff nurses are writing the lozenges on the inhalator sheet without looking.

Learning:
This concern has been addressed with the qualified nurses on Willow.  The NRT folder has been updated and made clearer. Folder now includes separate sections for inhalator and lozenges.

Service user was satisfied with the response and mentioned how the folder "seems better" and that there have been no further issues since.

Concern, Specialist Care Group, Sexual Health Burton (Branston Clinic)

Q3 2023/24
 

Concern:
Concern raised about standards of practice/ hygiene in the service and in response to this the following steps have been put in place.

Learning:

• Patient Survey Form – to be used to give consistent reassurance that the practices remain in line with guidelines.
• The Infection Control team to provide an additional update specifically regarding the importance and relevance of hand hygiene in additional to decontamination and cleaning methods.  This will also incorporate a practical session on the correct technique.
• Two staff members to retake their Infection Prevention & Control mandatory training.
• Team to order hand sanitizer that have a pump-action mechanism.
• Coat hooks to be reinstated to backs of toilets doors.

IMHT Stafford Neighbourhood

Quarter 1 2024/25

Concern:

Caller contacted Customer Service on behalf of her partner.  She explained that her partner was discharged from St George's Hospital in March 2024 and placed under the care of the crisis team for a couple of months and then transferred to IMHT.

Caller said her partner has been assigned a care coordinator, but they haven't been able to get in touch with him.  Last Friday the caller rang the Admin Hub for the care coordinator to get in touch; however, they never returned the call and service user became more unwell overnight resulting in a hospital admission.  

Response:

Following the review, it was evident that contact was attempted however this was unsuccessful. Apologies have been provided as no further contact was attempted throughout the day. There were also alternative numbers available on the records; however, calls to those numbers did not take place.

The actions following this are as follows:

Staff to be reminded of staff process and policy and to attempt alternative numbers documented on the care records, if a person has requested support and we have not been able to make contact.

Long COVID Service

Q3 2023/24

Concern:
Complainant contacted PALS to advise that they attended a Long COVID workshop group. The group were asked to add their name for the online session and the service user is a very private person and used an initial as ‘D’ as they did not wish to share their full name with the group. The Facilitators of the workshop then shared the service user’s full name to all participants during the session.

Response:
The service manager spoke with the two clinicians who facilitated the workshop. Reassurance was given that the staff take patient confidentiality and privacy seriously and they do not use patient names or surnames unless the patient has used it within their guest name displayed on the screen or openly disclosed in the chat.

By reflecting on the events of that evening, the team have identified lessons learned. Moving forward, at the beginning of the session, the staff will ask the participants if it is acceptable to verbally call them by the guest screen name that they have chosen for themselves, or the name they put in the chat section. If a participant is using a name not on the attendance register, we will ask them to email us with their actual name separately to maintain their privacy and confidentiality.

Learning:
Staff to ask participants if it is acceptable to verbally call them by the guest screen name that they have chosen for themselves, or the name they put in the chat section. If a participant is using a name not on the attendance register, we will ask them to email us with their actual name separately to maintain their privacy and confidentiality.

Sexual Health Leicester City

Quarter 1 2024/25

Concern:

Experience of appointment in 2019 and detail of extreme pain experienced during internal examination and conduct of nurses throughout. At time of appointment service user was only 19 years old and did not feel able to speak up about her experience.

Response:

The team apologised for the upset and distress experienced and that the service user left the service feeling this way without the ability to talk to the service. The team acknowledged how extremely courageous service user was in revisiting such a difficult personal experience and appreciated the time she had taken to email the service. Following a review of the clinical record it was confirmed that swabs were taken. The records indicate that no smear test was performed during this appointment. Generally, patients tell us they do feel the tip of the swab being rotated, however, the team recognise this was not the service user’s experience and for that an apology was given. The couch stirrups and position for female examination can feel very exposing and the reason for this is to allow the doctor/nurse greater visibility and accessibility which should reduce the time spent exposed and feelings of discomfort. But this did not occur for the service user. The team acknowledge that they should have communicated better and took more time to make sure service user was feeling comfortable with what was being undertaken.

Learning/Action:

Share concern with clinical staff for reflection and discussion. Team to integrate service user experiences into a scenario and therefore using this as an opportunity for learning for the wider health care team that assisted with improving skills in clinical practice and to mitigate anyone else experiencing the pain and discomfort that was experienced.

Case Study – Talking Therapies ST&W (IAPT) 

Q3 2023-24
 

Concern:
Service user received no support or promised documentation following assessment some months prior. Feels let down by service as declared it had taken them a long time to find the courage to self-refer and to ask for help and then nothing.

Outcome:
It was established that the assessor acknowledged that they did not send out the required information to the service user as agreed.

Learning:
To reduce the risk of this happening again, a checklist is now in place to ensure that all required actions are completed following assessment. Enquirer was accepting of this.

Talking Therapies ST&W (IAPT) also agreed that service user would be allocated to a therapist for video consultation, which is the shortest wait time of 3-4 weeks approximately. It was agreed that should service user not find the online therapy helpful, they could be moved back to the wait list for face-to-face appointments at the same stage as where they would have been.