Formal Complaint Adult Social Care
Quarter 1: 2022/23
Concern:
Relative raised concerns about lack of information provided by her mother’s Social Care Team. She said that her mother was transferred to a nursing home for 24 hour care after discharge from hospital but that neither she nor her mother were told of the need to self-fund this placement after Covid-19 funding ceased in April 2022. She complained therefore that unnecessary costs had been incurred, without her having opportunity to consider or make alternative arrangements beforehand.
Response:
The Trust responded, stating that records indicated funding may have been discussed during a visit to the home by the social worker, with which the daughter was involved. However, details of what was discussed were not clear from the records and this took place whilst the service user was already incurring costs, the costs being for 16 days in total.
It was agreed that both the relative and service user had not been informed that the placement would be self-funding in good time before this commenced and it was agreed that the Trust would settle the payment direct.
Learning:
Social care teams are regularly reminded of the importance of clear records, including information shared with service users, families and carers about charges that may be incurred and available options.
Formal Complaint Adult Social Care
Quarter 4 2021/22
Concern:
Relative of a service user raised concerns following a service user placement at a residential home in relation to:-
- Lack of information regarding the financial aspect of the placement.
- That a Continuing Healthcare Assessment was not completed prior to the placement.
- That the placement was unsuitable.
- That the treatment of the service users spouse in relation to the safeguarding allegations was poor.
Response:
A full investigation report was completed which identified:-
That the service user and spouse were fully informed with regards to the financial aspects of any placement prior to the placement being identified and that they had capacity to understand the information provided. Information regarding charges for the placement were discussed following the placement and the spouse declined the offer of a financial assessment.
The placement was arranged as an emergency respite placement at the service users request and therefore staff were unable to complete a CHC assessment prior to the placement. Prior to the request for an emergency respite placement there was no indication that the patient was eligible for CHC funding.
The placement was identified as suitable, based on the service user presenting and known needs in the community as reported by the service user and spouse. Following the placement into 24 hour care, the service user displayed behaviours which staff members were unaware of, the service user was reassessed and it was identified that the service users needs would be best met in a nursing home placement. Due to COVID there was a delay in an alternative placement being sourced by the Local Authority.
There was no evidence that there was any maltreatment of the service users spouse in relation to safeguarding referrals. Actions as a result of the safeguarding allegations were communicated in an open, transparent and caring manner, with evidence in the records that staff members were trying to ensure that both the service user and spouse were supported in the community and the service user and spouse were encouraged to accept additional support.
Learning:
No learning action identified, although apologies were offered to the spouse if at anytime they felt that staff members treated him unfairly.
PALS Concern AHP Referral Centre
Quarter 2 2022/23
Concern:
Service users and carers are attempting to contact the AHP referral Centre to arrange an appointment with therapy services. Service users are unable to get through and the message states that they are in queue position 20. This then encourages the service user to wait on the phone as the queue positions become lower; however after 45 minutes the call automatically terminates. Service users have been raising this with PALS and Experience as it is causing additional stress and they are unaware on how they can contact the service to arrange their appointment.
Response:
There has been an increase in demand and the service have reduced staffing levels with vacancies available. The service managers have been escalating the concerns to the senior leadership teams and this will be added to the Trust risk register. Apologies are being provided to service users and carers and where possible a member of the team is making direct contact to arrange an appointment.
Learning:
The AHP Referral Centre have raised this feedback with our Health Informatics Service (HIS) who have made the following changes to the automatic voicemail. This is to ensure service users and carers are aware of the current delays when they make contact;
Introduction when calling 0300 123 0991
Welcome to the Therapy Referral Services, part of Midlands Partnership NHS Foundation Trust. Calls are recorded for training and monitoring purposes.
Please be advised that we are experiencing a high volume of phone and email queries. You may be waiting up to 45 minutes for your call to be answered. If you have not been connected to one of our agents after this time, your call may be disconnected.
If you have been referred from the GP, please allow at least seven working days before contacting the referral services to book your appointment, as the team will be unable to process your referral before this time.
If you would prefer not to wait in the call queue, you can contact us via email on NIMSadmin@mpft.nhs.uk Please ensure to include your full name, NHS number or date of birth, postcode and full details of your enquiry.
Formal Complaint BeeU
Quarter 4 2021/22
Concern:
Relative of a service user raised concerns about the following areas:-
- There was a lack of communication by Crisis Resolution Home Treatment (CRHT) Bee U staff with family/guardian of young person referred into services.
- Young person had been triaged by telephone and assessed as low risk (shortly afterwards she was admitted to hospital following self-harm with suicidal intent).
- Mental Health Act Assessment (MHAA) was vigorously pursued by CRHT Bee U team.
- Poor communication between family and social care and the Trust.
- Family wanted psychological support therapy for their young person.
Response:
A full investigation report was completed which identified:-
The findings did show there could have been better communication between services and the family guardians/young person who was deemed to be gillick competent.
There was a lack of openness and honesty when working with the family and the plans to pursue a MHAA.
Social care staff and health staff had different views around the element of risk posed and how this should have been best managed.
There were lengthy delays in completing the MHAA and this was due to a lack of discussion between Social Care Advanced Mental Health Practitioners and Heath staff in CRHT BeeU service. The psychological assessment and therapy was delayed as service user was in crisis and it was not considered conducive to work on her psychological issues at the time of her contact in crisis.
Learning:
Work between Health and Social Care to be improved as a result of senior managers from both organisations to hold regular meetings to understand how both organisations can work together to provide a more positive experience for the service and their family/guardian which should involve a dialogue with the family /guardian young person if deemed gillick competent.
Formal Complaints Case Study BeeU
Quarter 4 2021/22
Concern:
Concerns were raised from a family that they did not feel the patient or family were receiving the appropriate level of care and support from the service, as the patient was discharged from the BeeU service without having an assessment for ASD/ADHD and that information within the discharge letter was inaccurate.
Response:
The investigation identified that following assessment in the service the patient did not meet criteria for onward assessment for ASD or ADHD, it was documented that the patient’s presentation was due to hypervigilance linked to their early years development.
The investigation reviewed the discharge information and the information contained was accurate based on the assessment completed.
Learning:
No learning was identified from the investigation.
PALS Concern - CAMHS West
Quarter 2 2022/23
Concern:
Mum called on behalf of her 14 year old son who is going through the transgender process. She said earlier this year they saw a new mental health practitioner as his usual therapist has been off sick.
Mum said during the appointment the practitioner miss-gendered her son on more than one occasion which made him feel uncomfortable. She also questioned him about his medical choices and ongoing treatment with trans-identity.
Mum explained that her son has been in gender therapy since the age of 9 and is happy with the therapy and treatment he receives.
Mum explained they have declined any further appointments with this therapist as she made her son feel worse and had the audacity to question him about his gender when she was not in the capacity to do so.
Response:
Enquiry shared with Service Manager about staff member's conduct and breach of the Transgender Inclusion Policy.
Learning:
Mum updated that the team has identified the breach of policy, and that our actions will be to:
To discuss with staff member conduct and breach of the Transgender Inclusion Policy.
To reaffirm the Transgender Inclusion Policy with the staff member in a form of education. Share policy within the team to refresh the team around the appropriate ways to address a young person who identifies as transgender.
Formal Complaint CAMHS
Quarter 4 2021/22
Concern:
Concerns were raised regarding the CAMHS team and Children and Young People Autism Service (CYPAS) for autism assessment in relation to:-
- The CYPAS did not following NICE guidelines when assessing the patient.
- Medical history and family history was not included or considered as part of the assessment process.
- Communication was poor.
- Assessment findings were not shared face to face or sensitively.
- Question why the patient was not suitable for support from CAMHS and that the suggested referral to another organisation were inappropriate.
Response:
The investigation identified that the assessment completed by CYPAS was in line with NICE Guidance and that all medical information, family history and information provided by the family was considered as part of the assessment. It was acknowledged that the guidance was not fully met because there was not a single point of contact or a care coordinator allocated. The investigation acknowledged that the experience of care would have been improved if these were in place.
Due to COVID the assessment findings could not be discussed face to face and therefore the findings of the assessment were discussed in a telephone call. It was noted in the records that this was a distressing call for the family and changes to the process have since been identified to ensure families and clinicians are supported when outcomes are provided.
Following review of the referral to CAMHS it is identified that the patient did not meet criteria for CAMHS intervention, and was appropriately signposted to alternative services. The investigation acknowledged that the rationale for this decision making was not clearly explained in order for the family to understand the clinical rationale for the decision making.
Learning:
The following recommendations were made as a result of the investigation:-
For CYPAS service to provide an overarching care coordinator and single point of contact for each family
CYPAS and CAMHS to provide an explicit rationale as to why signposting is required and clinically informed.
For CYPAS to review their risk assessment and management process
For CYPAS to develop a robust intervention offer for children being assessed for autism. This should include of the interventions, resources and signposting evident during care pulled into one integrated intervention plan
Formal Complaint CAMHS
Quarter 4 2021/22
Concern:
Concerns were raised regarding the CAMHS team in relation to the following:-
- The diagnosis given to the patient.
- The quality of the assessment completed prior to the diagnosis being given.
- Poor communication and conflicting advice being given.
- The style of questioning used during the assessment.
- Staff absences within the team impacting on care.
Response:
The investigation concluded that clear rationale had been given to support the diagnosis, the correct processes had been followed and the consultant acted appropriately during the assessment. All medical information, family history and information provided by the family was considered before giving the diagnosis.
It was identified that the families’ expectations could have been better supported if the team had produced a clear care plan, in line with Trust standard practice.
There were occasions when communication was below the standard expected by the Trust, particularly during times of staff absence. A full handover of the patients care did not take place when a member of staff left the team resulting in a gap in services which had been offered to the family. A particularly high level of staff sickness negatively impacted on the standard of communication with the patient and their family.
Learning:
The following recommendations were made as a result of the investigation:-
A caseload review to take place prior to staff leaving their roles ensuring a full handover of tasks. The team leader designed a checklist template to be used.
The importance of attendance at MDT meetings to be reiterated to staff to ensure that significant information is shared regarding progress in a patients care and treatment
Discussions to take place with Family Therapist prior to the service being suggested to families to ensure they are suitable
All staff to be reminded of the importance of good communication and any change in roles or impending departures from the Trust to be shared with families at the earliest opportunity with reassurance offered around the handover of care
Formal Complaint CAMHS
Quarter 4 2021/22
Concern:
Concerns were raised with regards to the service received by the CAMHS service, the concerns related to:-
- Delay in meaningful interventions.
- CAMHS delay, decline to share information with social services.
- Overall support provided.
- Management of concerns.
- Communication.
Response:
The investigation identified that the service user received appropriate care and support from a Youth Worker with regards to the reported low mood. Following an escalation in behaviour due to a personal matter, the service user had multiple agencies providing support. The investigation acknowledged that once the Youth Worker was aware of other agency involvement, this could have been explored further to identify if the service user required any additional emotional support and escalation to the CAMHS MDT.
Following the relative requesting further CAMHS involvement, CAMHS were conscious of the number of agencies involved and therefore were linking with these agencies to identify who was providing what support in order to identify if there was a role for CAMHS. Following concerns raised with the management team a further assessment was arranged with a clinical psychologist and it was identified that the service did not have any mental health needs at that time and her needs were being appropriately met by the other agencies involved and the patient was discharged from the CAMHS service.
The investigation acknowledged that the CAMHS did not attend a meeting with social services due to capacity and demand on the service and apologies were offered for this. It was acknowledged that verbal update was provided to the meeting on behalf of the service. A further chronology was requested for the next meeting, however the family withdrew from the process and therefore the next meeting was cancelled and the chronology was no longer required.
The investigation also identified following the relative raising concerns with the operational management team that there could have been more timely communication with relatives.
Learning:
The following recommendations were made as a result of the investigation:-
Team leader to ensure that there is a clear pathway to escalate complaints and that patients/relatives should be informed of potential timescale for response from the service
Report findings to be discussed with Youth Worker in 1:1 supervision to identify any personal development needs.
Formal Complaints Case Study CAMHS/Eating Disorders
Quarter 4 2021/22
Concern:
Concerns were raised regarding the delay in appropriate support for a patient.
Response:
The investigation identified that the appropriate pathway for support from the eating disorders service was appropriate, however acknowledge that support relating to anxiety could have been provided sooner.
Learning:
The following learning was identified as a result of a review of the care:-
Increased joint working between CAMHS and Eating Disorders Team to provide treatment sooner as required.
Formal Complaint Children’s & Young People’s Autism Service
Quarter 1 2022/23
Concern:
Parent raised a complaint that ther daughter had been given insufficient and inappropriate support for ther Autistic Spectrum Condition and Selective Mutism. She said that following ther daughter’s referral to the service she had not received good communication about waiting times and that she needed to chase this up. She said that the session work provided was the unsuccessful and the wrong approach, with the decision about a way forward being predetermined, regardless of parents thoughts and feedback. The parent considered that her daughter should be seen by a specialist in Selective Mutism but this did not happen. Parent felt that the service did not effectively engage with her daughter and that parent was not invited to be involved in Multi-disciplinary team (MDT) meeting discussions. When the parent asked for a copy of minutes of the MDT meeting, these were not provided.
Response:
The Trust agreed that waiting time from referral to intervention was much longer than the Trust would like to see and that parent's frustrations were understandable.
It was recognised that the support sessions to help the young person with anxiety were unfortunately not successful, although this was considered to be that despite best efforts to encourage communication through various methods, the young person did not feel able to engage with the practitioner. Without being able to successfully complete this support to deal with the anxieties that caused the Selective Mutism it was not possible to commence Speech & Language Therapy support. A meeting had been held with the parent to discuss concerns and the investigation found that these were listened to and considered. It was reiterated to the parents that the young person may benefit from a trusted communication partner either from her home or school environment to be able to engage with the service. The service remained of the view that session work on her anxieties which caused her Selective Mutism needed to be successfully completed before SALT support could be progressed.
As this did not resolve matters it was appropriately suggested that MDT would discuss this case further to agree a way forward. MDT felt that the appropriate decision had been made and did not recommend a change to the approach.
Learning:
Additional staff have been recruited and work continues to ensure improvements in waiting and treatment times. It was confirmed that as a result of parents concerns all future initial letters would advise parents/carers that the next time the service will be in contact is when an appointment is available. Families are now encouraged to contact the service direct if there are any changes that they need to discuss or if support is required.
With regard to the MDT meeting, it was considered appropriate that minutes were not recorded as discussions took place about several patients during each meeting. For this reason and due to the volume to be discussed it was also appropriate that parents and carers did not join the meetings. Records however did not identify which members of staff were in attendance at a particular MDT as would be expected and the team were reminded of the importance of this and confirmed that such detail is now logged. Apologies were relayed to parent.
Formal Complaint Health Visiting
Quarter 4 21/22
Concern:
Concerns were raised that a referral to the First Response Team was completed following attendance at the health visiting clinic
Response:
The investigation showed that staff acted appropriately and completed a referral to the First Response Team following the identification of a bruise on a non-mobile baby, which is in line with best practice guidance.
Learning:
The following learning was identified as a result of a review of the care:-
All universal staff should be reminded of the importance of ensuring that all staff members present should be introduced to service users and their families and their role explained.
The importance of accurate documentation to be reiterated to the 0-19 team including health visitors in relation to the recording of characteristics of bruises in non-mobile babies.
Body mapping training will be provided to the 0-19 team including the Health Visitors to support accurate recording of bruising in non-mobile babies.
The statement around evidence (within the Stoke on Trent and Staffordshire Safeguarding Children’s Board Practice Guidance for bruising in non-mobile babies) leads to ambiguity and is therefore not clear to professionals as it implies that the health visitor should do some level of investigation prior to making a referral, which is not the role of the health visitor and therefore the guidance should be updated
PALS Concern 0-19 Service
Quarter 4 2021/22
Concern:
Parent shared their concerns regarding possible traits of Autism Spectrum Disorder (ASD) with the health visitor (HV) who agreed to make a referral. The young person was referred to a Paediatric Consultant as the results of the Ages and Stages Questionnaire (ASQ) form indicated behavioural and social ASD traits over any delays in growth/development. Parent believes the child should have been referred to CAMHS Autism Service not the Paediatric Consultant.
Response:
At the appointment with the health visitor the parent consented to a referral to the community paediatrician which is in line with NICE guidance, due to concerns that were raised following further assessments which took place using the ASQ and SE questionnaire.
In line with NICE guidance the child did score fairly in fine motor skills, hence why a referral into the Community Paediatrician was made.
Learning:
The team to have further learning in when to refer to the Community Paediatrician and when to refer to CAMHS.
HV Service approached the CAMHS (ASD team) to complete a piece of work to improve links and communications, and to produce guidance to further support healthcare professionals referring into the service.
The CAMHS (ASD Team) is a service provided by another organisation and is not a service provided by the Midland Partnership NHS Foundation Trust (MPFT) who provide HV services across Staffordshire.
Guidance has been shared with the HV team around NICE guidance for ASD and further learning has taken place to understand symptoms of ASD. This will also be shared across all HV Teams within MPFT where appropriate.
All guidance is to be used in conjunction with professional judgment and individual assessment.
Team Leads discussed enquiry and agreed that every referral received would be reviewed into the triage centre for CAMHS, and would be either accepted or rejected at source, before it is sent to the individual team to be placed on the waiting list for assessment.
Formal Complaint Community Nursing Service
Quarter 4 2021/22
Concern:
A relative raised concerns with regards to a patients end of life care, reporting that the appropriate equipment and medication were not in place/administered.
Response:
The investigation identified that appropriate equipment in place to ensure their comfort at end of life, however following the family reporting that the patient was more comfortable on a different mattress the mattress was ordered for next day delivery.
All appropriate end of life medication was in place on the patient’s return home and the district nurses attended as required to support the family and ensure the patient’s pain was managed.
Learning:
It was identified that a bereavement visit for the family was not arranged following the patient’s death and the team leader was requested to review the process for arranging bereavement visits to ensure these are completed in a timely manner.
PALS Concern South Alliance Out of Hours Community Nursing
Quarter 4 2021/22
Concern:
Unable to contact the out of hours’ community team in an emergency and are only able to leave a voicemail message and wait for a call back.
Response:
In March 2021, referrals into the out of hours’ community team were via a mobile phone. Due to the poor phone signal in parts of South Staffordshire, calls received were diverted to a landline where a message could be left by the caller. This was then accessed by the nurse on duty and was done approximately every 20-30 minutes. There was no one to answer the call at times; however contact would be made by the nurse on duty following any messages left. It has been recognised that this is not acceptable practice and that an alternative process was needed.
Learning:
The service have made changes to their contact systems and since March 2021, have implemented a 24 hour telephone system that allows all calls received into the service to be answered by a call handler and managed from the first point of access. They will ensure that all of the appropriate information is taken from the caller and this information is then passed to a nurse coordinator for triage. They will then liaise with the patient or relative to arrange a visit.
Formal Complaint Dental Service
Quarter 1 2022/23
Concern:
The patient reported that she had been provided with inappropriate advice with regards to pain relief, which resulted in her taking an accidental overdose and being admitted to hospital.
Response:
The investigation identified that the patient was advised to alternate medication every 3 hours, however the patient had misunderstood and was taking paracetamol and ibuprofen every 3 hours, resulting in the overdose.
Learning:
Although there were handwritten notes available regarding the telephone conversation with the patient, the full details of the conversation had not been included on the electronic patient record. The staff member was reminded of the Trust policy regarding record keeping.
Formal Complaint - Dental Service
Quarter 1 2022/23
Concern:
The patient reported that she had been provided with inappropriate advice with regards to pain relief, which resulted in her taking an accidental overdose and being admitted to hospital.
Response:
The investigation identified that the patient was advised to alternate medication every 3 hours, however the patient had misunderstood and was taking paracetamol and ibuprofen every 3 hours, resulting in the overdose.
Learning:
Although there were handwritten notes available regarding the telephone conversation with the patient, the full details of the conversation had not been included on the electronic patient record. The staff member was reminded of the Trust policy regarding record keeping.
Formal Complaint Integrated Mental Health Team
Quarter 1 2022/23
Concern:
Patient raised concerns regarding the delay in care from the mental health team. Patient reported that 7 months after her initial assessment she still did not have a care plan.
Response:
The investigation identified that although a plan of care had been discussed and agreed with the patient her care plan had not been updated in a timely manner to reflect the plan of care agreed and the patient had not been provided with a copy of her care plan.
Apologies were offered to the patient and a review appointment was arranged to ensure the care plan was completed with the patient and that the patient was provided with a copy of her care plan as a matter of urgency. The investigation also identified that the care plan written was not completed on the current care plan documentation.
Learning:
The following learning actions were identified:-
The investigation findings were discussed with the staff members involved in the patient care as part of their one to one supervision to identify any personal development needs in relation to care planning.
The Trust standards regarding care planning were reiterated to the wider team, to remind staff that care plans should be produced collaboratively with patients, that patient should be provided with a copy of their care plan and the correct documentation to use for developing a care plan.
PALS Concern Mental Health Access Pathway East and West
Quarter 2 2022/23
Concern:
A service user raised concerns about how his care was managed by the Access service. The service user feels that the text message prompts do not provide any indication on what a service user needs to do if they are unable to take the phone call. Service user has also raised concerns that from contacting the service he received a letter and the wording of the letter was poor, where it mentions that if a service user does not return their contact within a certain time frame they would close the referral. Service user feels that ‘the wording is very poor from a department that should be putting their arm around a patient, not pushing them away’.
Response:
Apologies were provided to the service user as it would not be our intention to cause any further distress. The findings identified that the service user only received the first text message prompt to state that a call handler would be making contact within ten minutes. It is normal practice to then send a 2nd message and attempt to make contact again; however this did not take place.
Learning:
The service manager will be reminding all staff to ensure a second text message is sent to service users or carers as the text message service has been successful and the answer rates have increased. The service manager has also confirmed that she will review the template letters and the content.
Formal Complaint Integrated Mental Health Team
Quarter 4 2021/22
Concern:
Patient complained about the attitude and approach shown towards her by a member of the community mental health administrative staff during her telephone call to the service. Patient said that the administrator’s tone was intrusive and inconsiderate and that the administrator was not interested in information shared by the patient about her support dog and how this would help her to find the confidence to attend sessions, telling her that the call was not an emergency.
The patient added that the administrator took an extraordinary amount of time to find her details on the system and then ended the call abruptly, having informed the patient that an assessment letter was in the post. The patient felt that the administrator should have transferred her to the duty worker in order that her queries could have been answered appropriately.
The patient felt that telephone calls should be routinely recorded and that if this call had been recorded then details of the exchange could be easily verified.
Response:
The response reiterated information previously provided by the Patient Advice & Liaison Service (PALS) when an informal concern was raised with them which stated that details of the conversation were not recorded on the patient’s records as they should have been. As the patient was able to provide the exact time of her call, telephone records showed that the patient’s call was received by the Access Team and transferred to the team administrative hub at the time stated.
It was confirmed who the administrator was to whom the patient spoke to and the administrator had been asked for their recollection of the conversation. They recalled that the patient referred to her plans to move location with her dog and that as such advice was given that the team could not provide support relating to housing or pets. The administrator said that they were unaware the dog was a support dog. The administrator did not recall a request from the patient to speak to the duty worker although transfer to the duty worker would only usually happen where an urgent need is indicated to ensure that the line remained free for that purpose.
The Trust advised that the administrator involved was on leave at that time and it was not possible to ascertain why it had taken a while to find the patient’s details on the system. However, it was explained that this can happen due to system/network delay or through inadvertently inputting incorrect details. The Team was not aware of this being a wider problem based on service user and staff feedback.
Due to the member of administrative staff being on sick leave during the investigation it was not possible to obtain their response regarding why the call may have abruptly ended. There was no indication however that the patient was considered to be unreasonable or abusive.
With regard to the request for telephone calls to be recorded it was explained that this functionality was disabled at the time whilst service managers looked to adapt this system so that callers could choose whether they wanted their calls to be recorded or not.
Learning:
The administrator had reflected on the patient’s experience when asked about this following the patient’s contact with PALS and they appreciated that they may have inadvertently appeared as though they did not wish to help the patient based on the patient’s feedback. The administrator stressed that this was not their intention and offered personal apologies for how their manner was perceived.
With regards to record-keeping, the administrator was reminded during routine one to one management supervision of the necessity and importance in logging all telephone conversations on patient records. This would be monitored through one-to-one supervision.
In terms of concerns that the telephone call ended abruptly, the administrator and team staff were reminded that calls should only be terminated in such a way when they are experiencing abuse or unreasonable behaviour and in those instances the caller should be warned that the staff member intends to hang up before taking this course of action.
It was reiterated that if the patient’s dog was a registered support dog that this could be brought along to all future appointments.
Apologies were offered to the patient for the issues and distress she experienced as a result of her contact with the service and that she had not had the option to ensure her telephone call was recorded at that time.
Formal Complaint Community Mental Health
Quarter 4 2021/22
Concern:
The relative of a service user who had sadly died as a result of suicide expressed concerns regarding the decisions made in his relatives care. A full investigation had been completed in line with Trust policy, however the relative expressed the following concerns as a formal complaint.
The relative requested further clarity on the decision making of the Multi-disciplinary team who had reviewed the service user and granted her request to be discharged.
The relative expressed concern that the service user had not been detained under a section of the Mental Health Act (MHA) 1983.
Response:
A full investigation report was completed which identified:-
The report gave assurances that the Multi-disciplinary team had taken into account a variety of factors when determining a suitable management plan for the service user. These included the events that had led to the admission, the progress during the admission, and the available support in the community. With these factors in mind, and after completing a clinical review, whereby it had been determining that the service user had capacity to make this decision, her request was discharge was facilitated.
The report provided information about the Mental Health Act 1983, this included information about the criteria in which a person is considered detainable under this legislative framework. There is evidence within the report which indicates that the service user did not meet the criteria for detention.
Learning:
The service identified that some improvements could be made in the way in which they complete their documentation. These were included as part of an action plan to ensure this learning is embedded into practice.
PALS Concern Integrated Mental Health - Shropshire
Quarter 1 2022/23
Concern:
Mental Health Assessment appointment attended and service user seen by a Senior Mental Health Nurse. Concern related to a lack of informed consent about students being present in the meeting, and the conduct of the staff member during.
Response:
Quality Lead met with service user to discuss concerns and apologies given for the distress caused. Review of care plan completed and agreed changes to support service user’s wishes and progress.
Learning:
It was agreed that there would be changes to service processes in relation to;
1. If students are shadowing clinicians that the service user is to be asked permission, before the student is present, so the service user can be honest with the clinician.
2. The pathway have an assessment template, and staff have been encouraged to follow this for a consistent approach.
Formal Complaint Older Adults Inpatient Ward
Quarter 4 2021/22
Concern:
The family of a service user raised concerns following the care their relative received whilst an inpatient, these included the following concerns;
- Family expressed their concern that the inpatient staff had not given full consideration to their relative’s physical health when making prescribing decisions.
- The family wanted to ensure that the concerns they had raised on behalf of their relative regarding side effects was taken into account by the prescribing clinicians.
- That a staff member had spoken to a family member using inappropriate phrases which had caused the family member distress.
- The family requested an explanation regarding actions taken by a pharmacist.
- The family expressed concern that the inpatient ward manager had prioritised the ward staff over their relative.
- The family expressed frustration that the inpatient staff had referred to one of the family members as intimidating.
- The family had been requested to contact the inpatient ward at designated times for information on their relative, however there were times when their call went unanswered.
Response:
A full investigation report was completed which identified:-
The family were provided with assurances that all aspects of their relatives full physical and mental were taken into consideration when making prescribing decisions. Evidence was shared that the clinical team consulted with a variety of colleagues to discuss the treatment plan.
The report confirmed that the concerns raised by the service user’s family regarding medication were noted within the clinical records. These concerns were taken into account by the clinical team which in turn assisted in the clinician decision making relating to the medication regime.
The report included apologies for the unintentional distress that a staff member’s articulation of a complex presentation has caused.
An explanation was provided regarding the actions of the pharmacist which were in line with relevant policies and guidelines.
The report explained that the Manager had conveyed to the family that in order for her to ensure that the very best care is provided to all the inpatients on their ward it is her role to ensure that the staff have all of the things they require in order to perform their role to the best of their ability. The report offered its apologies if this sentiment was not articulated as well as it could have been and for any unintentional distress it may have caused.
The report clarified that the staff had not described the family member as intimidating, however it is acknowledged that at times the relationship between the staff and the family was at times fraught. Apologies were again offered for any unintentional distress caused.
The report gives the rationale for the request from the inpatient staff for telephone calls at pre-arranged times, however it also recognised that at times these calls were not always successful due to the clinical activity. Apologies were offered for any unintentional distress caused.
Learning:
No learning action identified, although apologies were offered to the family for any unintentional distress caused by the issues above.
PALS Concern – Sexual Health Services, City of Leicester
Q1 2022-23
Concern:
Receptionist had poor communication skills, was extremely rude and showed no respect or empathy towards service user. Receptionist had asked what the appointment was for, service user did not feel comfortable discussing with the Receptionist; Receptionist informed service user she would look on her records. Service user concerned that the receptionist should not be looking in her health records.
Response:
Apology afforded if the service user felt she did not receive a caring service when speaking with the switchboard. Explanation provided on the process when patients call the service switchboard. The team run several specialist clinics each day across Leicester, Leicestershire and Rutland in addition to a selection of online services. Therefore, it is imperative that staff ascertain the reason for any requested appointment as a face-to-face appointment is not always necessary. If it is established that an attendance is necessary it is important to ensure that this appointment is with the most appropriate clinician to avoid any delays in care or treatment and unnecessary additional appointments.
To book an appointment our switchboard staff need to ensure that any patient attending the service has a medical record on our electronic system. Their access to these records is very limited and they would only be accessing the demographic section to book an appointment. There may have been some confusion in the conversations today about this access and the terminology used by our staff.
Assurance afforded that the team do not have access to the clinic notes that the clinicians write and they would not need to look at this section to make an appointment. Our staff have received guidance and training in relation to assisting callers with their requests and how to manage these, and also about accessing our electronic patient record system, restricted and unauthorised access and GDPR regulations.
Learning:
Team Lead to ensure that concern regarding some of the terminology and style experienced by the service user are raised and addressed at the team meeting. Nurse has made contact with the service user and an appointment has been arranged.
PALS Concern – Sexual Health Service Leicester
Q2 2022-23
Concerns:
The receptionist's attitude was poor and unprofessional, being rude and unreasonable.
It took a long time to get an appointment. Staff shortage as a result of sickness and leave were reported.
They were encouraged to seek treatment elsewhere Nottingham, Birmingham or elsewhere in the East Midlands.
Response:
Service apologised for how the receptionist came across and that their manner and tone were not supportive. As a result of this feedback we will share this experience with our receptionist staff members to discuss the concerns that have been raised. All staff have their calls monitored by their line manager and are listened into on a quarterly basis and assessed. They annually attend the services customer service training and have regular update training delivered throughout the year as part of the monthly team meeting agendas. Staff that are identified by patients where behaviours have not been as expected are asked to repeat customer service training and to complete a reflection session with their line manager to show understanding of the complaint and to support with growth and learning.
Team only have a finite amount of appointments and once these have gone they are unable to offer an appointment until more become available which is why service users are asked to call back on another day or try an alternative pathway. For example online STI testing.
The team receive approximately 5000 calls per month and see over 5000 people across all clinics with 80 percent of all appointments being seen at Haymarket Health, situated within the Haymarket Shopping Centre. The service also have clinics in Loughborough as well as Rutland and other peripherals across the County. Team have tried to diversify the service to increase capacity through online services such as STI testing, oral contraception, Emergency Hormonal Contraception (EHC) and some treatments which can be posted to a patient’s home or a location of their choice. Team also offer telephone appointments for certain conditions or where repeat treatment is required that allows for medication to posted to an address of choice or available for collection at one of our sites.
The team have had a high sickness rate and number of COVID related isolation in the last 12 months. Along with the wider NHS they have found it difficult to recruit, leaving vacancies for consultants and nurses, but they have diversified recruiting speciality doctors and band 5 development nurses (moving to band 6 on completion of 18 month training programme).
Once appointments are full there is a triaged system in place to ensure that the team pick up emergency or high risk individuals (e.g. severe pain, symptomatic GU, Emergency contraception, PEPSE, Sexual Assault, High risk individuals). Those that are low risk will be signposted to alternative provision within LLR (e.g. GP, Pharmacy or online). It is not our practice to signpost to another sexual health service with the East Midlands region and we will ensure this is shared with staff to avoid this happening in the future.
Learning:
• Online booking service now has a new message to make it clearer when no appointments are available.
• Staff member received additional training as well as receiving regular assessment by her line manager.
• Concern shared with the wider team.
•Team have recruited 2 new staff to assist with the telephones to support with answering calls to help with the waiting times.
Formal Complaint Integrated Sexual Health Services (ISHS)
Quarter 4 2021/22
Concern:
Service user experienced extreme difficulty in contacting the service to make an appointment, long waits to get through, being directed to website to book an appointment which had already been attempted. Staff are unhelpful. Service user unhappy to have received a letter from the Trust Security Lead.
Response:
Team apologised for the difficulties experienced. Explanation provided that there are only a finite amount of appointments and once these have gone the team is not able to offer an appointment until more become available which is the reason why the team may ask to call back another day. The team has tried to diversify the service to increase capacity through online services such as STI testing, oral contraception and some treatments which can be posted to individual’s home or location of their choice.
With regards to the staff member, the service lead apologised for how the receptionist came across on the day and that the manner and tone were not supportive and appeared robotic in nature.
Service lead acknowledged that a letter was sent as a result of service user’s behaviour towards the receptionist. Whilst the team appreciate that service user was not happy with the letter received and that as stated service user’s behaviour was out of frustration from his experience and that he did not feel that he should have received a letter of this nature. Staff are encouraged to report where they feel they have experienced verbal or physical abuse or feel threatened and as a result the Trust will send letters to advise service users that this is not acceptable and will not be tolerated. On this occasion, following the incident, the Trust Security Lead, felt that this had occurred and service user’s behaviour towards the receptionist was not deemed acceptable which resulted in the letter being sent. Team were sorry for how the letter has made service user feel but we are unable to apologise for sending the letter or revoke this.
Learning:
To improve online booking system by changing the message to be clearer to advise when there are no appointments available. Line manager to be alerted to concern and asked to monitor staff member by listening into calls and arrangements to be made for staff member to re-attend the services customer service training as well as complete a reflection with her line manager to show growth and learning. Concerns to also be shared with the wider customer service team within ISHS for wider learning. Explanation provided that it is not possible to monitor calls as this is not the current policy.
PALS Concerns Haywood Hospital Ward 1/Specialist Pelvic Health Team (SPHT)
Quarter 1 2022/23
Concern:
A relative of a service user raised concerns that her father had been discharged from Haywood Hospital and no referral had been made to the Specialist Pelvic Health Team (SPHT), despite the ward stating this had been completed. The relative contacted the SPHT several months later to follow up the referral, however, she was informed no referral had been received.
Response:
The response from the ward was that a referral had been completed and it was later identified that the same form is used for both supply of products and referral for an assessment. For a referral there is an additional box to complete which wasn’t completed on this occasion and led to relatives having to follow up the referral which caused delays.
Learning:
A meeting was held between the Matron at Haywood Hospital and the Specialist Pelvic Health Team and it was agreed to improve communication between the two services to avoid further issues and for a quality visit to be undertaken to identify if any improvements can be made. A quality visit will be completed for the Specialist Pelvic Health Team which will be led by our Chief Nurse, to identify if a new process is required.
PALS Concern Podiatry Service
Quarter 1 2022/23
Concern:
Service user has not been receiving notifications of their appointments and has identified that sometimes appointments are sent by email which appear in ‘spam’ rather than ‘inbox’ and on occasion appointments details have not been shared with the service user causing this to result in a ‘Did Not Attend’ (DNA) and discharged from the service.
Response:
Apologies were provided and it was explained that emails arriving in ‘spam’ can be due to a person’s email settings and how the content of an email can pick up sensitive words where it will be relayed to ‘spam’ rather than inbox. During the review it was identified that the clinician had sent two appointments by letter to the home address. This was documented on the clinical system; however there was no evidence of the letter attached to the records. The service user had advised that these letters had not been received.
Learning:
All staff have been reminded that when a service user does not attend an appointment, this should be followed up with a telephone call to identify the reason and to arrange a further appointment. If letters are being sent to service users, the letters should always be uploaded to the clinical system as good record keeping. It should be advised that if a person DNA’s three times, they would be discharged from the service and a new referral from the GP would be required.
PALS Concern Minor Injuries Unit
Quarter 4 2021/22
Concern:
A service user who had contacted the Minor Injuries Unit (MIU) prior to attending was informed that the service was open. However, on arrival at 4.40pm (shortly after the telephone conversation), was informed that the service was closed. The Service user was redirected to a different hospital. The opening times on the internet stated that they were open until 8pm.
Response:
The Minor Injuries Unit is open from 9am-5pm seven days per week, however, the last admission is 4.30pm to enable triage prior to assessment/treatment. It was identified that, when making contact to check opening times, the service user spoke with the main hospital reception, not the MIU reception and that the information provided was inaccurate.
On review of the website the opening hours had been updated to reflect the current opening hours. However, ‘Google’ still stated the previous opening hours.
Learning:
The main hospital reception staff have been informed that any enquiries relating to the Minor Injuries Unit should be forwarded to the MIU reception desk to ensure that accurate information is provided and they have been informed of the correct opening hours. The Communications Team contacted Google to request that the opening hours are updated.
A review will be completed to identify how we can record how many people are redirected to the other services due to capacity or service opening times. This will identify the current demand of the service. The impact of the reduced opening hours will also be reviewed.