Complaints Handling Policy
Issue Number: Approved by: Issue Date:
Clinical Governance December 2006
18/01/07 and Social
Care & Health
Originated by: Agreed by: Review Date:
and Quality Or on receipt of
The purpose of the Complaints Handling Policy and Procedure is to:
Alert the PCT to conditions of risk or poor quality which by suitable early management and
remedial action can prevent complaints and adverse events occurring in the future.
Fulfil the PCT‟s obligations to manage patient complaints under the NHS (Complaints)
Regulations 2004 as amended by the National Health Service (Complaints) Amendment
Fulfil the PCT‟s obligations to externally and internally report and record patient complaints.
Ensure that the PCT makes a co-ordinated and efficient response to patient complaints in
order to increase patient satisfaction, improve communication and ensure continuing service
Provide a process whereby lessons can be learnt and the risk of future serious complaints is
Provide an early warning of potential for litigation
Proved an early warning of potential risks to patient and staff safety.
Shall apply to all PCT employees and employees providing a service under a service level
agreement within Lewisham PCT and Non-Executive Directors of the Lewisham Primary
Applies to any complaint regarding services provided by Lewisham PCT made by or on
behalf of any patient of Lewisham PCT.
Aims to support the development of appropriate systems and procedures for the
management of complaints in accordance with the NHS (Complaints) Regulations 2004 as
amended by the National Health Service (Complaints) Amendment Regulations 2006 and
best practice in complaints handling.
Aims to support the development of a fair blame culture where complaints are viewed as an
opportunity for learning.
Aims to ensure that staff are aware that patients care should not be adversely affected by
the fact that the patient (or the relative or carer who complains on their behalf) has
The reporting and management of complaints within Lewisham Primary Care Trust is an
essential element of the Risk Management, Controls Assurance and Clinical Governance
The purpose of the complaints handling policy is to:
Alert the PCT to conditions of risk or poor quality which by suitable early management
and remedial action can prevent adverse events and complaints occurring in the future.
Fulfil the PCT‟s obligations to externally report complaints.
Ensure that the PCT makes a co-ordinated and efficient response to all complaints.
Provide a process whereby lessons can be learnt and the risk of future such events and
Provide an early warning of potential for litigation.
The PCT has developed this policy and will conduct complaints reporting, investigation and
management in line with the NHS (Complaints) Amendment Regulations 2006. This Policy
shall apply to all PCT employees and employees providing a service under a service level
agreement within Lewisham PCT and Non-Executive Directors of the Lewisham Primary Care
Trust. It applies to any complaint by any person who is affected by or likely to be affected by
the action, omission or decision of the PCT, and to a complaint by anyone who is receiving, or
has received, NHS treatment or services. There are specific circumstances to which this
procedure does not apply, outlined in section 7 of the 2006 regulations and section 2 of
Appendix 1 of this policy.
This policy is based on the following principles:
That the Policy shall define best practice in the reporting and management of all patient
That complainants are communicated with fully.
That everyone in the Trust is responsible and takes ownership of the reporting and
management of patient complaints.
That the culture of complaints handling within the organisation is seen as positive, supportive
and non-threatening and encourages staff to participate in the investigation and learning from
patient complaints without fear of unfair blame.
That action shall be taken and documented in response to patient complaints.
That staff have adequate knowledge to notify, report, investigate and respond appropriately to
That formal debriefing and feedback to staff and service users, where applicable, involved in
patient complaints be provided.
That learning from complaints shall be shared appropriately in order to maximise the benefits
of the reporting and management processes.
2. THE POLICY
2.1 Policy Statement
The Trust will establish appropriate systems and procedures for the management of
complaints to minimise harm to service users, carers, employees and other stakeholders, to
maximise patient satisfaction and to develop a learning environment. These systems and
procedures will be in accordance with the National Health Service (Complaints) Amendment
Complaint – formal/informal
The NHS Executive has suggested that one definition of a complaint is “An expression of
dissatisfaction that requires a response”. Clearly this is an extremely wide definition and it
is not intended that every minor concern should warrant a full-scale complaints
investigation. Rather, the spirit of the complaints procedure is that front line staff are
empowered to resolve minor comments, grumbles and problems immediately and
informally. This principle is underpinned by the introduction of PALS in its problem-solving
role. The Primary Care Trust will therefore seek to distinguish between requests for
assistance in resolving a perceived problem and an actual/formal complaint. The former will
be dealt with in a flexible manner.
The first stage of the complaints process.
Local resolution aims to resolve complaints quickly and as close to the source of the
complaint as possible using the most appropriate means.
Conciliation is a confidential process that aims to resolve difficulties that have arisen
between a patient and a practitioner at the earliest stage possible.
The second stage of the complaints process.
If a complainant is unhappy with the response to their complaint under the local resolution,
they can ask the Healthcare Commission for an „Independent Review‟ of their case‟.
Patient Advice and Liaison Service (PALS)
PALS is a customer care service and does not replace the complaints procedure but is able
to provide “on the spot” help to sort out any problems and concerns before they become
PALS contact tel: 0800 587 7027
Independent Complaints Advocacy Service (ICAS)
The aim of ICAS is to give independent help and advice to people who wish
to pursue complaints about NHS services. It‟s main goal is to ensure complainants have
access to the support they need to put their concerns forward and navigate the complaints
Local ICAS contact tel: 0845 337 3061
2.3 The Culture
Patient complaints are used to:
improve quality of service user care
reduce the cost of litigation
benefit the service user, staff, the general public and PCT services through the
dissemination of learning from complaints
The 5 main steps to gaining as much good as possible from an otherwise bad experience,
and to enable learning from good outcomes are:
1. Identify and record
3. Investigate for root cause
4. Implement recommendations
5. Disseminate all learning to ensure benefits elsewhere
The PCT will manage complaints within a culture of fair blame, aiming to identify and
address all of the main causal factors, including systems failure, administrative failure and
human error through the process of fundamental (root) cause analysis.
The PCT will ensure that any failing is addressed appropriately and fairly with the aim of
preventing reoccurrence. Unless an individual has acted deliberately to cause harm, or
deliberately and knowingly in breach of policies and/or procedures designed to prevent
harm, or there is a clear case of misconduct, it will not be considered appropriate or fair to
use the PCT disciplinary route against any member of staff involved in a complaint.
Effective complaints handling can only be achieved when staff value complaints as a
positive working tool which support good practice and increase patient safety and patient
All patient complaints will be considered an opportunity for learning with the aim of
improving the quality of patient care, improving the safety of staff, patients and contractors,
and preventing the occurrence of serious adverse incidents.
2.4 Procedural Principles
The primary principle is that all complaints should be dealt with quickly and effectively.
The responsible Service Manager using the PCT online reporting form within the Sentinel
Risk Management System must report all patient complaints. (Please contact Complaints
and Quality Support Manager for information 020 7206 3223).
On receiving a formal complaint you must follow the procedure detailed in appendix 1.
On receiving a complaint, the primary responsibility is to identify and try, where possible, to
resolve the patient‟s concerns.
Until an initial investigation into the circumstances of the complaint takes place an informed
decision cannot be made about the implications. All complaints will require basic initial
investigation and, where necessary, risk assessment.
The extent of further investigation will depend on the assessed severity of the actual
complaint using the risk matrix. See appendices VIII and IX. A fundamental (root) cause
analysis should be undertaken for any serious complaint.
The complaint may also be related to an incident. (See Incident Reporting and
2.5 Complaint Review and Action
An action plan must be developed by the investigating manager or other designated
individual or group, to address the concerns identified following a fundamental cause
analysis of any serious complaint. The action plan must detail a timetable for action,
responsible individuals and/or teams, and a schedule for review.
The Investigating Manager will provide a summary of actions taken following an
investigation to the Complaints Manager. The summary will be prepared taking full account
of duties with regard to confidentiality.
Debriefing and encouraging formal and constructive discussion about complaints will enable
both individuals and the service to learn from complaints.
2.6 Aggregated Data on Complaints
The comprehensive system of reporting and analysing complaints will collect considerable
quantities of useful data. It will act as an early warning system and provide up to date
information on all the PCTs possible liabilities.
The reporting of complaints will enable trends to be identified and reported to relevant
departments, committees and the PCT Board in order that appropriate action may be taken,
learning disseminated and better quality services delivered.
In addition to anonymised aggregated data being made available to individual services, a
quarterly report highlighting causes of complaints and the actions taken or proposed will be
provided to the following groups:
The Clinical Governance Committee
Service Team Leaders and Managers, including Neighbourhood Managers
The Patient Forum
Contracted Services, Staff and the public via the PCT website
In the case of legal action against the PCT by a patient, or other on behalf of a patient, the
Associate Director for Quality should be informed to enable the immediate reporting of the
claim to the NHS Litigation Authority.
Personal details will only be disclosed on a „need to know basis‟, to facilitate the
investigation and management of the complaint.
Where information regarding complaints is to be disseminated for learning purposes, the
information will be carefully anonymised, and where possible and appropriate, aggregated
data used in preference to individual reports.
If the media approaches staff and managers they must seek advice in accordance with the
Communication Guidelines, as contact with the media must be through agreed channels
only. Where appropriate the Chief Executive will ensure that staff and managers are given
instruction and support in handling the media.
Whilst confidentiality is guaranteed within the PCT, there will be occasions, when for legal
reasons, the Trust is required to disclose information to other parties.
ALL reports and statements prepared during the course of an investigation should contain
only factual information and never matters of opinion or conjecture.
2.9 Policy Review
This Policy will be reviewed whenever the NHS complaint regulations change or every 3
years, whichever is soonest, by the Director of Neighbourhoods or Medical Direct (with
responsibility for complaints) and the PCT Board.
2.10 Policy Audit
A Trust-wide audit of compliance and/or quality improvements resulting from this policy will
be undertaken twelve months following the full implementation of this Policy and every
twelve months after that.
The Trust must designate a member of its board of directors to take responsibility for
ensuring compliance with the NHS (Complaints) Amendment Regulations 2006. It is the
responsibility of the director to ensure that action is taken in the light of the outcome of any
All have a responsibility to ensure that:
In any given situation patient, public and staff safety and security is given priority.
That PCT policies and procedures are followed as appropriate. (see appendix X)
That all complaints are reported and managed.
That the PCT learns from its mistakes.
That patient complaints are welcomed as an opportunity to change and to learn and to
improve patient safety, and not to blame colleagues when things go wrong.
Staff have a responsibility to:
Try and resolve patient concerns and queries as they arise
Report any patient complaint, formal or informal, to their line manager.
In the case of a formal complaint, to provide details to enable their line manager to
complete the complaints report in a timely manner, and to take any immediate remedial
Reassure patients that their care will not be adversely affected by their complaint.
Line Managers have a responsibility to:
Ensure that reporting procedures are complied with.
Provide information on support to staff affected by the complaints process.
Undertake a full investigation of any patient complaint, in liaison with other managers
Prepare an action plan to address any concerns identified.
Communicate with the complainant to keep him or her informed of the progress of any
investigation and of the final outcome.
Provide support to any investigating team or officer.
Provide the opportunity for staff to de-brief and feedback on specific complaint that is
documented and retained with the original incident form.
Monitor trends within the area of responsibility
Contribute to dissemination of lessons learned and implement any actions identified to
be their responsibility, or the responsibility of their team.
Service Leads have a responsibility to:
Review monthly all reported complaints within their areas and agree any necessary
actions or improvements required.
Provide feedback on complaints review to the Clinical Governance Committee from their
Investigate serious complaints in liaison with specialist advisors where necessary.
Assess all patient complaints, and where appropriate action plan to address the causal
factors, and to ensure learning is disseminated.
Monitor implementation of the action plan and of lessons learned
Monitor the quality of complaints handling within their service area.
The members of the FLAG have responsibility to:
Encourage a culture of learning from patient complaints.
Encourage a culture of fairness, so that the fundamental causes are addressed.
Act as the point of referral, assessment, and action planning for serious complaints.
Receive referrals where issues have been identified.
Conduct a root cause analysis where appropriate.
Review quarterly analysis of trends and outcomes.
Report to the Clinical Governance Committee.
Maintain clear records for the purpose of effective communication, transparency of the
process, and for accountability.
(see ToR of FLAG Appendix XI)
The Complaints and Quality Support Manager has responsibility to:
Ensure that the PCT is operating in accordance with current NHS (Complaints)
Regulations, guidance and good practice.
Ensure that the PCT communicates with the Healthcare Commission effectively and in a
timely manner with regard to all Independent Review investigations, and other matters
relating to the management of complaints.
Receive and review all patient complaints.
Maintain the complaint management database
Monitor the quality of complaints responses and ensure that they meet national and
Monitor the quality of complaints handling and patient communication relating to
Provide analysis of data and reports to the relevant groups and departments
Provide support to Leads in monitoring improvement actions
Co-ordinate the external reporting requirements
Produce an annual Complaints Report to the Clinical Governance Committee
Monitor complaints for the potential for legal action, and alert the Associate Director of
Quality where legal action is identified as a possibility.
Involve the complainant and seek to determine what they are hoping to achieve.
Ensure that the complainant has the opportunity to understand all possible options for
pursuing the complaint, and the consequences of those options.
Throughout the process review what further action might best resolve the complaint.
Keep the complainant informed.
Maintain a documentary record of the handling and consideration of the complaint.
Be readily accessible to the public and to staff.
Be available to complainants who do not wish to raise their concerns with those directly
involved with their care.
The Director of Neighbourhoods/Medical Director has a responsibility to:
Be the Board level Director with responsibility for complaints.
Ensure that immediate concerns are reported directly to the Chief Executive.
Ensure that the relevant Directors and Senior Managers are kept informed of specific
Ensure investigation into a serious complaint is carried out and reported within the
The Chief Executives Office has a responsibility to:
Manage the interface with the media.
The Clinical Governance Committee has responsibility to:
Monitor the implementation of the Complaints Handling Policy.
Receive complaints reports from FLAG.
Monitor that appropriate action and learning have been taken following
any formal patient complaint.
The Board has responsibility to:
Receive and review the quarterly complaints report.
Ensure that the organisation develops a fair blame, risk aware culture.
Ensure that the organisation develops a culture of reporting and learning from
The Chief Executive has responsibility to:
Receive, review and sign all complaints responses.
The Trust will ensure that the necessary training is provided for staff throughout the Trust to
assist in the implementation of this Policy.
All staff will be educated in the Trust‟s complaints handling procedure as part of their local
induction. The policy requirements and the principles that underpin the Policy will also be
included in on-site training.
Managers and other key personnel will be instructed in investigative practice.
Ongoing support and training will be provided as required by the Complaints Manager and
the Training and Development Department.
The Complaints Manager will maintain a record of training.
The effectiveness of the training programme will be monitored and will be considered
Managers are responsible for ensuring that their staff are aware of this Policy, and that this
information is given to all new staff on induction. In addition managers are responsible for
keeping staff up to date about any changes within the Policy.
Managers will keep evidence of their compliance with the requirements of this section.
Staff are responsible for strictly adhering to this Policy.
See also the NHS (Complaints) Amendment Regulations 2006
The aim of this procedure is to ensure that all complaints are resolved quickly and effectively and that
information gained from them is used to improve our services.
Information on how to make a complaint will be readily available to patients, clients and their relatives and
The procedure will focus on satisfying complainants concerns while being fair to practitioners and staff.
In line with the guidance on the Implementation of the NHS (Complaints) Amendment Regulations 2006,
the procedure in Lewisham Primary Care Trust will only cover Local Resolution.
A complainant may request the Healthcare Commission to conduct an Independent Review of their
complaint if they remain dissatisfied with the outcome of local resolution.
The Health Service Commissioner (Ombudsman) will be able to investigate complaints only after these
stages have been exhausted.
The same procedures must be followed for every complaint. The analysis of each complaint will help to
identify adverse trends and to take action to improve the care provided to patients and clients of Lewisham
Primary Care Trust. Quarterly monitoring reports are presented to the Trust Board.
Advice on managing complaints is available from the Complaints Manager.
A complaint can only be investigated once, under the Principle Regulations.
2. What is NOT covered by this Procedure
Staff concerns / complaints or incidents
Complaints about private treatment unless it has been commissioned by the PCT
Complaints made by other NHS Bodies or Independent Bodies
Complaints which are being or have been investigated by the Health Service Commissioner
Complaints arising out of the Trust‟s alleged failure to comply with a data subject request under the
Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000
Events requiring investigation by a professional disciplinary body
Events about which legal action is already being taken by the complainant
The disciplinary procedure but if the investigation of a complaint identifies the need for disciplinary
action then the normal disciplinary procedure will be followed.
A complaint that relates to any scheme established under section 10 (superannuation of persons
engaged in health services etc) or section 24 compensation for loss of office etc) of the Superannuation
Act 1972 (a), or the administration of those schemes.
3. Who can complain?
Anyone who is receiving, or has received, NHS treatment or services.
Any person who is affected by or likely to be affected by the action, omission or decision of the PCT.
If a patient or user is unable to complain themselves, then someone else, usually a relative or close friend,
can complain on their behalf if they have the consent of the patient or user.
It is important that complaints are made as soon as possible after the event occurs. Usually, complaints
can only be investigated if they are:
Made within 6 months of the event; or
Made within 6 months of the complainant realising that they had something to complain about.
There is discretion to extend the time limits, where it would be unreasonable in the circumstances of a
particular case for the complaint to have been made earlier.
When a complaint is made outside the time limits, it will be for the Complaints Manager (with advice from
the Associate Director for Quality or Director of Neighbourhoods/Medical Director if necessary) to take
responsibility for considering an extension of the time limit.
5. How should a Complaint be made?
Complaints may be made verbally or in writing.
A Complaint Form is available from the Complaints & Quality Support Manager for complainants to use
if they wish.
If the complaint is made verbally, then a written record of the complaint must be made and the record
must be sent to the complainant for signature as a true record, and returned (see paragraph 8.3).
If the complaint is made verbally, then a written record of the complaint must be made It must include
the name of the complainant, the subject matter of the complaint and the date on which it was made.
If the complaint is made in writing a record should be made of the date on which it is received.
All complaints, verbal and written, must be reported to the Complaints Manager.
Complaints may be made to any officer of the PCT.
Any person who is affected by or likely to be affected by the action, omission or decision of the PCT may
make a complaint. Where that person is a patient, the complaint may be made on their behalf by a
representative if they have given them their express permission to do so.
Written information should be made available to patients and clients on the PCT‟s Complaints procedure.
A patients‟ complaint information leaflet is available.
Complainants may also seek support in making their complaint from the Independent Complaints Advocacy
Service (ICAS) or from the Lewisham PCT Patient Advice and Liaison Service (PALS). Information on both
these services are included in the PCT complaints information leaflet which is available on the intranet.
5.1 Comments\Compliments\Suggestion Cards:
Comments and compliments should receive an informal written response from the Service Manager and a
copy sent to the Complaints Manager. Anonymised compliments will be published on the PCT website.
Comments may be used to inform service improvements and development. The card should not be used
for making complaints.
5.2 The patient without capacity
Where a patient lacks capacity, a complaint may be made by another individual on his or her behalf.
Lack of capacity will exist where the patient is not capable of knowing, retaining or understanding
information in order to make a decision with regard to the particular circumstances complained about. An
apparent lack of capacity to give consent to another complaining on the patient‟s behalf may in fact be the
result of communication difficulties rather than genuine incapacity.
The Service Manager and Complaint Manager will take steps to reassure themselves that the patient does
lack capacity before accepting a complaint from a representative which may involve the release of
confidential information about the patient or their care. This may include the involvement of appropriate
colleagues in making such assessments of incapacity, such as specialist learning disability teams and
speech and language therapists, unless the urgency of the patient‟s situation prevents this. If at all
possible, the patient should be assisted to make and communicate their own decision, for example by
providing information in non-verbal ways where appropriate. A complaint may be investigated if it is
considered to be in the best interests of the individual to do so.
From April 2007 an individual may appoint a Lasting Power of Attorney (LPA) to make decisions on their
behalf. In such a case, advise should be sought as to the scope an extend of the LPA and of the validity.¹
Confidentiality must be safeguarded and the principles of the Data Protection Act 1998 considered at all
5.3 Deceased Patients
If the patient is deceased, consideration should be given as to whether it is in the best interests to
investigate. An investigation may highlight service failures or systems failures, it may satisfy bereaved
relatives, and it may prevent similar problems from happening to another patient. Consideration should
also be given as to whether the complainant has a right of access to information relating to the deceased
person under the law (Access to Health Records Act 1990).
Where there is doubt, advice should be sought from the Complaints Manager, the Associate Director for
Quality, the Director of Neighbourhoods/Medical Director or the Shared Service Information Department.
6. Request for Medical Records
Where medical records have been requested the Complaints Manager should be informed immediately.
See Data Protection Act 1998, Access to Health Records Act 1990. Advice regarding the statutory
requirements for release of Health Records may be obtained from the Shared Service Information
Department, from the Complaints Manager, or from the Associate Director for Quality.
7. Staff complaints about Patient Care
If staff wish to use the complaints procedure to express concerns about the treatment of patients and
standards of care then the same process will be followed. In such cases, staff should always ensure that
they have the consent of the patient to make a complaint on their behalf.
8. First Stage – Local Resolution (Also See Flow Chart - Appendix II and Appendix III -
The aim of the procedure is to ensure that all complaints are resolved quickly and effectively.
The notes below and the attached flow chart are to be used when handling any complaint. Special
attention should be given to people who may need advice and support in using the complaints procedure.
8.1 Initial Response
All complaints whether written or verbal should receive the same consideration and sensitive treatment.
Making early personal contact with the complainant can assist in getting a full picture, demonstrate a rapid
response and provide an opportunity to offer an apology and explanation. Primarily, care should be taken
to ensure that the immediate health care needs of the patient are met.
It may be possible for staff to resolve the complaint at this stage and help initiate service improvement.
There are various simple ways by which this might be achieved such as:
Solving the complaint „on the spot‟ if possible.
Discussing the problem with the patient and what might be done about it.
Apologising for delays
Empathising with the patient.
Informal complaints should be logged by the service/department so that local trends can be identified and
appropriate action taken. All formal complaints received must be entered on the Sentinel complaints
database or passed onto the Complaints Manager for logging if staff do not have access to it.
The person complaining should be advised that they have the right to raise the matter with the Chief
Executive and or the PCT Complaints Manager.
If the complaint would be more appropriately dealt with by another local organisation, the complainant
should be informed. If they give their permission, the complaint will be re-directed and the complainant
informed that this has been done in the acknowledgement letter.
8.2 Investigation and/or conciliation
On many occasions the complaint will be resolved following this initial response. On other occasions
further investigation may be necessary.
The level and type of investigation should be appropriate to the complaint.
Every aspect of the complaint should be investigated with the intention being to respond fully to all
Other staff and services should be involved where necessary, with information shared on a need to know
basis only, i.e. with due regard for patient and staff confidentiality.
The PCT‟s Conciliation Service should be involved where the investigating manager, staff involved,
complainant and the Conciliator feel it is appropriate, and that it would assist in the satisfactory resolution of
Where there is a dispute with regard to clinical judgement, the clinician should be offered the opportunity to
provide evidence to support their judgement. Where possible, the complainant should be offered an
opinion from an independent source.
8.3 The NHS Procedure
Refer to flow chart and detailed process notes Appendix II & III.
Process Time Scale
Informal Complaints Dealt with on the spot.
Acknowledgement sent to complainant Within 2 working days.
Investigation completed and final response Within 25 working days.
If it is not possible to complete the complaint within 25 working days, a letter of
explanation will be sent to the complainant by the Complaints Manager at 25 working
days, and then every 10 days thereafter until completion. It is therefore essential that
the investigating officer informs the Complaints Team if for any reason, they are
unable to complete the investigation within the timescales, in order that we can seek
the complainant’s permission and explain the reason for the delay.
The first letter acknowledging the complaint must be signed by the Chief Executive (use LH1) and sent
within 2 working days by the manager who first received the complaint, a copy of the complaint leaflet
should be enclosed.
If the complaint was made orally, the acknowledgement must be accompanied by the written record made
at the time the complaint was made with an invitation to the complainant to sign and return it.
A Senior Manager should oversee all complaints relating to the service that they manage and will be
responsible for ensuring that each complaint is investigated at the appropriate level. An initial assessment
as to the seriousness of the complaint should be made. It may be helpful to use the risk matrix (Appendix
VIII and IX) to make an assessment of risk presented by the complaint. Factors to consider should include
harm to the patient(s), harm to staff, risk to the service, financial risk and risk to the reputation of staff, the
service and the organisation. It should also be considered whether many complaints have been received
about the same problem. Where the complaint is of a serious nature (a significant or high risk) it should be
brought to the attention of the Director responsible for that service.
The Complaints Manager should immediately be informed (where staff do not have access to the Sentinel
database) that you have received a complaint and sent all details. The complaints monitoring form should
be sent to the Complaints Manager at the same time and must provide information on:
date complaint received
The original complaint letter, comment card or file note detailing the content of complaint should always be
sent to the Complaints Manager while you retain a copy.
The investigating manager dealing with the complaint should make personal contact with the complainant
as soon as possible.
8.4 Recording the complaint investigation
A clear written record should be maintained of the investigation detailing discussions with staff and
complainant, covering what was asked and the responses given.
In the event of the complainant making direct contact with the Chief Executive’s office, this will help to
ensure that the CEO is aware of the complaint.
Statements should record the subject/purpose of the statement, who the statement is by, their job title, their
work address and the date the statement was made.
The statement must contain only the known facts; opinions must not be recorded.
The statement must be signed by the author and dated.
A member of staff may be accompanied by a companion/Trade Union Representative in the following
If requiring help with writing a statement
During interview/s as part of the investigation
If police are involved and wish to interview staff a solicitor either via a trade union or the Trust solicitor may
represent the member of staff.
Managers have a responsibility to support staff during this process.
Where the police wish to interview a service user the Responsible Medical Officer must be involved.
File notes should record the subject/purpose of the file note. The name, job title and work address of the
person making the file note and the date the note was made.
Please note that all statements, file notes, correspondence and other written information
including e-mails are disclosable2 in a claim for clinical negligence. Please ensure that all
such information is full, accurate, contemporaneous and factual.
8.5 The response
The investigating manager will produce a written report and draft response in „plain English‟ on behalf of
the Chief Executive which should always contain the following points:
A formal apology
Ensure all issues of the complaint have been addressed
Where appropriate, an explanation of what went wrong and an outline of the action that has been
taken to try to prevent future occurrences of the same problem3
The investigating manager should send the draft response and report to the Manager of the Service. Once
the Manager of the Service has agreed the letter of response, he/she will send it to the Complaints
Manager together with the report. The Complaints Manager will then send the response to the Chief
Executive for approval and signature.
Once the Chief Executive has signed the letter, it is sent to the complainant. A copy of the letter will be
retained by the Complaints Manager and kept in the Master file. A copy of the letter will also be sent to the
investigating manager for their file. The letter sent to the complainant by the Chief Executive will formally
close the complaint and will include information on how to request an Independent Review (IR).
8.6 Learning from complaints
Lewisham Primary Care Trust considers that complaints are an important measure of people‟s satisfaction
with the NHS. The PCT recognises that correct handling of complaints can result in both increased patient
satisfaction and an improvement in the quality of care for future patients. Patients, their relatives and carers
Except where made in direct contemplation of legal proceedings.
This may not be appropriate where a complaint has been made due to a misconception regarding the service
complained about, in which case, the response should address the misconception and be used as an opportunity to
inform the complainant.
are therefore encouraged by the Primary Care Trust to make their concerns known in order that these may
be responded to appropriately.
The major benefits of a robust complaints procedure are:
Prevention of mistakes and learning from them will reduce complaints.
Fewer formal complaints will speed up the overall process for others
An action plan should be put into place for any improvements that are identified. This should also include
risks reduced as a result of complaints. The plan will be monitored by the manager for the service and a 3
monthly progress report provided for the Complaints Manager. The Complaints Manager will produce a
quarterly report and trend analysis which will be presented to FLAG, the Clinical Governance Committee
and the PCT Trust Board. The report will be shared with Service Managers who will cascade the
information to their staff to ensure appropriate changes to services are made an acted upon.
The For Learning and Action Group will also review complaints received and actions arising at their
quarterly meetings. Recommendations will be made by the group as necessary to improve complaints
handling and improve service delivery.
Lessons learned from complaints will be used in an anonymised form to inform other staff and services
about good complaints handling. Training will be provided for frontline staff who often face complainants
and managers who have the responsibility for conducting investigations. This will help change staff
attitudes to complaints so they are valued as a way of driving service improvement. By improving the
patient experience in the way staff deal with them, fewer complaints will be made. All new staff have a
compulsory complaints handling session during their induction training.
Copies of all correspondence and associated file notes should be kept to ensure that all issues are dealt
with appropriately and lessons are learned. All original documents must be sent to the Complaints
Manager who will retain them as part of the Master File.
8.7 Closing a complaint
Once all letters are sent, the monitoring form will be completed and closed by the Complaints Manager
noting the action taken and the response made. The Complaints Manager will also close the complaint on
the complaints database.
The complaints procedure should cease if the complainant explicitly indicates an intention to take legal
action and claim for negligence. Advice should be sought from the Complaints and Quality Support
Manager or Associate Director for Quality.
The complaint should be closed if, as a result of its investigation, disciplinary proceedings are begun
against a member of staff. See appendix VII.
9 Vexatious Complaints
Staff are trained to deal sympathetically with patients, assisting them through the complaints process.
Exceptionally, there are occasions when the complainant persists with a complaint when there is nothing
more that can be reasonably achieved in respect of the problem raised.
The decision to end a complaint as vexatious rests solely with the Chief Executive who must be satisfied
that that the PCT has made every effort to answer the complaint appropriately and the complainant is
exhibiting one or more of the following:
Behaving in a manner which could be judged as unfair harassment
Rejecting accurate documented evidence
Refusing to define a complaint that can be investigated
Continuing to evolve the content of the complaint to prolong the complaint
Has threatened or used actual physical violence or been personally abusive or verbally aggressive on
more than one occasion towards staff dealing with their complaint or their families or associates. Staff
should document all incidents of harassment.
In extreme cases, Lewisham PCT will reserve the right to take legal action against the complainant.
Where the Chief Executive has decided that a complainant is vexatious, a letter will be written to patient
informing them that:
The reply to the complaint has fully responded to the points raised
Every effort has been made to try to resolve the complaint
There is nothing more that can be added and the correspondence is now at an end
Future letters will be acknowledged but not answered.
They have the right to take their complaint to the Healthcare Commission.
10 Primary Care Complaints for Family Health Service Practitioners
(General Practitioners and Dentists)
There is separate guidance policy for FHS practitioners entitled „Complaints in Primary Care‟. This is
available from the complaints department.
11 Complaints Received from Members of Parliament
The same process is followed for complaints from patients sent through their MPs although there are a
number of additional steps involved. The response to the complaint is always sent from the Chief Executive
and the Complaints Manager to the MP and not to the complainant unless the MP stipulates otherwise.
If a letter is received from an MP with a complaint about their constituent‟s care, please send it
IMMEDIATELY to the Chief Executive‟s office or the Complaints Manager.
12 Procedure for dealing with Complaints – Health and Local Authority
There is a duty to co-operate between NHS bodies and local authorities where a complaint concerns more
than one organisation. In these circumstances, discussions should take place between the relevant
Complaints Managers from each organisation, as to whether the issues should be handled separately or as
a joint response. In the case of a joint response, one Manager will be nominated to co-ordinate the
investigation(s), and to be the main point of contact for the complainant during the investigation.
Complaints relating to NHS bodies will be dealt with in accordance with the Principal Regulations, as
amended by the 2006 Regulations. For those complaints relating to local authorities, these will be handled
by them under the Social Services Complaints Regulations. However, where complaints concern both NHS
and Local Authority Services, where the complainant so wishes, the organisations involved must co-operate
to deal with part of the complaint that relates to them and provide a co-ordinated response to the complaint.
The PCT‟s Complaints Manager must notify the complainant as detailed below:
12.1 Complaints Procedure – Health and Local Authority (Social Care)
Complaints Manager - receives a
complaint by letter, email, telephone or
If the complaint relates to (1), (2) or (3) the
following will be applied:
NHS only (2) Local Authority
Complaint will be handled NHS & Local Authority Complaint will be handled under the
under the NHS Complaints Complaint involves both NHS and Local Social Services Complaints
Procedure Authority Services Regulations
Complainant’s Consent Complainant’s
If a complaint involves both NHS and Local Must obtain the complainant‟s
Authority Services, the Complaints Manager will consent to send a copy to the
need to obtain the complainant‟s consent within 10 other agency‟s Complaints
working days of receipt of the complaint. Manager within 5 working
Consent not received Consent received
Inform complainant that they are unable to Forward the complaint to Local Authority
deal with the complaint and advise them of as soon as possible
the contact details of the relevant Local
Consent not received Consent received
Inform complainant that they are unable Forward the complaint to Local
to deal with the complaint and advise Authority as soon as possible
them of the contact details of the
relevant Local Authority
12.2 Consent and Patient Confidentiality
In transferring complaints between agencies (including the Healthcare Commission), it is particularly
important to ensure that patient confidentiality is maintained at all times. Consent to share information
should be obtained in writing wherever possible. If this is not possible, verbal consent should be logged
and a copy sent to the complainant.
13 Second Stage – Independent Review (IR)
When a complainant is not satisfied with the response to his/her complaint, he/she may request an
The Healthcare Commission is responsible for reviewing formal complaints about the NHS that have not
been resolved under Local Resolution. Complainants will be advised in the final response from the PCT
that, should they remain dissatisfied with the response they have received, they have the right to ask the
Healthcare Commission for an Independent Review of their complaint. They will further be advised to make
the request direct to the Healthcare Commission within six months of receiving of receiving their final
14 Letters of Thanks/Compliments Procedure
The aim of this procedure is to ensure that all letters of thanks and appreciation are made known to people
in the Trust and that the information is included in the quarterly monitoring reports to the Trust Board.
It is important for the Chief Executive via the Complaints and Quality Support Manager to receive copies of
letters of thanks concerning PCT services. These letters and cards indicate how highly our services are
regarded and the value placed on them by patients, clients and their relatives and carers.
Details of all letters of thanks are included on the PCT website.
Good practice identified will be shared across Directorates and teams.
15 Performance Management – Data Collection
Quarterly Reports will be produced for the Trust Board, FLAG and the Clinical Governance Committee for
An annual report will be provided for the Clinical Governance Committee, who will:
Monitor the implementation of this policy and procedure
Monitor arrangements for local complaints handling
Monitor the quality of local complaints handling
Review trends in complaints and monitor that appropriate action has been taken
Consider any lessons that can be learnt from complaints and monitor that this information has been
The annual report will also be provided to:
The London Health Authority and
The Healthcare Commission.
All complaints acknowledged within 2 working days
The majority (80%) of complaints resolved in 25 working days
All complaints resolved within 30 working days.
In exceptional circumstances where this cannot be achieved, an explanation and update will be provided to
the The 2006 Regulations stipulate that the 25 day deadline can be extended, but only by agreement with
the complainant. In cases where the Investigating Manager considers it appropriate to seek an extension
of the complainant every 10 working days by the Complaints and Quality Support Manager. time limit i.e.
because of the complexity of the complaint, they should contact the complainant to invite their agreement,
explaining the reasons for the request. It is therefore important the Complaints Manger is kept informed
about potential delays.
Managers will provide quarterly updates to the Complaints manager on the implementation of agreed
actions/recommendations following complaints.
Lewisham Primary Care Trust
COMPLAINTS FLOW CHART
Verbal – try to obtain in writing if possible
Independent Complaints Advocacy Service
Send proforma acknowledgement
letter within 2 working days from
receipt of complaint
Send copy of:
Complaints monitoring form
Details of the complaint
To the Complaints Manager at Cantilever House
Register the complaint on the Sentinel Database
All complaints seen by Chief Executive
Investigation not completed 25 working days
Complaints Manager will contact complainant
every 10 days and record dates of contact
Investigation completed in 25 working days Investigation completed 35 working days
Full written response to complainant Full written response to complainant
Complete monitoring form Complete monitoring form
Send copy of complete file to Complaints Send copy of complete file to Complaints
Investigation not completed in 35 working days
Complaints Manager will contact complainant
every 10 days and record dates of contact
Full written response to complainant
Complete monitoring form
Send copy of complete file to Complaints
Final closing letter from Chief Executive
formally closing the complaint
The Complaints Manager will send the final letter, signed by the Chief Executive, and will formally close all complaints. (NHSE
If the complainant is not satisfied they can request further investigation at Local Level or an Independent Review from the
Healthcare Commission. Information about the Independent Review is provided in the Chief Executive letter. Advice available from
the Complaints Manager, Cantilever House.
Handling complaints - Roles
Service Department Manager
On the day the complaint is received:
Complete a monitoring form.
Send the proforma acknowledgement letter (LH1) to the person who has complained.
Send copies of the file including details of the complaint/the complaint letter, a copy of the
acknowledgement letter and a copy of the monitoring form to the Complaints Manager who will maintain the
The complainant will sometimes contact the CEO directly on receipt of the acknowledgement letter.
Therefore, the Chief Executive will read the master file for her information.
It is good practice for the investigating manager to make early contact with the complainant. It is
recommended that direct contact be made, followed by a letter.
Keep a file note on all discussions, telephone conversations and interviews with staff and complainant.
On resolution of the complaint, the Investigating Manager should produce a report and draft response on
behalf of the Chief Executive and send to the manager of the service for their agreement. The response
should confirm the outcome, the agreed action, explanation and apology.
The manager of the service should make any necessary adjustments to the draft response and send to the
The Complaints Manager will forward the response to the Chief Executive for approval and signature
On completion of the complaints process, the Complaints Manager will complete the monitoring form and
close the complaint on the complaints database.
Copies of correspondence and all documents relating to the complaint must always be copied to the
Advice on all aspects of the Complaints Procedure is available from the Complaints Manager, who can also
support you in writing a final letter.
Complaints Monitoring Form
Name of complainant_______________________________________________________________________________________
_____________________________________________ Tel No: ____________________________________________________
Date received_____________ Date acknowledged____________ Ethnic Group Recorded *? Y/N If Yes, specify______________
Name of Investigating Manager and contact details
Name & Contact Details of others involved in investigating/processing complaint
Nature of main complaint as expressed by the complainant
Code Please tick Code Please tick one only
01 Discharge and Transfer arrangements 11 Patients Property
02 Aids & Appliances, Equipment, 17 Discrimination (e.g. racial,
Premises (including access) cultural, gender, age & religion)
03 Appointments Delay/Cancellation 05 Staff Attitude
07 Communication 19 Transport
15 Health Records (including medical) 22 Hotel Services
09 Complaints Handling 23 Other:
06 Direct Care/Clinical Care a) Violence/Assault
08 Consent to Treatment b) administration
10 Patients Privacy & Dignity including c) Interpreting Service
confidentiality and Patient status
16 Failure to follow agreed procedures
Tick date Tick Date
Complaint passed on for investigation Investigation completed
Complainant visited Complainant informed of outcome
Meeting arranged with complainant
Please indicate the main actions resulting from the investigation of the complaint (tick any that apply)
Apology given although complaint unfounded Environment improved
Apology given Recommendation for action sent to Board Member
Procedure to be changed Staff to receive training
New Procedure to be introduced Staff disciplined
Information leaflet to be produced Other action, please specify
Information leaflet to be amended
Now send this form and a copy of All correspondence including the original complaint or a report if a written complaint to The Office of the PCT
Complaints Department at Cantilever House.
Please ensure you have file copies of all the information relating to the complaint, including a copy of this form.
*Record ‘Yes’ only where your Department is recording this information according to the National 16 + 1 categories.
Definition of Category of Patient Complaints.
Transfer/Discharge Arrangements - component of the complaint relates to services, waiting times or delay around the discharge
or transfer of a patient from hospital or from care, includes bereavement arrangement and management. Also relates to transf er
between Lewisham PCT Services e.g. Health Visitor to School Nurse.
Aids and appliances, Equipment, Premises (including Access) - an element of the complaint relates to the environment of
care, adequacy of facilities, timeliness or quality of support services. Any part of Lewisham PCT‟s facilities, aids, appliances,
equipment or complaints arising from the environment which includes any difficulties in accessing premises and facilities within.
Appointment Delays/Cancellation - the component of the complaint relates to not sending, or delays in appointment being
offered, not responding or delayed response to messages or to correspondence or any errors in administration.
Cancellation - the complaint relates to the cancelling of a service, appointment or visit regardless of who may have cancelled it.
Waiting Times - relates to time waiting to get an appointment, to receive a visit or to access a service. This can also relate to time
spent waiting for continuation of care once in contact with the service.
Communication - the component of the complaint relates to mis-information, lack of information or lack of timely information from
any staff member; relates specifically to the content of communication, the presence-absence of communication or to the means of
communication. This should also cover lack of appropriate translation or interpretation of information.
Personal Records including medical and/or complaints - an element of the complaint relates to the ability of the client or his/her
carer to access their records, the contents of their records, the loss of records, or any breech of confidentiality in any form whether
verbal or written.
Complaints handling - Anything to do with the way the complaint has been handled. To be counted as a separate complaint from
the original one.
Direct Care/clinical care - an element of the complaint relates to the content or nature of care provided by direct care staff
whether they be medical, nursing, chiropody or therapy.
Consent to treatment - (Formal Consent) an element of the complaint relates to patients consent to treatment, medical, nursing
or therapy. e.g. Consent for immunisation, school medicals, and consent to therapy treatments.
Patients Privacy and Dignity - The component of the complaint relates to not ensuring patients privacy and dignity as defined by
the patient. This includes issues of Patient Confidentiality and status.
Failure to follow agreed procedures - An element of the complaint relates to specifically to failure to follow or inapt agreed
National or local procedures.
Patients Property - The component of the complaint relates to any loss or damage to patients property.
Discrimination (e.g. Race,culture, gender, age and religion) - Any complaint whereby any employee of the Trust is accused of
any form of discrimination towards a staff/patient/client/relative or any member of the public in contact with Lewisham PCT.
Staff Attitude - the component of a complaint refers to the attitude of one or more staff members e.g. rudeness, flippancy,
generalised complaints about the manner of communication.
Transport - the component of the complaint relates any aspect of transport provided by Lewisham PCT.
Hotel Services, includes - Catering, Portering, Security, Domestic, Car Parking, Stores/Supplies, and Telecommunications.
Violence/Assault - any complaint whereby any employee of Lewisham Primary Care Trust is accused of assaulting or otherwise
harming a patient, client or relative. Complaints covering members of the public using our buildings and assaulting either
staff/patient/client or another member of the public should also be included.
Administration/Handling not included elsewhere - the component of the complaint relates to losing notes, not responding to
correspondence or any errors in administration. It does not only relate to clerical staff alone but to any part of Lewisham PCT.
Interpreting Service - Specific complaints which relate to this service.
STAFF/CUSTOMER FEEDBACK FORM
Here at Lewisham PCT we welcome your feedback. This comment card will help us
collect any comments or suggestions you may have about our services and the
treatment you have received.
However, if you wish to make a complaint about the treatment you have
received, please contact reception who will try to resolve it for you. If you still
wish to make an official complaint you should not use this form. Instead, you
need to write to the PCT Complaints Manager at the Trust Headquarters,
Cantilever House, Eltham Road, Lee Green, SE12 8RN.
Your comments will help us to monitor the quality of our services and allow us to
make improvements where necessary.
Please help us by completing this comment card and placing it in the box provided at
COMMENTS AND SUGGESTIONS
Name of Clinic/Health Centre and service used: __________________________
If you would like a response, please Office use:
enter your details below. You can
stay anonymous if you wish.
Name: ________________________ Response by: __________________
Address:_______________________ Job title/department: _____________
______________________________ Date: _________________________
Management action in the case of an investigation leading to suspension of/or disciplinary
action against a member of staff.
Suspension is a neutral act which removes an individual from the situation while an investigation
is carried out. It serves to protect both the service users and the staff member.
The NHS Complaints process should continue during the period of the investigation. The
complainant should continue to be informed every 10 days of the progress of the investigation as
set out in the Trust‟s Complaints Policy.
If, as a result of the investigation, a decision is made to invoke the Trust‟s Disciplinary Procedure
the Complaint should be closed.
The complainant should be informed that this decision has been taken and a copy of the closing
letter sent to the Complainant and the Complaints Manager as required by the Complaints Policy.
The NHS Ombudsman also considers that it is good practice to inform the complainant of the
outcome of the disciplinary action.
This should have due regard for the confidentiality of the staff member and should not include any
detail of hearings.
Risk Impact Matrix
Impact level Insignificant Minor Moderate Major Catastrophic
Financial Up to £1,000 £1k-5k £5k-£10k £300k £1M
5% project budget 10% project budget
Injury Near miss Verbal abuse Over 3 day absence or Death of patient Deaths of patients
Up to 3 days absence additional hospital stay. (depends on (depends on
RIDDOR reportable circumstances) circumstances)
accident Permanent disability Multiple deaths
Long term recovery Hostage
Legal Early compromise Improvement notice Prohibition notice Criminal prosecution
agreement with full Civil action Prosecution – some – no defence
disclaimer Industrial tribunal defence Executive director
Reputation Local press adverse National press mention Commons select
comments M.P. interest committee
Malicious negative appearance
rumour National press
M.P. negative interest
Quality Failure to meet internal Repeated failure to Intermittent failure to Sustained failure to
And standards meet internal standards meet professional meet national
Performance Failure to meet national standards and/or professional
performance statutory requirements standards and/or
Qualitative Risk Assessment Matrix
Level of Risk Rating
LIKELIHOOD/PROBABILITY OF REPEAT
CLASS OF Rare Unlikely Possible Likely Almost
INCIDENT: 20% 60% 90% Certain
CONSEQUENCES/ chance chance chance
1 2 3 4 5
1 – Insignificant 1 2 3 4 5
2 – Minor 2 4 6 8 10
3 – Moderate 3 6 9 12 15
4 – Major 4 8 12 16 20
5 – Catastrophic 5 10 15 20 25
GRADE OF INCIDENT
1-3 Low Risk: To be brought to the attention of the
Manage by routine procedures
4-6 Moderate Risk: To be brought to the attention of the
Department/Team Leader. Specific responsibility for risk
assessment and action planning must be allocated
to a named person. Deadline for completion will usually be within
6 to 12 months and will depend on the availability of resources.
8-12 Significant Risk: Urgent attention required. To be brought to the
attention of the responsible Director. Within one month of
identification appropriate action must be agreed.
The deadline for implementation and reassessment will normally
be no later than 6 months from identification.
15-25 High Risk: Immediate action required. To be brought to the
attention of the PCT Board and Risk Committee/Clinical
Governance Committee. A Director must be informed and he/she
will take responsibility for immediately planning action.
Policies and Procedures
Reference may need to be made to the following Policies or Procedures, to establish
whether further immediate action needs to be taken or if any other people require
Major Incident Policy
Directions on work to tackle violence against staff and professional who
work in or provide services to the NHS (See Appendix 6)
Child Protection Procedures
Personal Safety Policy
Incident Reporting and Management Policy
Claims Handling Policy
Whistle blowing Policy
Health & Safety Policy
Guidance on Medical Device Incidents
Manual Handling Policy
Withdrawing Care and Treatment Procedures
Infection Control Policy
Fire Safety Policy
Fraud and Corruption Policy
For Learning and Action Group
Terms of Reference
Lewisham PCT Clinical Governance Sub Groups
Terms of Reference
Purpose and Principles
The current purpose of FLAG is 2-fold
A. Performance Management
To provide a forum to support the responsible officer in decision making with regard
to issues of concern that arise in relation to independent contractors.
To provide a forum to support PCT managers in decision making relating to serious
B. Learning from adverse events
To encourage a culture of learning from adverse events and near misses
To encourage a culture of fairness so that the root cause of adverse events is
A . Performance management
1. To act as a central local referral point for
performance issues relating to independent contractors within the PCT
performance issue impacting on patient care and relating to employed healthcare
professionals within provider services
2. Support responsible officer (MD/Director of Neighbourhood development in
decision making and assessment in accordance with the PCT Performance
3. To act in accordance with other PCT policies including whistle blowing, incident
reporting and management and complaints handling
4. To act on the findings of the analysis in accordance with PCT policy and to agree
onward referral if necessary.
5. To advise the Senior Management Team of actions taken
6. To advise PCT Board of issues of serious concern
B learning from adverse events
1. To act as central local referral point for looking at adverse events
2. Undertake root cause analysis of serious adverse events and nears misses
3. Produce action plans to address causes and provide support and ongoing
4. Ensure dissemination of learning from good practice adverse events and near
5. To ensure that the process is disseminated to all those working in the PCT and
that reporting and referral mechanisms are disseminated to the other
6. To provide anonymised minutes of Flag meetings to Clinical Governance
7. To maintain clear records for the purpose of effective communication,
transparency of the process and for accountability
A core membership will form the Performance advisory Group responsible for the
Performance management objectives of FLAG. These members will be: -
Medical Director (Chair)
AD Primary Care
Non –Executive Director
Other Members will be cooped at times to advise where appropriate. These will include
LOC representative or other Optometry adviser
LDC representative or other dental advisor
AD Pharmacy or other pharmacist adviser
ADS provider services – adult and children‟s divisions
FLAG Full Membership
The core members plus
A quorum will be 75% of core membership
Frequency of meetings
Performance Advisory group
Meetings monthly to consider new cases and review progress where matters are ongoing
Quarterly meeting to review action plans and issues arising from PAG and also review
complaints, SUIs, claims and appraisal issues, and review learning from these cases.
Frequency of meetings will be reviewed periodically to assess whether it meets identified
These terms of reference will be reviewed in November 2008.
LEWISHAM PRIMARY CARE TRUST
END OF QUARTER COMPLAINTS REPORT FOR THE PERIOD
1. Overall Summary of Complaints
Qtr 1 Qtr 2 Qtr 3 Qtr 4
PCT Managed Services
Details of individual complaints for quarter ………. are attached as an appendix to
2. Performance Indicators (Qtr …… only)
National performance standards:
Standard 1:100% complaints acknowledged within 2 working days
Standard 2: 80% complaints resolved within 25 days
Standards achieved by managed services for the quarter ending ………. by
3. Independent Review Requests – Healthcare Commission
Although this report focuses on complaints, it should be noted that individual staff
and departments within the PCT receive thank you letters and compliments. These
are reported in anonymised form in the PCT newsletter. The complaints department
received ..... compliments for the following service areas (examples).
Foot Health …..
Sexual & Reproductive Health Department …..
Walk in Centre …..
Complaints & Quality Support Manager
APPENDIX (To quarterly report)
Ref Date Date of Response Summary of Issues Outcome
Ref Date Date of Response Summary of Issues Outcome
Ref Date Date of Response Summary of Issues Outcome
Ref Date Date of Response Summary of Issues Outcome