Wakefield District by mikesanye


									          COMPLAINTS POLICY AND

Author         Corporate Risk Manager

Issue Date     June 2007

Review Date    June 2009

Version        1.2
                                 Contents Page

Content                                                   Page Number

Complaints policy                                               3

Complaints procedure                                            9

Local resolution process- stage 1                               9

Independent review – stage 2                                    25

Health Service Ombudsman – stage 3                              27

Appendix 1 – Local resolution process diagram                   29

Appendix 2 – Vexatious complaints procedure                     30

Appendix 3 – Statement writing- guidelines for staff            36

Appendix 4 – Proforma for writing a statement                   37

Appendix 5 – Matters excluded from complaints procedure         39

Appendix 6 – Process for dealing with discrimination            40

Appendix 7 – Process for dealing with referral form the         41
Healthcare Commission or the Heath Service Ombudsman

Appendix 8

Wakefield District Primary Care Trust



1.1 Introduction

Wakefield District Primary Care Trust (WDPCT) is firmly committed to
continuously improving the quality of care and the services it provides and one of
its aims is to ensure the satisfaction of its customers and users. The PCT is
accountable for its services and is keen to promote and adhere to the values of
public service. It therefore encourages the views, comments and suggestions of
its service users.

Competent handling of complaints can assist in improving the quality of care and
minimising claims by listening to the voice of service users and using this as an
opportunity for the organization to learn from complainants. It is therefore
important that WDPCT has a consistent and orderly process for receiving and
handling complaints appropriately and makes positive use of the information
gained to avoid similar occurrences and to generally improve services.
This policy identifies the aims of the complaints procedure, accountability
arrangements for complaints management and the interface between complaints
and the Patient Advice and Liaison Service

1.2 Definition

A complaint is an expression of dissatisfaction about any aspect of the PCT‟s
services requiring a response.

1.3 Aims

WDPCT‟s complaints procedure aims to meet the following criteria:

(For Patients)
    To be well publicised, so that complainants are helped to make complaints
    Simple to understand and use
    Fair and impartial
    Dealt with promptly and as close to the point where they arise as possible
    Provide answers or explanations quickly and within established time limits
    Ensure that rights to confidentiality and privacy are respected
    Provide a thorough and effective mechanism for resolving complaints and
      also investigating matters of concern

      Ensure patients‟ care actively promotes their privacy and dignity and
       protects their modesty
    Ensure that the unique needs of children and young people are met in
       terms of compliments and complaints
    Ensure complainants are treated courteously and sympathetically
    To use information from complaints to improve services where appropriate
    Regularly reviewed and amended if found to be lacking in any respect
(For Staff)
    To support staff who may be the subject of a complaint
(For WDPCT )
To ensure that
    Consistent with national guidance. NHS (complaints) regulations
    To ensure the essential information is obtained to respond fully to the
       complainant, to monitor response timescales and report externally to the
       Department of Health
    Lessons are learned from complaints to improve the quality of services


2.1 General Principles

It is important that the correct procedures are followed and that the contents of
this procedure are brought to the attention of all staff that are likely to receive

Complaints should be viewed in a positive way, by using them to identify what
service improvements should be promoted.

WDPCT has a statutory duty to respond to complaints and to do all that is
possible resolve situations for patients as soon as possible

Great emphasis is placed on resolving complaints quickly and where possible by
those on the spot. This may be through an immediate informal response by a
front-line member of staff or practitioner, or through subsequent investigation.

2.2 Who can complain?

Any person who has received care or treatment from WDPCT and is dissatisfied
with the care or treatment they have received or the commissioning decisions
made by WDPCT, is entitled to make a complaint. If the person has died or is
otherwise unable to act for him or herself, a close relative or friend, or an
independent advocate may register a complaint on their behalf. The Complaints
Officer should ensure that a complaint made by a third party is made with the full
consent of the patient or carer

2.3 Complaints to WDPCT

A complaint to WDPCT may be about any matter reasonably connected with

      its provision of healthcare or any other services including its provision of
       primary medical services under section 16CC of the 1977 Act
     the commissioning of healthcare or other services or making arrangement
       for the provision of care or services with an independent provider or NHS
       foundation trust.
Matters that cannot be dealt with by WDPCT under the NHS complaints
procedure are shown in Appendix 5.

2.4 Communicating with the Complainant

The following principles are to be applied in any communication with the
    Listen to the concerns being expressed
    Be open, fair, flexible and conciliatory
    Be courteous and sympathetic
    Be apologetic where appropriate. An apology is not an admission of
    Be prompt and follow the established time limits for reply
    Exhibit empathy and gain an agreed understanding of the complaint

2.5 Roles and Responsibilities

Board Members – have a responsibility for the effective management of
complaints and are held accountable for the performance of the organisation in
handling complaints.

Chief Executive – is responsible for responding in writing to all complaints and
needs to have an overview of all recorded dissatisfaction recorded by service

Director of Corporate Services – has the responsibility for ensuring the
complaints policy and procedure is in place.

Caldicott Guardian – has the responsibility for safeguarding the confidentiality
of patient information

Head of Corporate Governance - is the officer responsible for administrative
co-ordination and ensuring that complaints are actioned in line with the guidance.

The Head of Corporate Governance will hereafter be known as the Complaints

Complaints Manager - has the responsibility for managing the complaints
process. In the absence of the Complaints manager, the Complaints officer can
be contacted for advice on the process. The role of Complaints manager can be
delegated for purposes of annual leave and sick leave.

Complaints Officer – has the responsibility for the administration of the
complaints process, including acknowledgement and response to complaints and
the maintenance of a complaints register.

Heads of Service – are responsible for ensuring complaints are fully
investigated and drafting final responses before submission to the Complaints
Officer. The role of the Head of Service is to organize investigation into
complaints and to respond to the key issues of complaint within 10 working days
to the Complaints Officer.

Investigating Manager- (e.g Modern matron, service lead) responsible for
collating information, undertaking the investigation and reporting back to the
Head of Service.

All staff – any member of staff who is approached by a patient or their
representative with a complaint should endeavour to resolve the matter there and
then. (See chart Appendix 1) All PCT staff should know how to react and what to
do if someone makes a complaint. Staff are individually responsible for
familiarizing themselves with the Complaints Procedure.

2.51 Committee accountabilities
The Risk Management Committee and Clinical Governance Committee monitor
complaints with quarterly reports submitted to these forums. An annual report on
complaints is presented to the Board.

2.6 Staff training and support

The PCT will arrange for all new staff to have as part of their induction an
introduction to complaints handling. Additional complaints training is provided as
part of the PCT‟s training programme,

The Complaints Manager and Complaints Officer will be available for help and
advice at any time.


It should be the choice of the individual to use either the Patient Advice and
Liaison Service (PALS) or the NHS Complaints Procedure; there should be no
requirement for service users to use the PALS service first if they wish to make a
formal complaint.

There is close collaboration between the PALS service and the Complaints team
to ensure a coherent and seamless approach to resolving patient‟s concerns.
There is a clear differentiation between the roles of PALS and Complaints
Departments. PALS will not investigate complaints and their role is to inform and
support people to access the complaints procedure when requested:

PALS provides assistance to members of the public, patients and carers with
queries about health related matters When patients first have a concern or issue
they wish to raise, their first point of contact will often be with a member of staff
or PALS.

A key PALS role is to help people to talk through their concerns so that they can
identify the nature of the problem and work out various options, including use of
the formal complaints procedure, for resolving the issue, explaining the potential
consequences of each option. Where an individual approaches PALS and
subsequently decides to make a formal complaint, this is referred to the
complaints team.

There may be occasions when patients, their carers or relatives contacting PALS
have previously made a formal complaint, or taken other action to gain resolution
regarding an issue. Patients should not use PALS to pursue a concern once the
complaints procedure has been exhausted. PALS staff may decide that no action
they can take will provide an effective and speedy resolution, and that the issue
is outside their remit. PALS should provide information regarding appropriate
independent advocacy or alternative means of pursuing the matter. It is important
that PALS are able to work in an independent way and inform people of all their
options and rights.

Contacts with PALS may initially frame their concern in the form of a complaint
but the PALS staff should seek to identify if the concern can be dealt with
informally through PALS. In all cases the choice of action should be agreed with
the person raising the concern or issue.

Using PALS will not remove the right of patients to pursue the complaints option
at any stage; however, it would not be appropriate to use PALS and the
Complaints Department simultaneously to address the same problem. PALS will

act as a gateway to the complaints service in the PCT. In certain cases it will be
necessary to refer an individual to the complaints procedure. For example:

      The person chooses to use the complaints procedure rather than the
       informal process.
      The issue cannot be resolved through the informal process.
      Allegations of staff assault or incidents of similar seriousness.

Wakefield District Primary Care Trust



This complaints procedure details Wakefield District Primary Care Trusts
(WDPCT‟s) arrangements for dealing with NHS complaints. The procedure has
been developed in line with the NHS (complaint) regulations 2004 and the
amendments in September 2006. It should be used in line with WDPCT‟s
complaints policy

The procedure covers complaints relating to services provided by WDPCT and
those relating to independent contractors where the complainant requests the
involvement of WDPCT

The majority of patients receiving care within the NHS are happy with the care
provided. It is recognized however that there will inevitably be circumstances
where the expectations of some of the service users are not met and they will
need to voice their feelings through the complaints procedure. Complaints are
viewed positively within WDPCT and every effort is made to identify lessons from
complaints to make positive improvements in services for patients.

Complaints guidelines information is handled in line with data confidentiality and
should only be shared on a “need to know” basis.

The complaints team is based at PCT headquarters at White Rose House and
can be contacted for advice in dealing with any aspect of an informal or formal
complaint on the following number: 01924 213193

The roles and responsibilities of individuals within the PCT for complaints are
detailed in the complaints policy.


1.1 General Principles

The local resolution stage of the complaints procedure refers to the period when
the PCT seeks to resolve the issues raised in a complaint locally to the
satisfaction of the complainant. The majority of complaints received by WDPCT
are resolved at this local resolution stage.

A complaint is an expression of dissatisfaction about any aspect of the PCT‟s
services requiring a response.

1.2 Time Limits

A complaint should normally be made within six months from the incident that
caused the problem, or within six months of the date of discovering the problem,
The PCT has discretion to extend this time limit where it would be unreasonable
in the circumstances of a particular case for the complaint to have been made
earlier and where it is still possible to investigate the facts of the case.

Where the PCT decides not to investigate a complaint because it is “out of time”
the complainant must be informed of their right to refer this to the Healthcare

1.3 Provision of care whilst a complaint is in progress

It is recognised that, on rare occasions, the relationship between a patient and a
clinician may break down and the patient may feel cause to complain about that
individual. This may happen in any discipline and specialty, within the services
operated by the PCT. It is PCT policy not to withdraw clinical treatment or
support as a result of a complaint. (The procedure to be followed to avoid
complainants being treated adversely is attached as appendix 6)

If a patient complains verbally to a clinician, in accordance with the local
resolution procedure, the recipient of the complaint should try and resolve the
matter to the complainant‟s satisfaction at that time or within a very short period,
so as to minimise any ill effect on the patient‟s continuing need for care.

If a patient complains in writing, the investigating officer will endeavour to resolve
matters quickly, also having regard to the patient‟s need for continuing care. If
either side feels that the matter cannot be resolved and the complaint is
impacting on the relationship between the patient and the clinician, the clinician
must contact their line manager and appropriate professional head of service as
a matter of urgency (i.e. within 24 hours) to discuss the most appropriate way to
resolve the matter. They will refer the matter to the Complaints manager who will
inform the Chief Executive.

The clinician and Complaints Manager, in consultation with the appropriate
professional head of service, will consider the options and agree whether it is
appropriate to ask a different clinician to take over the patient‟s care a) on a
temporary basis until the complaint is resolved or b) permanently, if it is felt that it
would not be in the patient‟s best interests to remain under that individual‟s care.

If a complaint is registered at the time the clinical treatment is completed, the
clinician has a duty of care to ensure that the patient is advised of the situation,
separating the issue of treatment and any aspect relating to a complaint.

1.4 Types of Complaints

1.4.1 Written Complaints

The Chief Executive, Complaints Manager, Investigating Manager or any
member of staff working within the PCT could receive written complaints. All
written complaints should be forwarded to the Complaints Manager for
acknowledging as soon as they are received. This should not delay the
investigation commencing.

1.4.2 Verbal Complaints

Verbal complaints should be viewed as seriously as written complaints. Any
member of staff who is approached by a patient or their representative with a
complaint should endeavour to resolve the matter there and then. Whenever
possible, complaints should be resolved at the time. Any verbal complaint that
cannot be resolved at the time should be handled in the same timescale as
written ones.

If the matter remains unresolved, the member of staff receiving the complaint
should prepare a clear record of the details as soon as possible and seek
confirmation of these by the complainant

It may be appropriate for the entire process to be resolved verbally, without any
written communication. However, where the complainant indicates that they are
not satisfied with the verbal response, then the complainant should be referred to
the complaints department.

1.4.3 Complaints via Email

Complaints received via email should be viewed as seriously as written
complaints and processed in the same manner. Patient sensitive information will
not be sent by e mail. Acknowledgement or response letters should be sent by

1.4.4 Complaints via a Third Party - Consent

There are many occasions where a complaint is made indirectly through a third
party (eg GPs, parent or sibling, MP‟s). The process and investigation will
normally follow the same procedure as a complaint that is made directly by a

In all cases, when a letter of complaint is received by a third party, the complaints
manager will acknowledge the letter and gain consent from the patient to
investigate. When drafting the response, the Investigating Manager should

always be aware of the confidential nature of the response. All final responses
will be copied to the patient.

Exceptions include requests from a parent of a patient under the age of 16
(although under Data Protection if a child is considered capable of understanding
the implications of their decisions then their wishes should be followed) and
complainants who have guardianship or power of attorney that has been
registered with the Court of Protection. In all cases the status of the complainant
should be confirmed and each request should be considered on a case-by-case
basis. If it is evident from the complaint that the patient is unable to consent to
the investigation, the Complaints Manager will decide whether to proceed,
following discussion with the complainant.

When a complaint is received relating to a deceased patient, a response should
be sent to the next of kin only.
Occasionally, a complaint will be received where the complainant has no
apparent connections with the patient concerned. In such cases, before any
investigation commences, the following points should be clarified:

      Does the patient know a complaint has been made on their behalf?
      Has the patient authorised the complainant to make enquiries or can an
       acceptable connection be established?

Letters received from solicitors raising a complaint on behalf of an individual
should be dealt with in the same way as all other complaints unless it is explicit
that legal action is intended, in which case the matter should be referred to the
Complaints Manager who will liaise with the Risk Manager.
If consent is not given, the complaints manager will determine whether the
patients would like to receive a response to the complaint themselves. In either
case a letter will be sent to the complainant detailing the patient‟s decision.

The HO communications team usually deals with responses to MP‟s letters
regarding patients. Where there is a specific complaint, the PCT does not need
to seek further consent as this is taken as being implied

1.4.5 Complaints by a disabled person

WDPCT seeks to facilitate complaints from disabled people and will seek to
assist as appropriate to that individual‟s disability. For example if a complainant
has a sight disability the complainant should be invited to submit details in Braille,
or on tape and the Complaints Manager should arrange for this communication to
be transcribed and verified by the complainant.

1.4.6 Complaint involving Family Health Service Practitioners (FHSP’s) e.g.
GPs, dentists, opticians, pharmacists & commissioned services

FHSPs are independent contractors to the Primary Care Trust and not
employees. The NHS complaints procedure is based on local resolution. In this
case the Practitioners are obliged to investigate their own complaints at local
resolution stage.

The PCT is obliged to support the NHS complaints procedure by giving advice to
both patients and practitioners and facilitating the next stage, which is called
independent review.

Where a complainant wishes to complain directly to WDPCT about FHSP
services or where a joint FHSP/WDPCT complaint is received, then the
Complaints Officer will facilitate the investigation and response

Where a serious complaint is received about commissioned services provided by
a private provider then WDPCT will ensure that there is a full review of the
complaint asking appropriate clinicians to comment.

1.4.7 Complaints about a continuing care decision / special referrals decision

It is important to recognise that the review procedure for continuing care or
special referrals is not a complaints procedure. The fact that someone has had
their case considered by a continuing care review panel or special referrals
panel, does not affect their rights under the NHS complaints procedure. They can
complain about the original decision on discharge, or the continuing care review /
special referrals process, through the NHS complaints procedure.

1.4.8 Mixed sector complaints

Where a complaint involves more than one NHS provider, or one or more other
bodies (e.g. Social Services), there should be full co-operation in seeking to
resolve the complaint through each body‟s local complaints procedure

Where complaints are about both NHS and Local Authority services, the new
regulation 3a ,in the 2006 amendment to the Principal regulations, provides that
where the complainant so wishes, the organizations must co operate to deal with
the part of the complaint that relates to them and provide a coordinated response
to the complainant.

1.4.9 Complaints concerning a possible Criminal Offence, Alleged Physical
Abuse of Patients or Serious Untoward Incident Involving Harm to a Patient

Where a complaint concerns either
  a) A possible criminal offence;
  b) The alleged physical abuse of patients,
  c) A serious untoward incident involving harm to a patient or

   d) A matter which should be referred to one of the professional regulatory
The appropriate Investigating Manager must be informed immediately. This
notification may be made at any point during any stage of the complaints

The investigating manager must refer to the multi agency adult protection policy
in relation to the alleged issues which fall under the definition of adult abuse and
follow the agreed procedure. Other matters may need to be referred to the police
and the Chief Executive if a possible criminal offence has been committed. This
should be reported to the next Confidential Board meeting. If an issue is referred
to the police, any investigation must stop. The Investigating Manager must
involve the Director of Finance in any possible financial offence.

1.4.10 Complaints Involving Litigation or Requiring Legal Advice

Legal advice on particular aspects of a complaint should be sought if there is the
possibility of litigation ensuing. Where a complaint is already a case of possible
litigation and particularly where the approach is made by solicitors acting on
behalf of the patient, the matter should be referred immediately to the Complaints
Manager who will liaise with the Chief Executive and Risk Manager.

A letter acknowledging receipt of the complaint should be sent. Investigation of a
complaint should not be delayed as a result of legal advice being sought. The
Investigating Manager should initiate enquiries immediately but any
correspondence with the complainant should be agreed with the Complaints
Manager who will seek legal advice if necessary.

Following consultation, the Investigating Manager may wish to explore with the
complainant the options available, which could prevent the possibility of litigation
ensuing (e.g. an apology, admission of liability, offer of compensation). Copies of
the letters will be passed to the consultant and other professional staff involved
informing them that the case has been referred for legal advice and advising
them to contact their defence or professional organisation and, if appropriate, the
solicitor acting on behalf of the PCT. The Complaints Manager will refer
complaints to the Chief Executive and Risk Manager where a complainant
explicitly indicates an intention to take legal action.

1.4.11 Correspondence from the Press

If correspondence is received from the press regarding a complaint, the Head of
Communication should be contacted in the first instance.

1.4.12 Freedom of Information Act

The complaints procedure cannot deal with complaints about non-disclosure
under the Freedom of Information Act. These are dealt with under a separate
policy and should be referred to the Head of Communications.

1.4.13 Staff Grievances

Staff grievances should not be reported through the complaints procedure but
should be dealt with through the PCT‟s Grievance Procedure. Further advice can
be obtained from the Human Resources department.

1.4.14 Unreasonable Complaints (vexatious complaints)

The PCT is committed to treating all complainants equitably and recognises that
it is the right of every individual to pursue a complaint. The PCT therefore
endeavours to resolve all complaints to the complainant‟s satisfaction. However,
on occasions, staff may consider that a complaint is unreasonable in nature, e.g.
the complainant raises the same or similar issues repeatedly, despite having
received full responses to all the issues they have raised.

Unreasonable complainants are often symptomatic of an illness and the
complaints procedure may not be the most appropriate means of dealing with the
issues involved.

There may also be occasions when staff may receive telephone calls from
complainants where the complainant is abusive and/or uses threatening or bad
language. In such cases, the recipient of the call should remain calm and inform
the caller that he is not prepared to continue the call and will put the phone down
unless the caller modifies his language. The staff member should document the
phone call and fill out an incident form.

 If it is considered that a complainant is becoming unreasonable, the member of
staff should refer to the Vexatious /Habitual Complaints Procedure (Appendix 2)
for guidance.

1.4.15 Prison complaints

 Wakefield District PCT has taken over the handling of Complaints relating to
healthcare services commissioned and provided by WDPCT in the two local
prisons (Wakefield and New Hall). Where healthcare complaints cannot be
resolved on a local basis within the prison then the WDPCT complaints
procedure should be instigated.

1.4.16 Leaflets and Posters

The complaints procedure should be advertised widely throughout the premises
where PCT services are provided. Leaflets and posters should be displayed
within departments. Further supplies can be obtained from the Complaints

1.4.17 Conciliation

It is a requirement to offer a conciliation service as part of the Complaints
procedure. WDPCT has four lay conciliators appointed and where it is
considered appropriate, and with the agreement of the complainanant, the PCT
will make arrangements for conciliation for the purposes of resolving the

1.4.18 Independent Complaints Advocacy Services (ICAS)

Section 12 of the Health and Social Care Act places a legal duty to make
arrangements to provide Independent Advocacy Services to assist individuals
making complaints against the NHS.

ICAS focuses on helping individuals to pursue complaints about the NHS. Its aim
is to ensure complainants have access to the support they need to articulate their
concerns and navigate the complaints system. The service can deliver advice but
if the individual needs advocacy in terms of writing letters or attending meetings
then the service can also provide this.

Patients who want to complain about NHS services are able to access ICAS
through many avenues (NHS Direct, national and local websites). PALS will
provide a valuable gateway to ICAS by raising patients‟ awareness of the service
and referring patients to it.

The local ICAS service can be contacted on 0845 120 3734

1.4.19 GP Out of Hours Complaints

Complaints relating to the GP Out of Hours service, should be dealt with by the
provider of that service (Currently Local Care Direct)

1.4.20 Counter Fraud Measures

Where a member of staff suspects any fraudulent activity or practice then they

      Make a note of all details

       Ring the NHS Fraud and Corruption helpline on 0800 028 40 60
       Or report suspicions to the local Counter Fraud Specialist or Finance
        Director immediately

They should not
    Ignore their suspicions
    Investigate themselves
    Tell colleagues or others about their suspicions

1.5 Receiving Complaints

1.5.1 Receipt of Complaint

Any member of staff receiving a complaint must notify the Complaints Manager
and a copy of all correspondence should be forwarded by fax. All written
complaints should be stamped with the date of receipt.
There have been occasions where acknowledgements have been delayed due to
post not being opened in the absence of the person to whom the complaint has
been addressed. Arrangements should be in place to ensure that delays do not
occur for this reason.

 The Complaints Officer will maintain a register in which each complaint is
recorded and given a unique number. This number will serve as a future identifier
for the particular directorate; the location involved and for entry into the PCT
central registers. The central register will be maintained to provide statistical
returns to the Department of Health and data for quality monitoring.

1.5.2 Out of Office Hours

Should a written complaint be received out of office hours, the process described
in section 4.4.1 should be followed.

 Should a verbal complaint be received out of office hours, relevant details should
be taken and the process described in section 4.4.2 be followed. Complainants
should also be advised that NHS Direct is available for out of hours advice.

1.6 Acknowledging Complaints

1.6.1 Acknowledgement

The Chief Executive must acknowledge all complaints within 2 working days of

The acknowledgement letter should be sent along with a form requesting ethnic
monitoring information. The letter should inform complainants about how records
will be used and issues regarding confidentiality. A stamped addressed envelope

should be enclosed to aid reply. The Complaints Officer will coordinate the
acknowledgement of the complaint and complete the Complaints Register. A
copy of the acknowledgement letter and the complaints register number is then
sent to the Investigating Manager. The Investigating Manager is responsible for
handling the complaint and for ensuring that the complaint is investigated
thoroughly and that a response is sent to the Complaints Officer.

1.6.2 Ethnic Monitoring

All Primary Care Trusts have been asked to complete ethnic category details of
Complainants and staff complained against. The collection of ethnic category
data on written complaints will be valuable in gauging fair and equal access to
health care across ethnic groups. There is no obligation on patients or staff
members to respond to the ethnic category question and no pressure should be
put on them to answer, or on staff to obtain an answer. Should the patient or staff
member not respond to the question, this should be classified as „not stated‟.

1.6.3 Patient Confidentiality

“Health Service Circular 1998/059 – NHS Complaints Procedures:
confidentiality” states the use of the patient‟s personal information to investigate
a complaint is a purpose for which it is not necessary to obtain the patient‟s
express consent. Care must be taken at all times throughout the complaints
procedure to ensure that any information disclosed about the patient is confined
to that which is relevant to the investigation of the complaint and only disclosed
to those people who have a demonstrable need to know it for the purpose of
investigating the complaint. Even so, it is good practice to explain to the patient
that information from his/her health records may need to be disclosed to the
Investigating Manager, to clinical assessors, and possibly to the convener and
panel members. If the patient objects to this, then the effect on the investigation
will need to be explained.

1.7 Investigating Complaints

1.7.1 Service level

The target for the response to be sent is within 25 working days from receipt of
the complaint. Where this is not possible, an interim reply must be sent by the
Chief Executive giving an explanation for the delay and an indication of when the
response is likely to be available.

1.7.2 Documentation

All aspects of the investigation should be clearly recorded and all documentation,
including staff statements, how the facts have been ascertained etc, should be
retained by the Investigating Officer. In the event that the complainant

subsequently requests an independent review, the PCT will require copies of all
documentation. Staff should be aware that, should the matter proceed to
litigation, all the complaints documentation is subject to disclosure. Copies of
complaints correspondence should not be held on the patient‟s health records. In
addition to ensuring good patient care, complete, accurate and timely records
allow a clear picture of events to be obtained which is imperative for managing
complaints, and for auditing practice.

1.7.3 The Investigation

The investigation must be independent and the investigating manager must have
the relevant skills to undertake the task and be selected according to the
importance and seriousness of the complaint.

The Investigating Manager will determine how the complaint is to be investigated
and by whom. It is anticipated that the Investigating Manager will normally be the
senior manager responsible for the area concerned. It is desirable that the
complaint is dealt with as close to the point of delivery as possible to ensure a
prompt reply and that appropriate remedial action is taken. The Complaints
Officer (via the investigating manager) may request a confidential statement from
staff members involve in the complaint. The form should be fully completed as
per the guidelines (Appendix 3 and 4) and returned to the Investigating Manager.

Where a complaint in any way concerns the professional care or treatment of a
patient or a matter of clinical judgment, the appropriate consultant or professional
head of service should be provided with a copy of the complaint and given the
opportunity to comment. When the matter has been investigated and a reply
prepared, it should normally be checked by the consultant/ head of service for
factual accuracy prior to the draft reply being submitted to the Chief Executive.

If a complaint involves a locum member of staff who is no longer working for the
PCT, a report should be gained from the staff member, via the agency from
which they were employed. If this is not possible, an investigation should be
undertaken obtaining as many details as possible and an explanation provided to
the complainant.

Where a complaint involves the professional conduct or competence of medical,
nursing or other professional staff, the Investigating Manager must immediately
notify the appropriate consultant or professional head of service. The advice of
the professional head of service should be sought before the reply is sent. The
Investigating Manager must also immediately notify the PCT‟s Medical Director of
any complaint involving professional medical conduct or competence.

Similarly, the Investigating Manager must be informed of any written or
unresolved verbal clinical or non-clinical complaint received by medical, nursing

or other professional staff within their directorate to ensure that the full
implications for the PCT can be assessed.
If a member of staff is implicated in a complaint and the allegation is serious and
could lead to disciplinary action, the member of staff will be informed by the
Investigating Manager and will be advised of their right to seek the help and
advice of a professional association or trade union before commenting on the
complaint. Consideration as to whether or not disciplinary action is warranted is a
separate matter for management, outside the complaints procedure, and must be
subject to a separate process of investigation.

Investigating managers should ensure that staff are aware of their special
responsibilities towards patients who would have difficulty in making a complaint
on their own behalf. They should also instruct staff to take any necessary action
to protect the patient's interests.

On completion of the investigation, the Investigating Manager should send a draft
response to the Complaints Officer.

1.7.4 Meetings

The Complaints Manager will, in consultation with other senior staff involved,
decide whether it is appropriate to offer the complainant an interview or
mediation meeting. Where the investigating officer arranges a meeting with the
complainant, the staff involved will be consulted to determine how the meeting
will be structured. The Complaints Manager (or mediator) will conduct the
meeting and will ensure that notes are taken. Two members of PCT staff should
normally attend any meeting and the complainant should be offered the
opportunity to have someone else present at the interview to assist them. The
meeting must be formally recorded and a copy of the notes forwarded to the

1.7.5 Draft responses

Wherever practical, replies to all complaints (e.g. written and oral) should be
agreed with those involved before the reply is sent. If the response cannot be
agreed with those involved, the Investigating Manager should be informed in
order to agree the wording of the response. Where it is clear that there has been
a mistake or failure in procedures, this should be clearly stated and an
appropriate apology given, except where this could constitute an admission of
legal liability. In this case, the matter should be referred for legal advice. The
Complaints Manager will contact the PCT‟s solicitors and then respond to the
Investigating Manager with the recommended course of action. The Investigating
Manager will forward the draft response to the Complaints Officer who will
organise signature by the Chief Executive.

Staff who may be the subject of a complaint can be anxious about the process
and their position. It is important that they are kept informed about progress with
the investigation by the investigating officer and that they are offered the
opportunity to discuss the matter with a professional colleague. Wherever
possible, they should have the opportunity to comment on the accuracy of the
draft response to the complainant and they should be shown a copy of the final
response to make them aware of its content.

1.7.6 Holding Letters

In exceptional circumstances, where it has not been possible to contact all those
involved to enable a full response, an interim response should be sent from the
Chief Executive. It is essential, however, to remain objective at all times and
present a fair reply to all complainants. Further holding letters should be sent
every two weeks to a maximum of three months.

1.7.7 No Investigation of complaint

A matter, which is the subject of a complaint, will not be investigated, or will
cease to be investigated, in any case where:

   a) The complainant has stated orally or in writing, that he intends to pursue a
      remedy by way of proceedings in a court of law; or
   b) Disciplinary proceedings are taken or consideration is being given to the
      taking of disciplinary proceedings.
   c) The subject matter has already been investigated.
   d) Where the complaint relates to section 10 or 24 of the Superannuation Act

(Where a complainant explicitly indicates an intention to take legal action, the
complaint should be referred to the Risk Manager within the PCT see 4.4.10)

Investigations, which have ceased, will resume:

   a) In relation to any matter which have not been dealt with by the
      proceedings in a court of law
   b) Should the complainant give sufficient assurance that he no longer
      intends to pursue or is no longer pursuing a remedy by way of
      proceedings in a court of law.
   c) in relation to any matter which has not been dealt with by the disciplinary

The Complaints Manager will notify the complainant, and any person subject to a
complaint, of any decision not to investigate. The notification will be in writing and
will state the reasons for the decision. A further letter will be written should the
investigation resume.

1.7.8 Investigation, which could lead to Disciplinary Action

Where it is likely that a complaint, if found to be justified, may lead to disciplinary
action being taken against a member of staff, the investigating officer should
ensure that the appropriate manager is notified of the complaint. The member of
staff may be asked to take part in the investigation and should be kept informed
of the progress being made with the investigation

 Any member of staff involved in a complaint must be informed of any allegation
at the outset and must be advised of their right to seek the help and advice of a
professional association or trade union before commenting on the complaint.

 In cases of this nature the Investigating Manager remains responsible for
investigating the complaint, but the decision on whether disciplinary action is
called for is a decision for the line manager in consultation with the Investigating
Manager or the professional head of service. This decision is made in
accordance with the normal disciplinary procedure and must be kept separate
from the PCT‟s complaints procedure so that the latter is only concerned with
resolving complaints and not investigating disciplinary matters.

1.7.9 Associated policies include:

· Policy & Procedure on Prevention of Harassment and Bullying at Work
· Policy for Professional and Personal Boundaries
· Disciplinary Procedure
· Grievance Procedure
· Procedure for voicing a concern
· Fraud protocol
. Vexatious Complaints Procedure

1.7.10 Coroner’s Cases

The fact that a death has been referred to the Coroner‟s office does not mean
that all investigations into a complaint need to be suspended. It is important for
the PCT to initiate proper investigations regardless of the Coroner‟s inquiries,
and where necessary to extend these investigations if the Coroner so requests.

1.8 Final Responses

1.8.1 Procedure

All written complaints concerning the Primary Care Trust (and any verbal
complaints, which are felt to be sufficiently serious) must receive a response in
writing from the Chief Executive (or in his
absence, his nominated deputy). Other than in exceptional circumstances, the
final letter should be dispatched within 25 working days from receipt of the

complaint, unless the complainant agrees to a longer period in which case the
response may be sent within this longer period. The Investigating Manager will
forward the draft response to the Complaints Manager who will organise
signature by the Chief Executive.

Complaints made concerning Family Health Service Practitioners will receive a
response directly from that practitioner. A copy of the response will also be
forwarded to the Primary Care Trust Complaints Manager.

 A copy of the signed response for Primary Care Trust complaints will be
returned to the Investigating Manager for filing. The final response should invite
the complainant to let the Chief Executive know if they have any outstanding
concerns and inform the complainant of the next stage of the complaints
procedure should the complainant be dissatisfied. In such cases, consideration
should be given to any further action which might resolve the complaint, including
offering a meeting.

1.8.2 Compensation and Ex-Gratia Payments

There may be occasions when, having investigated the complaint, the
Investigating Manager believes there are grounds for making an ex-gratia
payment (without accepting liability). An apology and gesture of goodwill may
avoid subsequent litigation and offers the opportunity to deal with certain
circumstances in a fair and responsible manner. The Director of Finance should
approve all ex-gratia payments

It is recommended that, before any compensation is offered in respect of a
complaint involving a member of staff, that member of staff should be involved in
the discussions when the subject of compensation is raised, to ensure that he
does not feel compromised by the decision to award compensation.

Any ex-gratia payments should be made having regard to the PCT‟s Standing
Orders and Standing Financial Instructions.

1.9 Action following Complaints

1.9.1 Action where the Complainant is Dissatisfied with the Final Response

A further response from the Chief Executive should be sent to the complainant
confirming the outcome of any further investigation and advising them of the
independent review process. If the complainant subsequently remains
dissatisfied, they may request an independent review of their complaint.

1.9.2 Learning lessons from complaints

Following investigation of the complaint, the Investigating Manager will be
responsible for ensuring action has been undertaken within a reasonable
timescale. The PCT must be able to demonstrate that following investigation of a
complaint, where changes, which will reduce risk, are identified these are
considered and implemented.

Investigating managers are routinely requested to consider and document any
lessons learned as part of the management of complaints. Any issues are then
discussed at the appropriate forum to ensure that lessons learned are acted
upon and shared. These lessons learned are anonymously reported within the
quarterly monitoring process.

1.9.3 Reporting Arrangements

A quarterly report detailing compliments, complaints, areas of concern and links
with PALS, Risk Management and Claims will be presented to:

      Clinical Governance Committee
      Risk Management Committee

A quarterly report is also sent to the Complaints Lead for West Yorkshire
An annual report is presented to

      Trust Board

A complaints report will also be included in the PCT‟s annual report. On an
annual basis returns to the Department of Health (KO41‟s) are completed

1.9.4 Archiving and Disposal of Records

The guidelines detailed in HSC 1999/053 „For the Record‟ apply to NHS records
of all types including:

      Administrative records (e.g. complaint handling)
      Microfilm
      Computer databases, output and discs and all other electronic records

Complaints records should be retained for 10 years. Where legal action has
commenced, records should be kept as advised by legal representatives. The
recommended minimum retention periods should be calculated from the end of
the calendar year following the last entry on the document. Records relating to
children must be kept for 25 years.

Destruction of confidential records must ensure that their confidentiality is fully
maintained. Normally destruction should be by incineration or shredding. Where
a contractor provides this service it is the responsibility of the PCT Records
Manager to satisfy itself that the methods used throughout all stages including
transport to the destruction site provide satisfactory safeguards against
accidental loss or disclosure.

Complaints records should be kept separate from health records, subject to the
need to record any information that is strictly relevant to their health in the
patient‟s health records.

1.9.5 Access to this policy

This policy shall be given, free of charge, to any person who makes such a

1.9.6 Compliments

The PCT keeps a record of all letters of praise / compliments received.
Information about compliments received should be sent to the Risk Manager.


The independent review stage of the complaints procedure is the second stage
of the complaints procedure when the complainant has exhausted the local
resolution stage.

2.1 Dissatisfied Complainant

The PCT and independent contractors must inform the complainant within the
final response of the next stage of the complaints procedure should they be
dissatisfied and give details of how to contact the Healthcare Commission.

Complainants who remain dissatisfied following the completion of local resolution
may contact the Healthcare Commission, requesting an independent review of
their case. This must be done within two months of receiving the final formal
written response from the organisation or practitioner about whom the complaint
was made. This request can be made in the following ways:

        Contact the Healthcare Commission on 020 7448 9200 or write to them
         at Healthcare Commission, Complaints Investigation Team, Peter
         House, 5thFloor, Oxford Street, Manchester, M1 5AN
        Complete their independent review request form.
        Visit their website at www.healthcarecommission.org.uk.

On receipt of the complaint the Healthcare Commission will assess the nature
and substance of the complaint and decide how it should be handled having
regard to:-

• The views of the complainant;
• The views of the body complained about;
• Any investigation of the complaint and any action taken as a result of such
investigation; and
• Any other relevant circumstances

As soon as is reasonably practicable the Healthcare Commission will notify the
complainant as to whether it has decided:-

• To take no further action;
• To make recommendations to the body, which is the subject of the complaint,
as to what action might be taken to resolve it;
• To investigate the complaint further whether by establishing a panel to consider
it or otherwise;
• To consider the subject matter of the complaint as part of or in conjunction with
any other investigation or review, which it is conducting or proposes to conduct in
the exercise of its functions;
• To refer the complaint to a health regulatory body;
• To refer the complaint to the Health Service Ombudsman;

The notice of the above decision will be sent to any person or body which is the
subject of the complaint and may be sent to any other body, which the
Healthcare Commission considers, has an interest in it. The decision will include
the Healthcare Commissions reasons for its decision and it will inform the
complainant of their right to refer their complaint to the Health Service

2.2 Investigation by the Healthcare Commission

Where the Healthcare Commission proposes to investigate a complaint itself, it
will, within 10 working days of the date on which it sent the notice, inform the
complainant and any other relevant person, its proposed Terms of Reference for
its investigation. The complainant and any other person who received the Terms
of Reference may comment on them within 10 working days.
The Healthcare Commission will conduct the investigation in any manner which
they deem appropriate.

2.3 Establishment of an Independent Panel

Where the Healthcare Commission proposes to refer a complaint to a panel, it
will make arrangements for the complaint to be considered by a panel of three
people, one of whom will be selected to be the chairman.

The panel will consider the complaint in any manner and adopt any procedure
which appears to be appropriate to resolve the complaint. The panel will ensure
that the participants are kept informed generally and in particular about:-

• The composition of the panel;
• The date and time of any hearing;
• The names of any person whom the panel proposes to interview or from whom
it proposes to take advice or evidence.

2.4 Report of investigation by the Healthcare Commission

Once the Healthcare Commission has investigated a complaint, it will prepare a
written report of its investigation which:-

• Summarises the nature and substance of the complaint;
• Describes the investigation and summarises its conclusions including any
findings of fact, the Healthcare Commissions opinion of those findings and its
reasons for its opinion;

• Recommends what action should be taken and by whom to resolve the
• Identifies what other action should be taken and by whom.

The report will be sent to the PCT and the complainant and may include
suggestions, which it considers would improve, services or which would
otherwise be effective for the purpose of resolving the complaint.


The final stage of the complaints procedure is referral to the healthcare services

Complainants may approach the Ombudsman where

• the complainant has been denied investigation because the complaint fell
outside the time limits
• they have been denied independent review but remain dissatisfied with the
outcome of the local resolution process
• an independent review has been held by the Healthcare Commission, but they
remain dissatisfied with the outcome of the review.

The Ombudsman will not automatically investigate all complaints received but will
consider complaints before deciding whether further investigation is required.
The role of the Ombudsman includes investigating complaints about matters
involving clinical judgment (with appropriate professional advice). The complaints
file and medical records are usually requested by the Ombudsman when

investigating a complaint and a copy of the Ombudsman‟s response to the
complainant is sent. to the complainant and the PCT.

                                                                                                           Appendix 1
                                              LOCAL COMPLAINT RESOLUTION


            Written                  No                 Concerning front line staff?



                                                         Verbal response/ refer to PALS

                                                             Complainant satisfied?                Yes


             Complaints Manager

         Clinical aspects?                No                 Written reply from Chief Executive/
                                                                   Identify Lessons learned


Consult relevant healthcare professional(s)                    Complainant satisfied?



                                   Appendix 2

          CARE TRUST


Corporate Risk Manager

Issue Date        June 2007

Review Date       June 2009

                  Wakefield District Primary Care Trust



    1.1    Habitual and/or vexatious complainants can be a problem for NHS
           staff. The difficulty in handling such complainants can place a
           strain on time and resources and cause undue stress for staff who
           may need support in difficult situations. NHS staff should respond
           with patience and sympathy to the need of all complainants but
           there are times when there is nothing further that can reasonably
           be done to assist them or to rectify a real or perceived problem.

    1.2    In determining arrangements for handling such complainants staff
           are presented with two key considerations.

    The first is to ensure that the complaints procedure has been correctly
    implemented so far as possible and that no material element of a
    complaint is overlooked or inadequately addressed and to appreciate that
    even habitual or vexatious complainants may have issues which contain
    some genuine substance. The need to ensure an equitable approach is

    The second is to be able to identify the stage at which the complainant has
    become habitual or vexatious. One approach to the situation is to develop
    an approved policy that is formally incorporated into the Complaints
    procedure. Implementation of such a policy would only occur in
    exceptional circumstances. Information on the handling of habitual and
    vexatious complainants could also be made available to the public as part
    of the material on the complaints process as a whole.


    2.1    Complaints about Trust services are processed in accordance with
           NHS complaints procedures. During this process Trust staff
           inevitably have contact with a small number of complainants who
           absorb a disproportionate amount of NHS resources in dealing with
           their complaints. The aim of this procedure document is to identify
           such difficult situations, and to suggest ways of responding to
           these, and to set out the policy for dealing with vexatious or
           habitual complainants.

    2.2    It is emphasised that the identification of a complainant as habitual
           or vexatious should only be used as a last resort and after all

           reasonable measures have been taken to try to resolve complaints
           following the NHS complaints procedure. The Chief Executive and
           the Complaints Manager must take this decision.


          Staff may encounter difficult circumstances when investigating a
          complaint. Suggestions for tackling some of the more common
          problems are set out below

    3.1    The complainant changes the substance of a complaint or
           continually raises new issues or seeks to prolong contact by
           continually raising further concerns or questions upon receipt of a
           response whilst the complaint is being addressed.

    If genuinely new issues have been raised, these should be considered as
    potential new complaints. The time limits should be considered before
    agreeing to investigate any new issues.

    3.2    The complainant is unwilling to accept documented evidence of
           treatment given as being factual, e.g. drug records, General
           Practitioner manual or computer records, nursing records

    Every effort should be made to verify any facts. If the complainant is not
    satisfied with a response to a complaint, they have the right to ask for an
    Independent Review, or to refer it to the Ombudsman.

    3.3    The complainant denies receipt of an adequate response in spite of
           correspondence specifically answering their questions.

    Check that the response does cover all the issues. Remind the
    complainant of their right to ask for an Independent Review, or to refer it to
    the Ombudsman

    3.4    The complainant does not accept that facts can sometimes be
           difficult to verify when a long period of time has elapsed.

    Every effort should be made to verify any facts. If the complainant is not
    satisfied with a response to a complaint, they have the right to ask for an
    Independent Review, or to refer it to the Ombudsman.

    3.5    The habitual complainant does not clearly identify the precise
           issues which he/she wishes to be investigated,

    The complainant should be encouraged to seek help from patient
    advocacy services, or other patient groups. Alternatively, the PCT can

draft a statement for the complainant, and ask for his/her agreement and
signature before proceeding with the investigation.

3.6    The complainant does not accept that the concerns identified are
       not within the remit of the Trust to investigate.

The Chief Executive should write clearly stating that he/she cannot
investigate the complaint. If possible, give the name of any organisation
that can investigate the matter or provide advice.

3.7    The complainant persists in pursuing a complaint where the NHS
       complaints procedure has been fully and properly implemented and
       exhausted (for e.g. where the PCT has not investigated a complaint
       because it is outside the time limits, where a Convenor has
       declined a request for Independent Review; or where a Panel has
       completed its report)

It must be established first that the complaints procedure has been
properly followed. Then the Chief Executive should write clearly explaining
that there is nothing further for the PCT to do, and remind the complainant
of their right to contact the Ombudsman

3.8    The complainant threatens or uses actual physical violence towards
       staff or their families or associates at any time

All such incidents should be documented, and arrangements put in place
to protect staff. These will reflect the severity of the incident but examples
include: restricting complainant to correspondence only; informing the
police; asking for correspondence to be sent via the PCT’s solicitor. The
Chief Executive should warn the complainant that such behaviour is not

3.9    The complainant has harassed or been personally abusive or
       verbally aggressive on more than one occasion towards staff
       dealing with their complaint or their families or associates. This will
       include racial harassment. (Staff must recognise that complainants
       may sometimes act out of character at times of stress, anxiety, or
       distress and should make reasonable allowances for this. They
       should document all incidents of harassment).

3.10   The complainant makes an excessive number of contacts with the
       Trust placing unreasonable demands on staff.

Every effort should be made to restrict all communication to one channel,
(e.g. correspondence with the Chief Executive) and any staff contacted by

the complainant should give the same message. The complainant should
be reassured that the complaint is being dealt with.
3.11 The complainant is known to have recorded meetings or face-to-
      face/telephone conversations without the prior knowledge and
      consent of other parties involved.

3.12    The complainant makes unreasonable demands and fails to accept
        that these may be unreasonable (e.g. insists on responses to
        complaints or enquiries being provided more urgently than is
        reasonable or recognised practice).

The complainant should be told when to expect the response, in line with
national guidelines


4.1    Where a complainant persists with any of the above courses of
        action, despite attempts by the PCT to explain then the Chief
        Executive and the Complaints Manager should agree to;

       Warn the complainant that if they persist with the approach they are
        taking, they will be classed as a habitual or vexatious complainant.

       Warn the complainant that in extreme circumstances the Trust
        reserves the right to pass unreasonable or vexatious complaints to
        the Trust‟s solicitors.

       If appropriate, draw up a signed agreement with the complainant,
        which sets out a code of behaviour for the parties involved if the
        Trust is to continue processing the complaint.

        If this is not successful, then inform the complainant that they are
        being classed as a habitual or vexatious complainant. State the
        reasons why and temporarily suspend all contact with the
        complainant or investigation of a complaint whilst seeking legal
        advice or guidance from the Regional Office, National Health
        Services Executive, or other relevant agencies.

        This notification may be copied for information of others already
        involved in the complaint, e.g. staff, Convenor, Member of
        Parliament. The Complaints manager must keep a record, as to
        why a complainant has been classified as habitual or vexatious.


5.1   Once a complainant has been determined, as „habitual or
      vexatious‟ there following mechanism will be used for withdrawing
      this status. At a later date if, for example, complainant subsequently
      demonstrates a more reasonable approach or if he/she submits a
      further complaint, which the normal complaint procedure would be
      appropriate. Staff should previously have used discretion in
      recommending „habitual or vexatious‟ status at the outset and
      discretion should similarly be used in recommending that this status
      be withdrawn. Where this appears to be the case, discussion will be
      held with the Chief Executive and Complaints Manager. Subject to
      their approval, normal contact with the complainant and application
      of NHS Complaints Procedure will then be resumed.

                                                                     Appendix 3



1.    Before providing a written statement, particularly if it relates to an incident
      that occurred some time ago, make sure that you have access to any
      relevant records.

2.    Give brief Curriculum Vitae details at the beginning of the statement:-
      -     Full name
      -     Post held and grade
      -     Qualifications (years‟ experience in the relevant profession)

3.    Confirm the date, time and location of the incident.

4.    Your account must be as accurate as possible and above all, factual.

5.    Describe exactly what you did (or didn‟t do) in relation to the incident in as
      much detail as possible.

6.    Explain your reasons for what you did (or didn‟t do).

7.    Detail the events in chronological order, giving dates and times where

8.    Do not include any of the following in the written statement:-
          Hearsay, (i.e. someone else‟s views or version of events)
          Speculation or hypothesis
          Views on causes
          Opinions on quality of work provided by other staff
          Derogatory comments about what happened

9.    Avoid jargon. It is acceptable to use technical words, but you should try to
      explain these in layman‟s terms wherever possible.

10.   Abbreviations should only be used if the full terminology is given at least
      once, followed by the conventional abbreviation in brackets.

11.   Statements should be legible, preferably typed and carefully checked
      before being signed.

12.   Sign and date your statement at the foot of each numbered page.

13.   Remember to keep a copy for your own records.

This is a guide to help you
 fill in the statement form                                            Appendix 4

             Proforma for Writing a Confidential Statement

        Confidential Statement regarding (Insert Patients Name)

Staff Details

Post Held:

Area of Work:

Date of Incident:

Patient Details


NHS No.:

Date of Birth:

Reason for Report:

Requested by:
Chronology of Events
This is a list of the dates, times and brief details of events as they occurred. It provides
a summary of events.

Description of my Involvement in the Incident
This should be a clear and concise account of what you saw, heard or did. Remain
focused. Start each part with a date and time as in Chronology of Events.
This statement is a tool for your manager, to tell a story. A good statement will give you
confidence and help you remember events in case you need to go to court.
It should be simple and brief, least is best. Do not write a suspense novel. Distinguish
between fact and opinion, only write fact in this section. Do not assume what someone
told you they were going to do is a fact,
e.g. by saying "17.00 hours Nurse Anne Brown left the room and telephoned the Health

You do not know she did this, therefore write "17.00 hours Nurse Anne Brown left the
room saying she was going to go and telephone the Health Visitor." She may have been
distracted, forgot or deliberately not done so. You do not know.

Imagine your manager is using your statement as a pair of spectacles, to look at the
evidence so that it comes into sharp focus. Ask a colleague to proof read your
statement and ask them "What do you understand from the statement?" It is not what
you write that matters but what the reader understands. Consider who is reading the
report and pitch the language at the right level. Do not use abbreviations.

Summarise the incident, it is here that you may give a professional opinion, but only if it
is relevant and backed up by fact in the previous section.

"I, (NAME INSERTED), believe that the facts stated are true" ...................................
Print Name

Date (Every page to be signed)

Note: If you are a member of a Trade Union you may wish to seek their advice
and ask them to read your statement.

If you are unsure of how to write your statement, do not hesitate to contact your
manager or the complaints manager. They will be able to provide you with a
named individual who can support and advise you appropriately.

                                                                Appendix 5


a)   a complaint made by an NHS body which relates to the exercise of its
     functions by another NHS body;

b)   a complaint made by a primary care provider which relates either to the
     exercise of its functions by an NHS body or to the contract or
     arrangements under which it provides primary care services;

c)   a complaint made by an employee of an NHS body about any matter
     relating to his contract of employment;

d)   a complaint made by an independent provider or an NHS foundation trust
     about any matter relating to arrangements made by an NHS body with that
     independent provider or NHS foundation trust;

e)   a complaint which is being or has been investigated by the Health Service

f)   a complaint arising out of an NHS body‟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;

g)   a complaint about which the complainant has stated in writing that he
     intends to take legal proceedings; and

h)   a complaint about which an NHS body is taking or is proposing to take
     disciplinary proceedings in relation to the substance of the complaint
     against a person who is the subject of the complaint.

                                                                        Appendix 6
Process for Avoiding Treating Complainants Adversely

Core Standard C14b of the Healthcare Commission‟s Annual Health Check
states that Healthcare organisations must have systems in place to ensure that
patients, their relatives and carers are not treated adversely, as a result of having

Wakefield District Primary Care Trust is committed to ensuring that complaints
are managed appropriately in line with national guidance and that patients and
their relatives or carers have the opportunity to complain if they are dissatisfied
with any of the services provided by the Primary Care Trust.

Staff are advised of complaints discrimination issues at Corporate Induction and
of the requirement to ensure that all patients, relatives and carers are not treated
adversely if they have made a complaint.

Flowchart for process to follow where a complainant claims they have been
treated adversely.

                                 Complainant alleges

          Family Health                                 PCT Provider
          Service Complaint                             Services /

             Considered by                               Investigation by
           Director of Nursing                          Director of Nursing
               and Quality                                  and Quality
           Standards who will                               Standards
          request organisation
               affected to

                                     Outcome shared
                                     with complainant

                                                                          Appendix 7

Actions to be undertaken when a complaint is referred back or upheld by
the Healthcare Commission or Ombudsman

     1. Complaints concerning Family Health Service Providers

When a complaint concerning a Family Health Service Practitioner is referred
back from the Healthcare Commission the Complaints Manager will identify the
points raised and ascertain if there are any points of action required by either the
PCT or the practice involved.

If the Healthcare Commission / Health Service Ombudsman has criticised the
handling of a complaint by a Family Health Service Practitioner the Complaints
Manager will:

        Contact the practice to discuss the issues raised.

        Undertake an audit the practice complaints policy to ascertain if it is in line
         with current national guidance.

        Assess if the complaint was managed in line with this policy.

        Notify and seek the opinion of the Dental Advisor / Medical Director or
         other specialist advisor where appropriate.

        Discuss with the practice an action plan to address the issues raised and
         ensure that the practice Complaints policy is in line with national guidance.

        Respond to the Healthcare Commission / Health Service Ombudsman
         regarding the action undertaken in line with requested guidelines.

        If the Healthcare Commission / Ombudsman has criticised the PCT
         directly the Complaints Manager will notify the Director of the area in

        After consideration by the appropriate Director, the Complaints Manager
         will ensure that a response is made within the set deadline established by
         either the Healthcare Commission or the Health Service Ombudsman, and
         where necessary a response is made to the complainant, outlining the
         action to be undertaken.

2.       Complaints concerning the Primary Care Trust

Where a complaint has been referred back from the Healthcare Commission or
the Health Service Ombudsman the Complaints Manager will notify the Director

and Head of Service of the area concerned and will outline the action required
and the criticisms made.

After consideration by the appropriate Director, the Complaints Manager will
ensure that a response is made within the set deadline established by either the
Healthcare Commission or the Health Service Ombudsman, and where
necessary a response is made to the complainant, outlining the action to be

                                                                    Appendix 8

              Supporting staff who are the subject of a complaint

This appendix is currently under development and will be added when complete


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