The following complaints were closed and upheld in September 2023:
Personal Recs
Information was incorrectly recorded.
Appointment
Appointment delayed.
Staff Attitude
Staff member spoke inappropriately.
The following complaints were partially upheld in September 2023:
Clincial Care
Questioned if appropriate care received from the nurse.
Clinical Care
Patient raised concerns about processes not being followed.
Staff Attitude
Attitude of the nurse did not meet expected standards of the patient.
Clinical Treatment
The team did not understand part of the diagnosis, therefore appropriate support not received.
Clincial Treatment
Unhappy with how pressure ulcer was managed.
Communication/info
Unhappy with care and treatment.
Clinical Treatment
Patient felt unfair assessment for CHCPatient felt unfair assessment for continuing healthcare.
Appointments
Patient unhappy with length of time waiting for appointment.
Communication/info
Communication with patient was poor.
Clinical Treatment
Lack of clinical input.
The following complaints were closed and upheld in August 2023:
Communication
Family members were not contacted when patient was transferred.
Clinical Care
Received referral but no action taken.
Clinical Care
Trust Policy was not adhered to with regard to the appropriate treatment.
The following complaints were partially upheld in August 2023:
Communication
Team should have picked up that the patient's pain medication may be causing her symptoms.
Medication
Electronic patient record entry confirms there was confusion by the inpatient team about what dose the patient was prescribed.
Care and Treatment
Communication strategies had not been discussed with the relative and if previously agreed, may have reduced concerns.
Clinical Care
No care plan developed during period of care.
Clinical Care
Staff could have communicated better with patient.
Appointments
Had had not been notified of appointments.
Communication
Poor communication with service user.
Appointments
Team did not communicate with patient.
Clinical Care
Nurse failed to examine the patient in pain which resulted in them being admitted.
Communication
Lack of contact from nursing services.
Clinical Care
Referral incorrectly signposted.
Staf Attitude
Clinic behind schedule for the appointment and therefore the appointments were late.
Appointments
Appointment delayed.
Appointments
Patient travelled to appointment and was advised it had been brought forward and they had therefore missed it.
The following complaints were closed and upheld in July 2023:
Communications/Care and Treatment
Patient was not receiving holistic care.
Care and Treatment
Nurses did not identify what their role was or what the process was that needed to be followed.
Personal Recs
Incorrect info held on records.
The following complaints were partially upheld in July 2023:
Leave
Patient leave was suspended.
Staff Attitude
Staff member acted inappropriately.
Care and Treatment
Medical review needed to manage symptoms at home was not completed correctly.
Staff Attitude
Staff member spoke inappropriately about another person.
Care and Treatment
Poor recording in clinical records, documentation, and staff attitudes.
Care and Treatment
Level of care could have been better.
Medication
Side affects of medication.
The following complaints were closed and upheld in June 2023:
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Personal recs Information was incorrectly recorded |
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All aspects of clinical treatment The reviewer also found a missed opportunity to attend and complete a full mental health assessment |
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Personal Recs The reviewer found that the standard of timely and effective communication to the family following the breach and follow up of the breach with was not of the standard expected from the Trust. |
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All aspects of clinical treatment Delay in package of care delivered |
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Communication/info Nurse Assessor had previously met the patient historically but did not meet her on the day of assessment. No communication of changes to representatives. |
The following complaints were partially upheld in June 2023:
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Communication/ info It is recognised that the doorbell for the ward was out of action, awaiting Patient felt she was over sedated this was not substantiated. |
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All aspects of clinical treatment There was conflicting information on both checklists completed. However the team communicated well about any changes with the family. |
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Attitude of staff The reviewer advised that The MHP concerned has reflected on their practice and whilst there was no evidence in the clinical records that the pt's concerns and presentation were treated any differently than others in the department, first impressions count, and this can impact on the reputation of the Trust |
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Admission/discharge/transfer The reviewer was unable to find any information within the clinical record to indicate that safeguarding advice had been sought or any documentation in relation to agreed actions to safeguard. |
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Attitude of staff Patient stated that an appointment was not offered but at the time they had not requested an appointment. Review of clinical documentation does appear to be limited in attempts to persevere with the patient’s engagement in conversation. |
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All aspects of clinical treatment Lack of support provided at times, however the medical review was comprehensive. |
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All aspects of clinical treatment The communication between the teams seems to have been ineffective. The reason for this breakdown in communication has been reviewed to minimise the risk of this occurring in the future, however staff did follow process. |
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Communication/info Info recorded should not have been, procedures followed |
The following complaints were closed and upheld in May 2023:
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Appointments-Delay/cancelled Reason for rejection of the referral not stipulated within the letter. |
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All aspects of clinical treatment due to the fact the assessment practitioner did not formally assess capacity although they did document 'lacking insight'. |
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Communication/Info Service did not communicate with service user in the format requested |
The following complaints were partially upheld in May 2023:
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Patient privacy and dignity The reviewer found that correct procedures around escalating concerns were not followed but found no evidence to support the other aspects of the complaint |
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Communication/Info Service aware of needing a specific appointment time and did not facilitate. However, communication preferences were considered. |
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All Aspects of clinical treatment Poor communication with the family identified however correct process followed. |
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Communication/info There is no evidence of face to face consultation, however the reviewer concluded the service user was sign posted correctly and communicated with regularly. |
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Appointments – Delay/cancelled One appointment was cancelled, however attempts were made to contact the service user. |
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Attitude of staff There have been occasions when appointments have been changed and times when the patient was expecting to contact him has not happened or this has been a different person |
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All aspects of clinical treatment The reviewer found that nursing staff should have considered constipation as a cause of agitation, that response times were not of the expected standard and communication with the family could have better, however correct documentation was provided. |
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Attitude of staff Safety management completed but did not receive a full comprehensive assessment. |
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All aspects of clinical treatment Discharged following non attendance at OPA even though informed they could not make the date however service did sent the referral to another service appropriately. |
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Non clinical No evidence incorrect documentation was sent. no clear recording of conversation had with service user |
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All aspects if clinical treatment The reviewer found that one aspect of the complaint as partially upheld in terms of lack of meeting emotional needs. The reviewer found all other aspects of the complaint not upheld. |
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Attitude of staff Staff member acknowledged the conversation was awkward, however did offer to call back at more convenient time |
The following complaints were closed and upheld in April 2023:
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Communication / Care and Treatment failed to deliver the correct feed on the agreed delivery dates. |
The following complaints were partially upheld in April 2023:
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All aspects of clinical treatment Poor communication and record keeping, it is not routine to complete a detailed wound care form however the reviewer found in this case it would have been helpful to of done this to substantiate the clinical decision. |
The following complaints were closed and upheld in March 2023:
- Care and treatment. Concerns about lack of information with family and patient complained of pain and staff ignored. The reviewer has not been able to evidence within the records that any family were invited to six reviews
- Diagnosis. Unhappy been misdiagnosed by two different doctors and medication dosage has been documented incorrectly. The discharge process was a key element to concerns both in terms of the service user’s view on readiness for discharge and the way in which planned medication changes were managed post discharge
- Staff attitude. Concerns raised about attitude and behaviour of staff. The impact of the family’s experience was explained to the staff nurse in full for her to reflect on this and consider it in future practice. This will be discussed regularly and monitored during regular one to one management supervision
- Care and treatment. Waiting time for psychological services. Informed at an earlier date unlikely to be admitted for treatment. Apologised and explained that the community mental health teams are unable to send electronic prescriptions directly to pharmacies in the community. The reviewer is hopeful this will be improved in future as primary and secondary care work together in a more collaborative way
- Documentation. Disagreed with information in discharge papers shared with GP, also disagrees with diagnosis. Diagnosis should be formally reviewed on balance with learning from this complaint and information available to the clinical team at the time of assessment
- Care and treatment. Unhappy with treatment from team, appointment being late, attitude of staff. Due to the staff member running late and not having prepared for the session before hand, there was a lack of understanding of the patient’s medical history.
The following complaints were closed and partialy upheld in March 2023:
- Staff attitude. Staff to liaise affectively going forward
- Clinical care. Community mental health team offer of care, routine appointments with a psychiatrist and duty contact did not meet needs
- Access delay. Missed opportunity to investigate blood pressure results in more detail. discharged before being assessed by the clinic
- Care and treatment. Consideration could have been given to remain on the caseload for lengthier period to reassess pain following GP intervention
- Care and treatment. Poor documentation and no seating plan
- End of life care. There was delay in the nurses responding to messages left on the answerphone
- Care and treatment. Poor communication
- Care and treatment. Lack of engagement and not enough documentation
- Care and treatment. The reviewer found that staff should be reminded of the importance of positive attitudes towards those who utilise our services
- Care and treatment. Better communication needed
- Staff attitude. Poor level of cleanliness on the ward
- Care and treatment. Failure in the communication between the Trust and the family within the 72 hour process
- Care and treatment. Review information given to patients in timely manner going forward with regard to application of medication
- Care and treatment. The team to ensure they have everything in place and also that they have the district nurse contact numbers going forward
- Care and treatment. Improved communication with patients and families going forward.
- Referral. Referral should have been sent there is no evidence to support this had taken place
- Care and treatment. Referral not sent when advised it had been.
The following complaints were closed and partialy upheld in February 2023:
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Care and treatment. Numerous issues raised regarding the ward. Lack of contact at the point of admission and inviting them to attend care reviews
- Confidentiality. Mother unhappy that breached her confidentiality. The reviewer found that the lack of communication from the service contributed to the situation
- Staff attitude. Issues raised about staff attitude and behaviour on ward. Staff should be working collaboratively when locking in and ending night time confinement.
- Bed not available. No bed available, patient at home and a fire being started accidently which as caused her to go into temp accommodation. Incorrect information shared at the bed management meeting
- Care and treatment. There was lack of monitoring and reviews when new to service
- Staff attitude. Issues raised about staff attitude and behaviour on ward. The importance of staff working collaboratively when locking in and ending night time confinement.
The following complaints were closed and upheld in January 2023:
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Physical health care. Son is unhappy that the plan to check his mother's blood pressure wasn't followed when doctor went on leave. This complaint evidences a break down in communication between the multidisciplinary team and the patient family
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Confidentiality. Received letter from team which was unsealed and open which caused distress. Reduced administrative support has a palpable, negative effect on service delivery. In this instance it has contributed to a deterioration in a service user’s mental health
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Care and Treatment. If assessed appropriately why was no definitive action implemented
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Medication. Patient wishes to change the format of her medication from tablets to liquid. Lack of documentation of open dialogue and co-production.
The following complaints were closed and partialy upheld in January 2023:
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Care and treatment feels let down by the team. Poor communication
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Care and treatment. Mother raised concerns around lost property, assault, lack of communication and care and treatment. Need to review process
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Care and treatment mum not happy with care and treatment received from Walk In Centre. Assessment was not given, this was due to the high number of patients
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Patient injury received meal on a broken plastic tray. Food container was compromised. Unproven that the patient accidentally choked
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Communication. Not contacted by services when he was feeling suicidal. Improvements were required to the Psychology Step 4 SOP
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Assessment. Parents concern around the ND Pathway and the assessments completed. The assessment should not have been recommended for a child who is nonverbal staff not aware of referral restrictions around third sector providers. Several instances where communication with parents could have been improved
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Patient Injury. Received meal on a broken plastic tray. The food container was compromised, unproven that the patient accidentally choked.