Ref SDU Team Site Details Of Complaint Outcome Upheld 15/16/0290 Adult Mental. Not Health. Newtown Hospital - Aconbury North AMH

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1 Complaints closed in April 2016 Ref SDU Team Site Details Of Complaint Outcome 15/16/0290 Adult Mental 15/16/0537 Children, Young People And Families 15/16/0638 Adult Mental 15/16/0778 Adult Mental Home Treatment Team Worcester and Malvern Paediatric Speech and Language Therapy Worcester Malvern Adult Mental Team Counselling & Psychology Worcester Newtown Hospital - Aconbury North AMH Isaac Maddox House CYPF Rowan House AMH Newtown Hospital - Wulstan Unit Patient's family raised further concerns as a result of the care and treatment their sister had received. Parents of a patient raised further concerns following the involvement of a staff member. Father raised concern that his son was discharged from services. Patient raised further concern following receipt of the Chief Executive's letter in regard to their appointment with staff members. It was acknowledged that this had been a difficult time for the family and assured that the complaint had been reviewed and further clarity was provided. Assurance was offered in respect of the involvement of the staff member and provided an explanation in relation to the delay that had been experienced for the meeting being arranged. An explanation was provided that the services are not commissioned to provide treatment for adult patients who are diagnosed with Attention Deficit Disorder and the response provided information on who should be contacted. An explanation was offered in regards to the conduct of the staff members who assured that they were able to see one another during the appointment with the patient and had not conducted themselves in the manner described by the patient.

2 15/16/0836 Adult Mental 15/16/0847 Adult Mental 15/16/0852 Adult Mental 15/16/0926 Counselling & Psychology Worcester Bromsgrove Adult CMHT Psychiatrist - Wyre Forest Mental Team Minor Injuries Unit Newtown Hospital - Wulstan Unit New Brook Robertson Centre AMH Malvern Hospital Patient raised further concern following receipt of the chief executive's response in relation to text messaging reminders and availability of appointment cards. Patient raised concern that they had not been referred to another area and that they had been discharged from services. Patient raised concern about the way they were spoken to by the staff member and that their medication was reduced without consultation. Parent raised concern following the treatment provided to their child following their attendance at An apology was provided for the fact that the new clinical record system at the present time was unable to generate text messaging reminders. A further apology was offered that there had been a delay in the development and printing of appointment cards. It was explained that the patient did not require input from mental health services however it was acknowledged that the decision to discharge the patient could have been communicated differently. Assured that a discussion had been held in relation to changes with medication, however it was acknowledged that this was due to the side effects that the patient shared that they were experiencing. An apology was conveyed for the misunderstanding together with clarification that the patient could remain on their existing medication. It was acknowledged that the patient should have been referred to specialist services at an earlier opportunity and an

3 15/16/0939 Children, Young People And Families 15/16/0943 Care North 15/16/ /16/0971 Child and Adolescent Mental Service Tier3 Wyre Forest Physiotherapy Bromsgrove Enhanced Care Team Worcester - Warndon Podiatry Droitwich Kidderminster Centre CYPF Princess Of Wales Hospital CCN Warndon Clinic Droitwich Medical Centre CC the Minor Injuries Unit for a burn. Patient's mother raised concern that they attended a meeting in regard to her daughter but was not made aware this was part of a child protection process. Concerns also raised regarding errors contained in a letter. Patient raising further concerns regarding their treatment by the staff member and the previous complaint response. Daughter of a patient shared concern regarding the delay in treatment and lack of communication from the older adult community mental health team at Studdert Kennedy House. Patient was unhappy with the way that the staff member had come across to them and apology was provided for the fact that there was a delay. As a result of the complaint a number of actions were implemented. An apology was offered for the errors that had been contained in the letter and assurance offered that this had now been corrected. In respect of the issues relating to safeguarding, advised that this issue continued to be investigated and a further response will be provided. An explanation was offered in respect of the treatment that had been provided to the patient. In respect of the previous response, it was acknowledged that further explanations could have been offered and an apology offered for this. An apology was offered for the delay that the patient had experienced in receiving an appointment and for the delay in the clinical appointment letter being typed up. Assurance was offered that the member of staff had been spoken to and wished to convey

4 15/16/0993 Adult Mental 15/16/1002 Adult Mental 15/16/1019 Adult Mental 15/16/1029 Adult Mental Hadley Unit Crisis Resolution Harvington Ward Redditch Adult Mental Team Newtown Hospital - Elgar Unit - Hadley Unit Wildwood (AMH) Robertson Centre AMH Orchard Place AMH that a letter had been sent to an incorrect address. Patient's wife raised concern regarding an incident whilst the patient was an inpatient on Hadley Ward. Patient raised concern about the way they had been spoken to by staff members during a telephone call. Mother raised concern about the security of adult mental health in-patient ward as the patient had been able to leave the unit. Grandfather of patient concerned about the care his granddaughter is receiving from the community mental health team. their apology as they had not intended to come across in the manner that had been described. In respect of the letter, confirmation was provided that the correct address details had been updated onto the system. Assurance was offered that staffing levels were in accordance with safe staffing levels and that staff are appropriately trained in deescalating situations on the ward. Assurance was offered that the telephone calls had been listened to and it was felt that the patient had been responded to in an appropriate manner. An explanation was offered that staff had provided treatment in the least restrictive manner and therefore the patient was able to leave the ward. It was acknowledged that the care provided had not been of the standard expected and an apology was offered for this.

5 15/16/1046 Adult Mental 15/16/ /16/1054 Adult Mental 15/16/1061 Early Intervention North Inpatient Ward - Malvern Hospital Psychiatrist - Worcester Mental Team Abbott Ward New Brook Malvern Hospital Studdert Kennedy House AMH Evesham Hospital CC Sister of patient raised concern that their brother and family members are not receiving appropriate mental health input. Patient raised concerns regarding the diagnosis of a fractured hip. Patient raised concern regarding the attitude of the staff member and input from the services. Father of patient shared concern regarding the transfer of their son from hospital. In respect of the discharge, assurance offered that all colleagues have been reminded to be clear and concise when planning a person's discharge. Advised that there had been a domestic issue and the family had been given appropriate advice to contact the police. An explanation was further offered regarding the discussions about medication between the patient and the clinicians involved in their care. An apology was offered for the fact that the x-ray had been cancelled and assurance offered that in future all x-rays will be pursued to ensure that they are undertaken. Investigation was completed in regard to the concerns raised, however consent has not been received from the patient to share information with her mother. It was explained that the patient had been transferred due to a deterioration in their condition and therefore required treatment at another hospital. 15/16/1064 Outpatients Evesham Patient unhappy with the Explanation offered that a

6 Evesham Hospital CC 15/16/1070 Children, Young People And Families 15/16/1078 Care North Child and Adolescent Mental Service Tier3 Redditch & Bromsgrove Podiatry Bromsgrove Pear Tree Clinic Princess Of Wales Hospital CCN treatment and tests they are receiving for an injured ankle and for the delay in receiving elbow crutches. Parents raised concern that a report had been shared with the school without permission. Patient raised concern that they had not been able to receive treatment from the podiatrist. number of tests and x-rays are required to be able to determine what treatment is required. It was acknowledged that the patient had experienced a delay in being able to receive crutches as they had not been in stock at the time of the appointment and therefore were ordered as a fast track item. An apology was offered that the report had been shared with the child's school without permission. Assurance offered that the pathway is currently being reviewed and this will include receiving confirmation of consent prior to a report being sent out. It was explained that the podiatry service are commissioned to provide treatment for high risk patients for example: patients who have diabetes with complications, patients with poor circulation or sensory loss. As the patient's condition had not fallen within these categories they were unable to receive treatment and were encouraged to go back to their General Practitioner.

7 15/16/P0162 Specialist 15/16/P0166 Specialist 15/16/P0171 Specialist 15/16/P0173 Specialist care - HMP Long Lartin care - HMP Hewell care - HMP Long Lartin care - HMP Long Lartin HMP Long Lartin HMP Hewell HMP Long Lartin HMP Long Lartin Patient raised concern regarding their appointments with a staff member, medication, cancellation of appointment. Patient concerned that medication they are receiving is not the same that they were previously prescribed by their General Practitioner. Patient raised concerns that they were being given incorrect medication. Patient raised concerns regarding the Prison Services. It was acknowledged that the therapeutic relationship with the staff member had broken down and the patient would now be seen by another staff member. In respect of the cancelled appointment, this decision had been made by the Prison staff. With regard to the request for diazepam medication it was explained that the Doctor did not feel that this was in the patient's best interest. As healthcare services are now provided by another organisation, the patient was encouraged to contact them as they will be able to look at what medication the patient receives. Assurances were offered that the patient had received appropriate medication and that an appointment would now be scheduled so that the patient could discuss their medication and treatment. An explanation was offered that the services that the patient raised concerns with, fell within the remit of the Prison service and assurances were offered in respect of the appointments with

8 15/16/P0175 Specialist 16/17/0006 Adult Mental 16/17/0027 Adult Mental 16/17/0038 care - HMP Long Lartin Wyre Forest Adult Mental Team Worcester Adult Mental Team Izod Ward HMP Long Lartin Robertson Centre AMH Studdert Kennedy House AMH Evesham Hospital CC Patient raised a number of concerns in regard to dental appointment, medical notes and request for doublebase gel. Patient's father raised concern that their son had been discharged from the Psychiatric Nurse. Mother of deceased patient raised new questions regarding the patient's diagnosis and information contained in the records. Patient's son raised further questions in relation his mother's inpatient stay in November the healthcare team. As healthcare services are now provided by another organisation, the patient was encouraged to contact them as they will be able to look at what is happening for future dental appointments and what medication can be provided. Assurance was offered that the discharge planning had been discussed with the patient and an explanation was offered for the reasons for the discharge. It was explained that within mental health a person's diagnosis can change and this was as a result of a second opinion. In respect of the information within the records assurance was offered that a note can be contained in the records to advise that there is a disagreement regarding an entry. It was acknowledged that some time had passed since the patient received services, however information was provided to explain the decision to use bed rails whilst the patient was in hospital. Further

9 16/17/P0002 Specialist care - HMP Oakwood HMP Oakwood Patient requested to receive dental implants. information was provided regarding the Care and Comfort rounds that are now undertaken on the wards. It was explained that the NHS are unable to provide a person with dental implants unless they have suffered with oral cancer or development abnormalities.