Agenda item: 10.1, Public Board meeting Date: Title: Prepared by: Brenda Leaman, Patient Experience Lead, Tracey Reeves, Deputy Chief Nurse / Midwife Presented by: Em Wilkinson-Brice, Deputy Chief Executive/Chief Nurse Responsible Executive: Summary: Em Wilkinson-Brice, Deputy Chief Executive/Chief Nurse The purpose of this paper is to provide the Board of Directors with assurance that formal complaints made to the Trust during the period 1 April 2016 to 31 March 2017 are being considered in accordance with the NHS and Social Care Complaints Handling Regulations (England) 2009. Actions required: Status (x): History: Link to status below and set out clearly the expectations of the Board when considering the paper. Decision Approval Discussion Information x This report is part of the annual planning cycle. The last annual complaint report was reviewed in January 2017. Link to strategy/ Assurance framework: The issues discussed are key to the Trust achieving its strategic objectives. Monitoring Information Please specify CQC standard numbers and tick other boxes as appropriate Care Quality Commission Standards Outcomes NHS Improvement Finance Service Development Strategy Performance Management Local Delivery Plan Business Planning Assurance Framework Complaints Equality, diversity, human rights implications assessed Other (please specify) 1 of 16
1. Purpose of paper The purpose of this paper is to provide the Board of Directors with assurance that formal complaints made to the Trust during the period 1 April 2016 to 31 March 2017 are being considered in accordance with the NHS and Social Care Complaints Handling Regulations (England) 2009. The report has been reviewed and revised following presentation at the Patient Experience Committee (November 2018). 2. Background This paper provides an overview of: The number of complaints and concerns received from 1 April 2016 to 31 March 2017, including any referrals for independent reviews to the Parliamentary Health Service Ombudsman (PHSO). Examples of Trust Wide learning Areas for development over the next year 3. Key Issues The complaints and concerns performance shows an overall increase in the number of complaints and concerns by 5.4%. The number of acknowledgements sent within the target time remained the same as for 2015/16. The Royal Devon & Exeter (RDE) results during the same period (1 April 2016 to 31 March 2017), showed there were only 285 complaints received compared to 377 for 2015/16, a decrease of 24.5%, a significant improvement. This is due to the conversion of complaints to concerns which has increased by over 30% in comparison to the previous year and making the first contact count with the complainant. Of the 802098 patients that were admitted or attended the hospital during 2016/17, 876 (0.11%) registered a complaint or concern with the Trust. The top complaint or concern themes are: Lack of communication Providing Information and Receiving Information Length of wait for review/treatment During the period 1 April 2016 to 31 March 2017, 13 complainants requested an independent review. Of these, final reports were received on four were either upheld or partially upheld with three not upheld. The PHSO did not investigate two cases. At the current time the remaining four cases are still under investigation by the PHSO. In the same period the Trust received ten Final Reports (three of which were outstanding from 2015/16. Of these cases five were either upheld or partially upheld with five not upheld. During 2016/17 nationally the PHSO upheld 40%. The Trust upheld rate for 2016/17 stands at 46% compared to 33% for 2015/16. 2 of 16
Regular meetings continue to be held with the Divisional Patient Experience Leads to ensure continuity in the handling of complaints with the opportunity to discuss learning from complaints. The percentage of cases resolved within 45 days has improved from 61% in 2015/16 to 78% in 2016/17. There remains a focus to further improve this throughout the next year. Last year s developments have been implemented with further areas identified for the forthcoming year ahead. 4. Resource/legal/financial/reputation implications Provision of assurance on Trust wide complaint handling. 5. Link to BAF/Key risks None 6. Proposals To continue to develop the performance management process to monitor progress and ensure learning from complaints is implemented. 7. Recommendation To approve the report. 3 of 16
1. Background Complaints Annual Report 2016/17 1.1 As part of the Complaint Regulations (2009) there is a specific requirement for an annual report on complaint activity to be reported to the Board. The Board report is prepared following publication of the KO41A (the annual complaints data collection report). The key findings from the KO41A report have been used to consider the Royal Devon and Exeter s performance (RD&E). 1.2 From 2015-16 the national annual written complaints data KO41a report NHS Hospital and Community Health Service (HCHS) was revised in both format and frequency (from annual to a quarterly publication). Due to these changes it is not possible to compare data below the overall totals from 2015-16 and 2016-17 with earlier years. The 2015-16 and 2016-17 HCHS data is being classed as Experimental Statistics. 1.3 Nationally there has been an overall increase of 1.4% in the number of HCHS written complaints for 2016-17 from 2015-2016. However, in the South West region there was an overall decrease of 1.8%. This is likely to be reflective of robust processes being in place to resolve potential and verbal complaints before they escalate to written complaints. The RD&E results during the same period (1 April 2016 to 31 March 2017), showed there were only 285 complaints received compared to 377 for 2015/16, a decrease of 24.5%. Figure 1 below shows the number of complaints received by month for the last three years. Figure 1: Comparison of complaints over the last three years. 4 of 16
1.4 During the period 1 April 2016 to 31 March 2017, the Trust received 591 concerns which is an increase of 30.1% on the figure (454) for 2015/16. Figure 2 below shows the number of concerns received each month for the last three years. The increase in March 2017 was for the Orthopaedic Outpatients and Cardiology departments. Figure 2: Comparison of concerns received by month for the last three years. 1.5 In total, there were 876 complaints and concerns received from 1 April 2016 to 31 March 2017 which is an overall increase of 5.4% on the total number (831) for 2015/16. Table 1: Complaints and concerns by quarter for 2016/17 Financial Quarters Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17 Total Complaints 64 78 68 75 285 Concerns 148 151 116 176 591 Total 212 229 184 251 876 1.6 The number of complaints and concerns received is low when compared to the number of contacts with patients. 5 of 16
Table 2: Number and type of admissions and attendances in 2014/15, 2015/16 and 2016/17. ED IP Day Case Outpatient Total Attendances Admissions Admissions Attendances 2014/15 105489 42353 86377 510468 744687 2015/16 107794 43936 87357 511875 750962 2016/17 98867 43347 90432 569452 802098 1.7 Of the 802098 patients that were admitted or attended the hospital during 2016/17, 876 (0.11%) registered a complaint or concern with the Trust. Table 3: Total number of admissions and attendances by clinical speciality and the number and percentage of complaints and concerns received in 2016/17 Specialty Number of admissions or attendance by patients No of complaints, concerns % of complaints Concerns by no. footfalls Medical Services (inc ED) 267668 277 0.10% Surgical Services 256869 358 0.14% Specialist Services 220412 171 0.08% Community Services 57149 8 0.01% Other (inc Finance & 62 Operations) N/A Total 802098 876 0.11% Table 4: RD&E Patient Ages for Complaints and Concerns 2016/17 1.8 The Royal Devon & Exeter (RDE) results during the same period (1 April 2016 to 31 March 2017), showed there were only 285 complaints received compared to 377 for 2015/16, a decrease of 24.5%, a significant improvement. This is due to the 6 of 16
conversion of complaints to concerns which has increased by over 30% in comparison to the previous year and making the first contact count with the complainant 2. Analysis of Complaints and Concerns 2.1 The table below shows the comparison of complaints by age between the national and South West figures for 2016-17. The data is similar to 2015-16. Age National South West RD&E Age 0-5 3.1% 3.0% 1.9% Age 6-17 3.4% 3.2% 4.6% Age 18-25 4.4% 3.8% 5.4% Age 26-55 26.0% 21.0% 29.9% Age 56-64 8.1% 7.4% 12.8% Age 65-74 10.0% 11.0% 15.6% Age 75 and over 14.9% 16.6% 21.8% Age Unknown 30.1% 33.9% 7.9% 2.2 The top three themes for all complaints nationally are the same as for 2015-16 as set out below. Theme 2015-16 2016-17 All aspects of clinical treatment 32.0% 26.7% Written & oral communication to patients 18.6% 14.7% Patient Care inc Nutrition/Hydration 15.2% 11.4% Attitude of staff 13.9% 10.1% 2.3 The clinical divisions have continued to analyse their complaint themes alongside the other patient experience work, which is presented to the Patient Experience Committee (PEC) on a quarterly basis. 2.4 RD&E Top Themes Comparison of the top themes from 2015/16 2016/17. Communication is one of the top 5 themes reported nationally during 2016-17 which is reflected in the top themes for the RD&E. Theme 2015-16 2016-17 Lack of Communication 11.3% 12.9% Providing Information and Receiving Information Length of wait for review/treatment 2.8% 5.9% 3.9% 4.8% 7 of 16
The following sections provide examples of the issues and changes that have been put in place to address the top trust-wide themes. 2.4.1 Communication Complaints featuring communication often link with other themes such as providing and receiving of information, attitude of staff and length of wait for appointments. All complaints and concerns logged under this heading are reviewed and are often spread across a number of specialities. Any actions and/or learning from complaints featuring communication are shared with the clinical teams concerned so that they can reflect upon the experience of patients or their families/carers in order to improve the care of patients in the future. Where appropriate, the member(s) of staff involved in a complaint is asked to meet with the respondent and the complainant s comments are explored. Where there is learning this is shared with the team through Comms Cell and newsletters. Communication and access to services is a key feature in many of the complaints for Fertility Services. This is being addressed through various streams of work including patient engagement work (feedback survey, open evening), leadership training for staff, review of the patient pathways and auditing of patient telephone calls. Some examples of where actions have been taken as a result of communication issues being raised: Advanced Dementia Awareness course arranged for a group of staff, to raise their awareness of these vulnerable patients, and the effect being in hospital can have on them. Feedback to staff regarding terminology used when speaking with patients, to avoid jargon and speak in plain English. One concern that was partially upheld related to a patient who had a procedure cancelled as they were allergic to the type of equipment being used. As a result of this the department are undertaking a review of their patient information leaflets in order that this allergy information is included. Acknowledgement that the manner in which patient s relatives found out they were on the Intensive Care Unit was inappropriate. The Matron has fed back to the staff that it is inappropriate to hold sensitive conversations in a corridor. A patient raised concerns regarding conflicting information received regarding appointments, and appointments not being cancelled despite the patient phoning to cancel. The patient wished for administrative processes to be improved. The Cluster Manager has found areas for improvement with the processes and the need for some training for staff, which should prevent a recurrence. 8 of 16
A relative of a patient was not allowed to visit despite prior agreement with staff. The Matron has discussed this with staff, and raised this at the ward meeting and Matron s meeting. A process has been implemented to ensure that communication with the patient in regard to the potential wait to see the speciality doctor in the Emergency Department is improved. In addition the Emergency Department are communicating to Trauma and Orthopaedics (T&O) to ensure that T&O are aware that a patient is waiting to see them. On discharge from the Emergency Department a patient was told they would have an appointment and be given advice, but did not receive any further contact. A meeting has been held with staff, and further training provided and a clear referral process has been implemented where patients have attended the Emergency Department and require further contact from other departments. 2.4.2 Providing Information and Receiving Information This theme is often linked with the lack of communication theme. examples of the actions that have been taken are: Some Staff to ensure that patients details are correctly checked when booking in at the Emergency Department reception. Feedback was given to staff to ensure it is clearly communicated to clinicians that a patient is booked for a telephone consultation rather than face to face. Feedback was given to staff to confirm that queries regarding booking/cancelling of appointments should be directed to the booking office. A patient pathway re-design is underway in the Eye Unit. Once this is complete, patient appointment letters will be revised to accurately reflect timings within the unit to avoid confusion. A busy shift resulted in a discharge letter/summary not being sent to a GP. Feedback was given to staff to ensure that GPs receive copies of patient discharge summaries. The Radiology bookings team are currently experiencing low staffing levels and additionally there are some issues with the current phone system. As a consequence they have upgraded their phone system to address this and improve the service to all patients. The Computerized Tomography (CT) patient information leaflet is now available on the Trust website. This has been highlighted to the Administration team so that they can advise patients when bookings are made over the telephone. Patients taking Metformin who receive contrast for their scans are given standard advice letters to stop Metformin and have their renal function checked at their GP surgery after 2-3 days. This is to avoid metformin- 9 of 16
induced lactic acidosis. Following the feedback from this patient, the letters have been changed to say that blood tests should be performed 3-5 days after the scan in line with the wording of the department policy. The 3-5 day period should cover weekend and Bank Holiday situations. Following concerns raised with regard to the Cardiology administrative team a review of processes took place and actions were put in place which included: o o o o o Introduction of voice recognition dictation for Cardiologist to facilitate timely typing times Recruitment of the full complement of the staff for the Cardiology admin team Reconfiguration of the admin team to create a Cardiology specific booking time. Short term additional admin support from other Medical specialties and Communities division to reduce the typing backlog. Reduced telephone cover to create protected admin time with the admin team. 2.4.3 Length of wait for review/treatment Complaints with this theme typically focus on the experience of patients who have waited for treatment following a consultation. Within the Emergency Department complaints relating to waiting times originate predominately from the evening and night-time and reflect the marked increase in the number of attendances being seen at these times. Some of the actions taken as a result of the issues raised under this heading are: The Emergency Department staff are trialling the use of a waiting room nurse in order to ensure care continues for these patients whilst they are waiting. This includes repeating patient observation, administering analgesia and to respond to any patient queries that patients may have. This means that staff remain visible to patients in the waiting room and at present seems to be successful in reducing written complaints. This role however is dependent upon staffing levels and is actioned only when staff can be made available. In addition there is an overall Trust action plan in relation to the 4 hr. target which as this delivers will reduce the current pressure on the Emergency Department. The Cardiology administrative team have faced workforce issues which have been escalated and are being addressed. A recovery plan was implemented which resulted in a reduction in the backlog of clinic letters waiting to be typed 3. Acknowledgement Rates 3.1 4. Of the 876 complaints and concerns received in 2016/17, 860 ((98%) of cases were acknowledged within three working days. This is the same as for 2015/16. Requests to the Parliamentary Health Service Ombudsman (PHSO) for an Independent Review 10 of 16
4.1 Complainants, if dissatisfied with the Trust s response to their complaint, can request the Parliamentary Health Service Ombudsman undertake a review of the Trust s management of their complaint. When reviewing the management of a complaint under its closer look process, the Ombudsman may decide that the complaint process has not been fully completed and refer the complaint back for local resolution or conclude that the Trust has done everything possible to resolve the complaint and no further action is required. If the Ombudsman decides that a formal investigation is necessary and the conclusion following that is that there has been poor complaint handling or serious clinical failings, the case will either be fully or partially upheld. 4.2 The top three reasons for complaints about Acute Hospitals that were identified by the PHSO in their investigations into NHS complaints were the same as for 2015-16 as listed below: Clinical care and treatment, Poor communication and Diagnosis failures 4.3 The PHSO state that all Trust s should use complaints data to examine how their organisation is performing relative to others, and to identify areas for improvement. From reviewing the upheld and partially upheld cases and ensuring that the actions identified have been implemented we will continue to learn from our patient/relatives experiences. During the period 1 April 2016 to 31 March 2017, 13 complainants requested an independent review. Of these, final reports were received on nine with four being either upheld or partially upheld and three not upheld. The PHSO did not investigate two cases. The remaining four cases were still under investigation at the end of March 2017. 4.4 4.5 In the same period the Trust received ten Final Reports (three of which were outstanding from 2015/16. Of these cases five were either upheld or partially upheld with five not upheld. During 2016/17 nationally the PHSO upheld 40% of all cases they received. The Trust upheld rate for 2016/17 stands at 46% (which takes into account those cases the PHSO received but did not take forward for investigation) compared to 33% for 2015/16. Themes identified by the PHSO in their final reports and actions taken by the Trust for the five cases either fully or partially upheld during 2016/17 are shown below. In addition to the below financial redress was made in three cases ( 4400 in total). Theme Lack of investigation into symptoms or referral to appropriate department Action Taken by Trust Establish joint working group between Acute Medicine and Neurology to review pathway for patients with suspected serotonin syndrome. Joint working group to make recommendations for suspected serotonin syndrome pathway, ensuring that all necessary referrals and investigations are undertaken before diagnosis is confirmed. Working group recommendations to be taken to the governance groups for Neurology and Acute Medicine for 11 of 16
approval and discussion with the wider clinical teams. Information not given to patient for informed consent Procedure carried out incorrectly Delay in surgery Delay in complaint response Treatment pathway not discussed with patient s family Regulations and Guidelines for Overseas patients not followed regarding the eligibility of a patient for NHS treatment Approved recommendations to be shared with all consultants who work on the Acute Medicine rota. A review of the consent process to provide assurance that, where necessary, written consent is provided, and the likely outcome of surgery is clearly communicated to patients. Review training of the Surgeons undertaking the procedure. Initial triage process of complaints reviewed to ensure urgent issues are identified early and highlighted to the Divisional Patient Experience Leads. Initial phone call by the Division to the complainant is also an additional opportunity to ascertain anything requiring more immediate action. Process reviewed and complainants to be kept informed of any potential delays, including the reasons for this. The reviewing of timescales for providing responses is ongoing, and any shortcomings or issues with this are highlighted to the Assistant Director of Nursing for the relevant Division with the expectation that remedial action will be taken. A performance metric has also been included in the monthly PAF meetings for the Divisions. The case has been discussed within the Cardiology and Emergency Department and educational sessions held to improve communication. In particular we have identified the importance of good communication to family members in patients with confusion. We have also made clinicians aware that where a patient has a Treatment Escalation Plans form there is likely to be a need for more in depth and detailed discussion about the risks and benefits of treatments. Increased the number of Consultants providing ward care for Cardiology. Review of process to be undertaken by the Private Healthcare Business Manager. Following the introduction of the 2015 regulations training sessions now take place predominantly amongst administration teams across the Trust. Over the last 18 months, awareness has improved greatly within the Trust regarding overseas visitors as a result. This training is repeated due to staff turnover. There is also a session planned with the Surgical Senior Nurses and Matrons. Further sessions are being arranged with the Emergency Department and other areas around the Trust. Patient status form has been updated as a result of the complaint to highlight the charging regulations. Work is underway to publish a patient information leaflet that can be displayed in Emergency Department and given to 12 of 16
patients to explain the reason for charging. Renal patient diagnosed with terminal cancer. Complainant states that there was no long term palliative care plan in place for when dialysis would need to stop. On discharge of the patient the complainant says there was no palliative care plan in place The PHSO ruled that it was not appropriate to have a discussion about this as early as the complainant felt it should have happened but this could have taken place a few weeks prior to the dialysis being stopped. An apology was given to the complainant for distress caused as a result of a miscommunication. A referral to the palliative care team should have happened for support to have been provided to the patient both in hospital and after discharge. The Trust will review the referral process to appropriate palliative care teams outside of the RD&E Trust when patients are discharged. 4.5 Actions resulting from a PHSO case are identified by a specific code on Datix. All overdue actions are monitored through the Incident Review Group and the Patient Experience Leads meetings to ensure all actions are being completed. A compliance audit on actions is undertaken on a yearly basis by the Trust Risk Manager as part of the Trusts Monitoring of the Incident Reporting policy. 5. What was proposed for the year 2015/16 and what has been achieved? Last year s annual report detailed a number of initiatives that would be implemented over the year. 5.1 Enhance the monitoring of complaints through performance Performance over the year has improved across all three clinical divisions. This is monitored through the monthly Performance Assurance Framework and going forward will include additional metrics that monitor contact with patients to ensure a personalised customer focused approach. 5.2 Increase 0-14 day s response times and increase number of responses by local resolution Whilst 0-14 day response times have not increased over the year, there has been a significant improvement in the reduction of complaints and conversion to concerns that are resolved by local resolution as a result of more direct contact with complainants on receipt of the initial complaint. This area of focus will continue through 2018/ 2019. 5.3 Scrutinise and learn from the cases that are investigated by the PHSO These are reviewed in detail through the Patient Experience Committee, Performance Assurance Monthly meetings and the Patients Experience Leads meetings. 5.4 Develop and implement a work programme to address the top three themes as detailed below: 1. Communication The Trust has for a number of years had restricted visiting for relatives. An open and honest conversation has taken place with the Consultant Body and through the Care Matters Forum with speakers from two other local hospitals who have moved to less restrictive visiting. The move to less 13 of 16
restrictive visiting as part of our strategy to improve communication with carers and relatives was broadly supported and an implementation plan is being developed to launch revised vising hours for 2018. This will include a charter for patients and staff outlining expectations in line with the Trusts Values and Behaviours. A targeted training programme, building on the principles of advanced communication has been developed to support the Patient Experience Leads in their role. This will be piloted to test out its usability for other professional groups in the Trust. 2. Attitude of nursing staff Compassion in practice and key aspects of this have been built into the Trust Induction programme, Clinical Leadership programme for band 6 and above as well as the Preceptorship and nursing auxiliary programmes. 3. Medication Focus on reducing missed medications by standardising visual triggers Trust wide for identifying that patients have their own stock of medication on the drug chart. The pharmacy department have worked with the pharmacy technicians to develop two visual triggers on the patients drug chart to identify Patients Own Drugs (POD) and Patients Supply At Home (POSH) to improve safety in this area. Second year of Medication Safety Thermometer focusing on high risk medication and omissions. Harm levels have remained low throughout the audit cycle this year. Review of high risk medication omissions show no areas of concern in relation to anti-coagulation, insulin or opiod omission as these are predominantly for sound clinical reason. Further work is underway to understand anti-infective omissions where rationale is given drug not available as one of the highest reasons. This work will continue to report through the Medication Safety Group. 6. Plans for the year ahead Enhance monitoring through performance to continue with the implementation of a metric to reflect timeliness of patient contact To continue to ensure that acknowledgement rates are maintained Undertake a review of the quality of complaint responses, aiming to see a reduction of cases upheld by the PHSO Develop and implement a work programme to address the top three themes. 1. Communication Consider training requirement for advanced communication skills for key staff groups. 2. Providing Information & Treatment This will be encompassed into the Outpatient re-design work that is due to take place through 2018 / 2019. As the information flow to patients in relation to appointments and how this is delivered will form a huge part of the transformation programme. 3. Length of Wait and Treatment This impacts through two main areas currently Trauma and Orthopaedics and Cardiology where there are detailed action plans 14 of 16
References: in place which will be monitored through the monthly Performance Assurance meetings with the relevant division. 1. Data on Written Complaints in the NHS 2016 17, (KO41A) Health and Social Care Information Centre. 2. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. 3. Parliamentary and Health Service Ombudsman Annual Report 2016/17 15 of 16
Appendix 1 Table 4: Number of written complaints received by Trusts in the South West Region during 2016-17 Trust Total New Received Total Resolved No. upheld % Upheld of resolved complaints RD&E 295 322 54 16.8% Avon & Wilts 346 314 62 19.7% Partnership Devon 208 217 20 9.2% Partnership Dorset 468 530 188 35.5% Healthcare University Gloucester 907 962 257 26.7% Great 660 516 151 29.3% Western North Bristol 627 776 472 60.8% N Devon 234 246 2 0.8% Plymouth 571 579 299 51.6% Poole 211 258 48 18.6% Royal 378 422 56 13.3% Cornwall Royal United 213 216 26 12.0% Bath Somerset 157 157 12 7.6% Partnership Torbay & 233 175 18 10.3% South Devon SWAST 1394 1393 737 52.9% Weston 248 125 69 55.2% Yeovil 153 147 51 34.7% 16 of 16