COMPLAINTS ANNUAL REPORT

COMPLAINTS ANNUAL REPORT 2006-2007.

CONTENTS 1. Introduction to Velindre NHS Trust... 3 1.1 Velindre Cancer Centre... 3 1.2 Public Health Division... 3 1.3 Welsh Blood Service... 5 1.4 Welsh Cancer Intelligence and Surveillance Unit (WCISU)... 5 1.5 Health Solutions Wales (HSW)... 6 2. Trust Complaints Management Policy and Procedure... 6 3. Reporting of Complaints... 7 4. Monitoring of Complaints... 9 4.1 Divisional Monitoring... 9 4.2 Trust Wide Monitoring... 9 5. Summary of Complaints... 10 5.1 Velindre Cancer Centre... 10 5.2 Screening Services... 13 5.3 Welsh Blood Service... 16 5.4 National Public Health Service... 18 5.5 Corporate Services... 20 5.6 Health Solutions Wales... 20 5.7 Welsh Cancer Intelligence & Surveillance Unit... 20 6. Independent Review Panels (IRP)... 20 6.1 Reporting Period 2005-2006... 20 6.2 Reporting Period 2006-2007... 21 7. Public Services Ombudsman for Wales - Investigations... 22 8. Staff Training... 22 9. Conclusions... 22 10. Further Information... 23 Page 2 of 28

1. Introduction to Velindre NHS Trust Velindre NHS Trust was established in 1994 with a budget of 9 million holding managerial responsibility for Velindre Cancer Centre. Since 1994 the trust has grown to incorporate; 1995 Breast Test Wales (as part of Screening Division) 1997 Welsh Cancer Intelligence and Surveillance Unit 1999 Cervical Screening Wales (as part of Screening Division) 1999 Welsh Blood Service 2002 Health Solutions Wales 2002 Newborn Hearing Screening Wales (as part of Screening Division) 2003 National Public Health Service 2003 Antenatal Screening Wales (as part of Screening Division) The Trust has since grown to manage a budget of 155 million during 2006-2007 and to employ approximately 2700 staff working in several locations across Wales. 1.1 Velindre Cancer Centre Director Mrs Andrea Hague Velindre Cancer Centre, based within Velindre Hospital in Whitchurch, Cardiff, provides specialist cancer services to the population of 1.5 million across South East Wales. Activity has continued to increase significantly over the years, and the Centre is now one of the ten largest Cancer Centres within the UK. The Division employs over 650 staff and volunteers, and has an annual budget of over 39 million. Velindre Hospital still remains the main focus for services, but there are also a large number of outpatient clinics held peripherally at other hospitals throughout South East Wales, as well as out-based chemotherapy services. 1.2 Public Health Division Director Dr Cerilan Rogers The Public Health Division of Velindre Trust comprises All-Wales Screening Services and the National Public Health Service. Screening Services Director Dr Hilary Fielder The Screening Services of Velindre NHS Trust comprise Breast Test Wales, Cervical Screening Wales, Newborn Hearing Screening Wales and is also responsible for the implementation of an Antenatal Screening Project in Wales. Detailed reports, including performance and activity of the services are published annually in the autumn. Page 3 of 28

Breast Test Wales (BTW) was founded in 1989, to: provide the NHS breast screening programme throughout Wales; quality assure the programme; train (or organise the training of) specialist staff; evaluate the programme; carry out research. BTW s aim is to reduce mortality from breast cancer. Between the years of 1988 and 2002, mortality from breast cancer in Wales in the age group of 55-69 years has fallen by 34%. This fall is attributed to better treatment and awareness and to the effects of the breast screening programme. Cervical Screening Wales CSW aims to reduce the incidence of and mortality from cervical cancer. The plan is to achieve this by ensuring that cervical screening is delivered in a consistent manner across Wales, according to national published standards, and by ensuring that all eligible women receive the same level of service and quality of care for the same level of need. CSW is responsible for the whole of the cervical screening programme provided to women resident in Wales, by both Welsh and English NHS Trusts, including: programme management and coordination call and recall arrangements cervical cytology services cervical histology services colposcopy services Newborn Hearing Screening An NHS Universal Neonatal hearing screening programme is being implemented across Wales under the name of Newborn Hearing Screening Wales (NBHSW). The new programme operates as a managed clinical network, crossing organisational boundaries, and will provide a uniform service of high quality within an all-wales policy and to all-wales standards and protocols. The programme is now fully implemented across Wales and it is the first national newborn screening programme in the UK Antenatal Screening Wales (ASW) In April 2003 the Minister for Health and Social Services agreed that a Managed Clinical Network for Antenatal Screening should be established in Wales, based on the principles described in the Antenatal Screening Project Report Choices. The network is known as Antenatal Screening Wales (ASW) and is based within Velindre Screening Services Division. The aim of ASW is to provide a sustainable, all Wales framework to improve the standard of antenatal screening offered to women. The implementation of the network will be the first step in developing an effective, appropriate, uniform, quality antenatal screening programme for Wales which includes all Wales policies, Page 4 of 28

standards, service monitoring, audit and reporting. An initial 2 year implementation period has been agreed and will run until 2005. National Public Health Service (NPHS) Director Dr Cerilan Rogers The National Public Health Service (NPHS) was established on 1st April 2003 and provides the resources, information and advice to enable the Welsh Assembly Government, Health Commission Wales, Local Health Boards, Local Authorities and NHS Trusts to discharge their statutory public health functions. To do this, the NPHS delivers a range of public health services including public protection, assessment of health needs, advice on evidence-based practice and promotion of health and wellbeing. Our Local Public Health Teams are responsible for developing local strategies and undertaking a wide range of specific health promotion initiatives. In this way, Wales has a national service that is locally delivered and able to engage at the most appropriate and effective points in the system. Involvement with a wide range of organisations means that the NPHS is able to harness and promote the efforts of individuals working in NHS and non NHS settings to improve the health of the population. The NPHS Infection and Communicable Disease Service (ICDS), brings together microbiology services, the Health Protection Team and the Communicable Disease Surveillance Centre and works to minimise the impact of infections on the health and wellbeing of the public in Wales. 1.3 Welsh Blood Service Director Mr David Evans The Welsh Blood Service (WBS) provides all blood and blood product support for South, Mid and West Wales. In addition, a reference and medical advisory service is provided to all hospitals in the region of supply. The 2.3 million population is also the blood donor base. Additionally through the Welsh Transplantation and Immunogenetics Laboratory (WTAIL) the WBS provides transplant immunology support to the solid organ transplant service. It hosts both the Welsh Bone Marrow Donor Registry (WBMDR) to enable bone marrow transplants to be provided nationally and internationally and an external quality assessment (EQA) scheme for laboratories in the UK and overseas for various aspects of tissue typing and matching. 1.4 Welsh Cancer Intelligence and Surveillance Unit (WCISU) Director Dr John Steward The primary aim of WCISU is the systematic collection analysis and dissemination of information about cancer incidence and mortality within the resident population. Such information is used to make judgements about the demand for screening and treatment, the effectiveness of these Page 5 of 28

services, epidemiological research into the causes of cancer, research into cancer prevention, clinical research and for the education of the public. 1.5 Health Solutions Wales (HSW) Director Mr Hugh Morgan HSW supports NHS Wales by providing access to accurate, relevant and timely information through the use of appropriate and cost effective technology. This includes the following systems and services: BSC/Screening Services Support (Breast Screening, Cervical Cytology, and Exeter Systems). Community Child Health Systems and Support Clinical Coding Consultancy/Project Management Data Acquisition Data Analysis Information Services NHS Jobs Bulletin NHS Administrative Register Prescribing Services Unit Processing Post Payment Verification Operational Development Information Development Hospital Pharmacy Services Pharmacy Radiology Information Systems Service Infrastructure Management Software Services Statistical Services and NHS Administrative Registrar Telecommunications Web Development 2. Trust Complaints Management Policy and Procedure During 2006 the Trust Complaints Management Policy and Procedure was reviewed to ensure its applicability to all Divisions and to ensure compliance with the changes to the Ombudsman s involvement in the Complaints Process and the changes regarding the referral of complaints from the GMC. These key changes are summarised below. Public Services Ombudsman for Wales For complaints concerning treatment or care received on or after 1st April 2006, you can choose not to request an Independent Review but can complain directly to the Ombudsman. If you make Page 6 of 28

a complaint to the Ombudsman you cannot subsequently request an independent review of your complaint, even if the Ombudsman decides not to investigate it. These changes are now included in the final response letters to complaints as well as a leaflet advising on the changes and outlining the next steps following a complaint where a final response has been issued from the Trust. In addition, further information is detailed in the Trusts Complaints Policy and Procedure. Transfer of Complaints from the General Medical Council (GMC) to Trust The General Medical Council will refer complaints that they have received back to NHS Trusts where they establish a complaint is of a nature that would be more appropriately dealt with under the NHS Complaints Procedure. Upon receipt of a complaint which can be identified as being transferred from the GMC, a further acknowledgement letter will need to be sent to the GMC in order to confirm receipt. In addition, the GMC will be kept updated of any outcomes or developments. The majority of the complaints received during 2006-2007 were managed at the Local Resolution stage, within the delegated timescales by the Divisional Complaints Manager. Overall during the year 111 complaints were received by the Trust and of these 3 complaints reached the Independent Review stage. The Trust responds to complaints in a positive manner and recognises them as a way of improving our services. A proactive approach is taken to complaints received in the Trust and key actions are identified and implemented where appropriate. Examples of these actions are highlighted further on in this report. 3. Reporting of Complaints Service users or their relatives may make a comment or complaint verbally to any member of staff or by writing in English or Welsh to the relevant representative of the Trust; Velindre Cancer Centre Health Solutions Wales Public Health Division (Screening Services & NPHS) Welsh Blood Service WCISU Chief Executive Chief Executive Divisional Director Divisional Director Chief Executive Complaints are always given consideration by the Chief Executive and/or Director of the relevant service and an internal investigation and the aim is that a full response is given within 4 weeks of receipt of the complaint. Often, if appropriate, the complainant will be invited to discuss their concerns with a suitable member of staff. Page 7 of 28

All members of frontline staff within each Service Division receives training in the handling of complaints and are made aware and have access to the guidance on the handling of complaints at a local level. All members of the public are also invited to offer comment on any aspect of Velindre NHS Trust by email to corporate.services@velindre-tr.wales.nhs.uk or by post at the following address: Velindre NHS Trust Headquarters 2 Charnwood Court Heol Billingsley Parc Nantgarw Cardiff CF15 7QZ During 2006-2007 the Trust received a total of 111 complaints, which is an increase from the 81 complaints received in the previous year. This is highlighted in the graph below. Number of Complaints Received by Financial Year 140 120 Number of Complaints 100 80 60 40 20 0 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 Financial Year The breakdown of the total number of complaints by Division are as detailed in the table below. YEAR 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 DIVISION VCC 35 83 47 38 41 WBS 25 24 26 21 37 SS 20 19 13 17 25 HSW 0 1 2 1 0 WCISU 0 0 1 0 0 NPHS N/A 0 5 4 6 CORPORATE 0 0 0 0 2 TOTAL 80 127 94 81 111 Page 8 of 28

4. Monitoring of Complaints 4.1 Divisional Monitoring All complaints are reported to the relevant senior management group; Velindre Cancer Centre Screening Services Welsh Blood Service WCISU Health Solutions Wales National Public Health Service Clinical Governance & Risk Management Group (quarterly reports received) Complaints Monitoring Group Monthly BTW Senior Management Group Monthly CSW Programme Co-ordinators and Nurse Coordinators meeting. Monthly NBHSW Divisional Co-ordinators meeting. Quarterly RMG meeting. Quarterly All Wales Management Group meetings for all 4 programmes. Monthly Senior Management Team Directors Briefs Chief Executive of any complaints received. Monthly Senior Management Team Risk Management Group 4.2 Trust Wide Monitoring Trust Clinical Governance and Risk Management Committee The Corporate Services Manager is responsible for reporting complaints from each Division on a quarterly basis to the Trust s Clinical Governance and Risk Management Committee (Appendix 1 Terms of Reference). An Annual Report is published following the end of each financial year, passed through the Clinical Governance & Risk Management Committee members to the Trust Board and then issued to the Welsh Assembly Government, all Community Health Councils and all Local Health Boards for information. A copy of the report is also posted on the Trust website at www.velindre-tr.wales.nhs.uk. Trust Claims, Complaints and Incidents Review Group During 2006-2007 the Trust held the third meeting of the Trust Claims, Complaints and Incidents Review Group (Appendix 2 Terms of Reference). This group meets on annual basis to discuss lessons learnt and share best practices in these key areas. In the November 2006 meeting the key changes to the complaints process were communicated and noted within the review of the Complaints Policy and Procedure. Datix Risk Management Software The Datix Project Manager has now coded the Complaints Module using the coding agreed by the Divisions. A guide book for populating the module is being developed and the implementation and training on the system will be undertaken during 2007. Page 9 of 28

Quarterly Reports To further strengthen the link and the identification of trends between Complaints, Claims and Incidents, the Quarterly Claims Report presented to the CG&RM Committee now includes a column indicating whether the claim derived from a complaint or an incident. 5. Summary of Complaints 5.1 Velindre Cancer Centre Velindre Cancer Centre received 41 complaints during this period. The number of complaints received increased from 38 in 2005-2006 to 41 in 2006-2007. The following tables are based on the total number of informal and formal complaints received by the Division. Formal and Informal Complaints have not been separated as the same procedure is followed when dealing with complaints in both instances. Number of complaints Total number of Complaints by Service Area 35 30 25 20 15 10 5 0 In-patient Out-patient Service Area Total Inpatient 11 Out- patient 30 Total 41 Service Area Number of Complaints 16 14 12 10 8 6 4 2 0 Total Number of complaints by Subject Area 1 2 3 4 5 6 7 8 Subject Area Key Subject Admission, Discharge and Transfer 1 Arrangements Aids, Appliances, equipment and 2 premises (including access) Outpatient appointments - delay or 3 cancellation 4 Attitude of Staff 5 All aspects of clinical treatment Written & Oral communication/information to 6 patients 7 Patients Privacy and Dignity 8 Transport(ambulance and other) Total Page 10 of 28

Subject of Complaint. Please note funding issues, i.e payment for high cost drugs, are becoming a feature of complaints. These have been recorded under All aspects of Clinical Treatment. The table below indicates the performance in relation to each stage of the complaints process from Local Resolution to those complaints forwarded further on to the Independent Review Secretariat and the Health Services Ombudsman. It also identifies the number of complaints received by Children or young people or AM s or MP s Total out of 41 Percentage Complaints Acknowledged within 2 Working Days 37 90% Complaints responded to within 20 Working Days 33 80% Complaints concluded after 4 weeks or more 7 17% Complaints still being pursued as at 31st March 2007 1 2% The average time taken to provide a full response to the complainant 9 days The total number of complaints closed at Local Resolution Stage 39 95% The total number of complaints that have been referred to the Independent Review Secretariat 2 5% The total number of complaints that have been referred to the Health Service Ombudsman 0 0% The total number of complaints received from children (or on behalf of) or young people. 0 0% The total number of complaints received from AMs or MPs 5 12% The total number of compliments received. As a result of the various complaints received, the following key actions and lessons learnt were undertaken during 2006-2007 Radiotherapy Waiting Times Over a quarter of complaints received (12/ 41) related to waiting times for outpatient appointments. The majority of these concerned radiotherapy appointments, either waiting for the first appointment and/or waiting over the allotted time of the appointment given. Radiotherapy waiting times have been an ongoing problem at the Cancer Centre. In 2005-06 it was reported that until radiotherapy capacity is increased for South East Wales, only then can these waiting lists be minimised. The Trust has continued to maximise efficiencies, following a thorough review by the Delivery Support Unit in 2006. Increased activity from extended working day projects is in place and to further improve efficiency, working through lunchtimes has now been implemented. Presently, a radiotherapy linac is under refurbishment. Monies have also been promised in the near future for upgrading the remaining linacs. Page 11 of 28

Complaints Monitoring Group A Complaints Monitoring Group has now been set up in the Division. Membership includes external involvement from the Patient Liaison Group and Cardiff Community Health Council. The group is still in its infancy but has already reviewed 3 months of individual complaints. Its aim is to identify trends, recommend further action if required, monitor performance targets, review internal procedures and identify training for staff. The other important message of the group is to ensure staff learn lessons from complaints Funding for drugs A complaint arose following the Trust s decision to not allow a patient to pay for their supporting care as a private patient, and to receive their drugs via the NHS during the same episode of treatment. This complaint has now been sent for Independent Review. The Trust is now awaiting a response following the review of this case Page 12 of 28

5.2 Screening Services During 2006-2007 Screening Services screened approximately 97,500 women at Breast Test Wales, 200,000 women at Cervical Screening Wales and 33,200 babies by New Born Hearing Screening Wales. Screening Services received 25 complaints during this period. The number of complaints received increased from 17 in 2005-2006 to 25 in 2006-2007. The number of formal complaints received was 18 and the number of informal complaints was 7. Number of Complaints 25 20 15 10 5 0 Complaints by Service Area BTW CSW Service Area Total Breast Test Wales (BTW) 22 Cervical Screening Wales (CSW) 3 Service Area Number of Complaints Informal Complaints by Subject Type 4 3 2 Informal Staff Behaviour (SB) 4 Administrative Error (AE) 2 Bad Experience (BE) 1 Screening/Results Delay (DEL) 0 Total 7 1 0 SB AE BE DEL Subject Type.

Number of Complaints 8 7 6 5 4 3 2 1 0 Formal Complaints by Subject Type SB AE BE DEL Subject Type Formal Staff Behaviour (SB) 6 Administrative Error (AE) 4 Bad Experience (BE) 1 Screening/Results Delay (DEL) 7 Total 18 The following table indicates the performance in relation to each stage of the complaints process from Local Resolution to those complaints forwarded further on to the Independent Review Secretariat and the Health Services Ombudsman. It also identifies the number of complaints received by children or young people or AMs or MPs. FORMAL COMPLAINTS Total out of 18 Percentage Complaints Acknowledged within 2 Working Days 18 100% Complaints responded to within 20 Working Days 17 94% Complaints concluded after 4 weeks or more 0 0% Complaints still being pursued as at 31st March 2007 1* 1% The average time taken to provide a full response to the complaint 9 days The total number of complaints closed at Local Resolution Stage 18 100% The total number of complaints that have been referred to the Independent Review Secretariat 0 0% The total number of complaints that have been referred to the Health Service Ombudsman 0 0% The total number of complaints received from children (or on behalf of) or young people. N/A N/A The total number of complaints received from AMs or MPs 0 0% Page 14 of 28

* One complaint was responded to out of the 20 working day timescale because: Background to the issues was investigated by CSW Programme Manager Complainant invited to discuss complaint with representatives from CSW Arrangements made to check in clinical history for previous colposcopy Arrangements made to for pathologist to examine biopsy Appointment made to see Lead Colpscopist at Gwent Specialist advice needed to be sought on her medical condition. BTW has worked hard to improve its performance in meeting turnaround times. This should reduce the number of complaints about delays in the future. As a result of the various complaints received, the following key actions and lessons learnt were undertaken during 2006-2007. Lessons Learnt and Best Practice in relation to the Actions taken below: Staff have continued to work to improve their communication skills at regular staff meetings and events More flexible appointment arrangements have been put in place during this period Compliments The services received a great number of verbal and written compliments from users, visitors and relatives. 24 formal letters of compliments and thanks were received for this period. BTW users are also able to express feedback on comments sheets; a great deal of positive feedback was received. Type Cardiff Llandudno Swansea Compliment -formal 16 8 8 letters etc Positive feedback comments sheets etc 863 705 607 Page 15 of 28

5.3 Welsh Blood Service During this report period, there were 123,716 whole blood donor attendances and 163,842 blood products (red cells, platelets and plasma) were issued out to customer hospitals. The Welsh Blood Service received 37 complaints during for the period 2006-2007. The number of complaints received increased from 21 in 2005-2006 to 37 in 2006-2007. Formal and Informal Complaints have not been separated as the same procedure is followed when dealing with complaints in both instances. Number of Complaints 20 18 16 14 12 10 8 6 4 2 0 Complaints by Service Area Donor Services Laboratory Services Other Service Area Service Area Total Donor Services 18 Laboratory Services 14 Other 5 Number of Complaints Total number of Complaints by Subject Type 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 Subject Type (See Key) Key Subject Type Total 1 Incorrect Information 4 (including Delivery Note) 2 Incorrect Order (including 3 incorrect product issued) 3 Staff Attitude 5 4 Donor Unhappy with 8 explanation/information provided 5 Admin Error 1 6 Waiting time for donation 1 7 Donor unhappy with being 6 deferred 8 Faulty Commercial Product 1 9 Other 9 The table on the following page indicates the performance in relation to each stage of the complaints process from Local Resolution to those complaints forwarded further on to the Page 16 of 28

Independent Review Secretariat and the Health Services Ombudsman. It also identifies the number of complaints received by children or young people or AMs or MPs. Complaints Acknowledged within 2 Working Days 30 Total out of 37 Percentage 81% Complaints responded to within 20 Working Days 32 86% Complaints concluded after 4 weeks or more 5 14% Complaints still being pursued as at 31st March 2007 0 0% The average time taken to provide a full response to the complaint 15 days The total number of complaints closed at Local Resolution Stage 36 97% The total number of complaints that have been referred to the Independent Review Secretariat 1 3% The total number of complaints that have been referred to the Health Service Ombudsman 0 0% The total number of complaints received from children (or on behalf of) or young people. N/A N/A The total number of complaints received from AMs or MPs 0 0% The Welsh Blood Service received a number of compliments during this period but do not monitor this information to be able to provide a figure. As a result of the various complaints received, the following key actions and lessons learnt were undertaken during 2006-2007. Lessons Learnt and Best Practice in relation to the Actions taken below: Post Donation Procedure For a number of years the current practice within the WBS on removal of the needle was to apply a gauze and wool dressing to the venepuncture site prior to flexing the arm. However, following a complaint which progressed to the Independent Review Secretariat an urgent review of the procedures was undertaken to ensure that we are compliant with best practice. The procedures have now been updated accordingly based on the evidence provided by the independent reviewer. Testing of Samples Due to a complaint that arose due to samples not being tested in a timely manner. The relevant procedures have now been amended and location trays installed. Commercial Products Dispatched to Wrong Destination In order to help prevent reoccurrence staff have been retrained and a new standard order form has been introduced and issued to all our customers hospitals (November 2006). Unclear Directions Map on the Welsh Blood Service Website has been amended to improve clarity and ease of reference. Page 17 of 28

5.4 National Public Health Service The National Public Health Service received 6 complaints throughout the period 1 April 2006 to 31 March 2007. There were 5 formal complaints and 1 informal complaint received. The number of complaints received increased from 4 in 2005-2006 to 6 in 2006-2007. Number of Complaints 4 3 2 1 Complaints by Service Area Service Area Total Infection 3 Communicable Disease Service (ICDS) Local Public Health 3 Team Total 6 0 ICDS LPHT Service Area Number of Complaints 6 5 4 3 2 1 0 Total number of Complaints by Subject Type 1 2 3 4 Key Subject Total 1 Information Governance 3 2 Lack of information provided regarding tests. 1 3 Staff Attitude 1 4 Other 1 Subject Type (See Key) The table on the following page indicates the performance in relation to each stage of the complaints process from Local Resolution to those complaints forwarded further on to the Independent Review Secretariat and the Health Services Ombudsman. It also identifies the number of complaints received by children or young people or AMs or MPs Page 18 of 28

Total out of 6 Percentage Complaints Acknowledged within 2 Working Days 6 100% Complaints responded to within 20 Working Days 6 100% Complaints concluded after 4 weeks or more 0 0% Complaints still being pursued as at 31st March 2007 0 0% The average time taken to provide a full response to the complaint 15 working days The total number of complaints closed at Local Resolution Stage 6 100% The total number of complaints that have been referred to the Independent Review Secretariat 0 0% The total number of complaints that have been referred to the Health Service Ombudsman 0 0% The total number of complaints received from children (or on behalf of) or young people. 0 0% The total number of complaints received from AMs or MPs 0 0% The NPHS do not collate information in relation to the compliments and thanks received. As a result of the complaints received, the following key actions and lessons learnt were undertaken during 2006-2007. Lessons Learnt and Best Practice in relation to the Actions taken below: Mistaken identity of Hep E patient ( June 2006) An individuals GP will be contacted prior to a letter being forwarded to the patient. The Health Protection Teams will also undertake additional checks to establish that the persons identity is correct. The procedure for recording and reporting positive culture results has been reviewed to include (incident date Dec 2006) o A traceable computer record identifying staff undertaking all steps of the test and reporting procedure, including the telephoning of the result. o An additional cross check and validation step, between request forms and culture plates in recording test results. o The telephone reporting procedure has been amended, so a clear record of the telephone result is now entered onto the lab computer system. Page 19 of 28

5.5 Corporate Services During 2006-2007 there were two complaints received against the Corporate Services Division of the Trust. These are detailed below. Complaint 1 Complaint regarding the content and circulation of the Equality Survey Outcome All concerns raised were explained and further information supplied to hopefully answer all the issues. Meeting offered with Diversity and Equality Manager, but offer not accepted. Complaint 2 Complaint from an applicant in relation to the recruitment process of Consultant Medical Virologist. Outcome The panels membership and rules were in accordance with the Good Practice Guidance of the National Health Service Regulations 1996. The two complaints received were acknowledged within two working days and a full response sent within twenty working days. The complaints were concluded at the Local Resolution Stage. The Corporate Services Division does not collate information in relation to the compliments and thanks received. 5.6 Health Solutions Wales Health Solutions Wales received zero complaints during this reporting period. 5.7 Welsh Cancer Intelligence & Surveillance Unit The Welsh Cancer Intelligence Surveillance Unit received zero complaints during this reporting period. 6. Independent Review Panels (IRP) 6.1 Reporting Period 2005-2006 The following complaints were received by the Independent Review Secretariat at the end of the reporting period 2005-2006 and therefore as noted in last years report the outcome of these reviews are included in this years Annual Report as the outcome was unknown at the time of the finalised report for 2005-2006. Velindre Cancer Centre Review requested on the 20.02.2006 Page 20 of 28

Complaint received in relation to the care management of their relative and in relation to the reporting of the complaint not reaching the Trust and therefore there was a delay in responding to complainant. Outcome: Response received from the Lay Reviewer advising that the case has been referred back to the Trust for further Local Resolution in order to answer the full extent of the complaint. However, at the time of writing this report a full response is being collated in order to be sent to the complainant and offer of a meeting was suggested. However, further correspondence received from the complainant advised that they have declined the offer of meeting and will be referring the complaint to the Health Service Ombudsman. At the time of writing this report the Trust had not been notified that this complaint had been referred to the Public Services Ombudsman for Wales. 6.2 Reporting Period 2006-2007 Velindre Cancer Centre Review requested on the 21.04.2006 Complaint received in relation to the care management of their relative. Outcome: Response received from the Lay Reviewer advising that the case has been referred back to Trust for further Local Resolution in order to answer the full extent of the complaint. Reviewer suggested that a face to face meeting is arranged with the complainant and clinician involved in the care of the husband. A meeting was held with the complainant involving the Clinician and General Manager of the Velindre Cancer Centre which addressed the remaining concerns. A follow up letter following the meeting was sent to the complainant and the complaint was then closed. Welsh Blood Service Review requested on the 20.11.2006 A complaint was received from the partner of a donor who had experienced bruising following blood donation. The complaint was split into three parts: best practice is not being adopted by the transfusion service in that flexion of the limb after phlebotomy or cannulation is unacceptable. The donor suffered an extensive haematoma of the donation arm with restriction of movement. Complaint response letter from WBS condones unacceptable continuation of flexing of limbs postphlebotomy. Page 21 of 28

Outcome: The Independent Review Secretariat referred the complaint back to Local Resolution to initiate an urgent review of the policy for bending the arm when removing the needle. The Director of the Welsh Blood Service is currently initiating a review of the current practice for bending the arm. The outcome of this complaint will be reported in the 2007-2008 Annual Complaints Report. Velindre Cancer Centre Review requested on the 27.03.2007 The complaint arises from the Trust refusing to allow the NHS to pay for the drug and a private insurance company pay for the remainder of the treatment during the same episode of treatment. Outcome: Information requested by the IRP was submitted within the timescales. The Trust is now awaiting a response following the review of this case. Due to this request being received at the end of this reporting period, the outcome of the review will be reported in the 2007-2008 Annual Report. 7. Public Services Ombudsman for Wales - Investigations There were no complaints investigated by the Public Services Ombudsman for Wales during this reporting period. 8. Staff Training Many of the training courses listed below have commenced throughout the Trust in order to raise awareness of the complaints procedure and the handling of complaints by front line staff; Violence and Aggression Customer Care Language Line Communication Skills Service Management Handling Conflict How to Handle Complaints Welsh Health Legal Service are also providing Complaints Training within Divisions upon request and in conjunction with Divisional Complaints Managers as appropriate. 9. Conclusions The Trust is committed to improve the ease of access for complainants and to improve communication between the service providers and the service users. Page 22 of 28

The Welsh Risk Pool did not formally audit Welsh Risk Management Standard 4 Complaints, during 2006-2007. However, the action plan was maintained and the Trust self assessed the standard at a score of 92% continued efforts will be made during 2007-2008 to ensure the high level of compliance is retained. During 2007-2008 the Trust will focus on the complaints element of Healthcare Standard 15 in order to work towards a high level of compliance with the new standard. The self assessment score achieved during 2007-2008 will be included in the next. The Trust will continue to sustain the high level of performance in complaints handling throughout the Trust during 2007-2008. 10. Further Information Should you require any further information on any aspect of this report, please do not hesitate to contact:- Cally Hamblyn Corporate Services Manager Velindre NHS Trust Headquarters 2 Charnwood Court Parc Nantgarw CARDIFF CF15 7QZ Tel: 029 2031 6956 Fax: 01443 841878 Page 23 of 28

Appendix 1 Terms of Reference Trust Clinical Governance & Risk Management Committee Name of Group/Committee/Board: Trust Clinical Governance & Risk Management Committee Summary of Role: Remit: To ensure all Divisions of the Trust are involved in Clinical Governance and Risk Management arrangements. To receive and monitor divisional risk profiles and to consider, prioritise and recommend actions upon issues of significant risk to the Trust as an entity. Receive and monitor regular progress reports from Divisions on compliance with and progress towards meeting Clinical Governance and Risk Management Action Plans in relation to the WRM standards and other guidelines - (e.g. future Healthcare Standards) Receive and monitor summary reports on incidents, near misses, complaints and claims and that lessons are learnt and shared throughout the Trust in relation to the control measures implemented in order to prevent recurrence. Ensure involvement of staff and service users in governance and risk issues clinical.approve the Trust Clinical Governance and Risk Management Strategies and through the Clinical Governance and Risk Management working group, monitor implementation and compliance with the strategies. Recommend approval of guidance on what is regarded by the Trust as a level of acceptable risk This is a condition where risks have been controlled to the level required by specific regulations/requirements that have been reduced to the green sections or to a risk rating of 5 and below, of the Trust s Risk Evaluation Categorisation Matrix (AS/NZS model) To discharge responsibilities as appropriate to the Clinical Governance and Risk Management Working Group to ensure Page 24 of 28

co-ordination of work at the corporate level for clinical governance and risk related functions. To oversee the work of other specialist risk management groups within the Trust to ensure full coordination of risk management activity across the Trust. These groups include: Health & Safety Committee, Infection Control Committee, Research and Development Committee and Medical Devices Working Group. To support the Audit Committee in reviewing the arrangements and systems in place for Risk Management and Clinical Governance. To receive audit reports from Audit Committee as appropriate. To receive clinical audit reports from the Divisions and monitor activity against Divisional audit programmes ensuring audit priorities are addressed and taken forward To ensure ongoing liaison between the risk and clinical effectiveness functions of the Trust Reporting to: Communicates with: Monitoring of: Sub Committees: Chaired by: Membership: Approve the Trust s Annual Clinical Governance and Risk Management Report Trust and Executive Board Audit Committee Health & Safety Committee, Infection Control Committee, Research and Development Committee, Medical Devices Working Group and CG &RM Working Group, communications group CG&RM Working Group Professor Vivienne Harpwood Non- Executive Director (Chairman) Non- Executive Director Non-Executive Director Chief Executive Executive Director of Finance Executive Director of Nursing and Quality/Lead for CG Executive Director of Human Resources/Lead for Risk Management Medical Director Service User Representative Page 25 of 28

Meeting Frequency: Documentation Required/Submitted From: Outputs (i.e. minutes of meeting submitted to other committee meetings) Contact: (secretary to meeting) PA to Executive Director of Nursing and Quality Director (NPHS) Director (Screening Services) Director ( HSW) Director (Cancer Services) Director (Welsh Blood Service) Director (Welsh Cancer Intelligence & Surveillance Unit) Clinical Governance Support Manager Health, Safety & Risk Manager Head of Planning & Corporate Development Corporate Services Manager Health, Safety and Risk Advisor Quarterly Documentation Submitted From Risk Management Annual Report Welsh Risk Pool Standards progress Divisions CG &RM Strategies PPI Strategy Infection Control Annual Report Research & Development Annual Report Risk & Clinical Governance Progress Reports Medical Devices Minutes Audit reports Child Protection Strategy Minutes to Trust Board and Clinical Governance & Risk Management Working Group CG&RM Working Group responsible for onward dissemination to Divisions Date ToR Last Revised Next Review Date October 2005 October 2007 Page 26 of 28

Appendix 2 Terms of Reference Trust Claims/Complaints/Incident Review Group Name of Group/Committee/Board: Trust Claims/Complaints/Incident Review Group Summary of Role: Remit: To discuss and review claims, complaints and incidents to ensure identification of significant issues where lessons can be learnt. A Review Group has been established by the Board to examine the implications of and any lessons which can be learnt from: Claims received, Claims settled, Incidents reported which may result in claims, Complaints received which may escalate into claims. identifying the failures in the systems which lead to the claim, ensuring that remedial action is identified, ensuring the remedial action is taken Reporting to: Communicates with: Monitoring of: Sub Committees: Chaired by: Membership: Clinical Governance and Risk Management Committee Clinical Governance and Risk Management Committee Action Plans and remedial action following an incident, complaint or claim. Not applicable Non Executive Director Chair of the CG&RM Committee. Chief Executive Medical Director Executive Director of HR Executive Director of N&Q Executive Director of Finance Corporate Services Manager Head of Planning and Corporate Development Clinical Governance Support Manager Service Directors NED s x 2 Page 27 of 28

Meeting Frequency: Documentation Required/Submitted From: Outputs (i.e. minutes of meeting submitted to other committee meetings) Annually Documentation Claims, Complaints and Incident Report Annual Claims Report Submitted From Minutes submitted to the Clinical Governance & Risk Management Committee. Corporate Services Manager and Risk Manager Contact: (secretary to meeting) Date ToR Last Revised Next Review Date Cally Hamblyn Corporate Services Manager Ext: 6956 20.10.2004 01.11.2005 01.11.2005 22.11.06 Page 28 of 28