Welcome to SPSO News. In his overview, the Ombudsman focuses on complaints handling in the NHS. He highlights the enormous emotional toll that poor complaints handling can exact on patients and their families. He also says that poor complaints handling represents a massive missed opportunity for health professionals and governance teams to learn from the mistakes that happen and to put things right. He welcomes the Scottish Health Council's review of feedback and complaints, and comments on the role the SPSO's Complaints Standards Authority (CSA) has been asked to play in supporting improvement.
There is also an update on other CSA activities, including local authorities' and registered social landlords' reporting of their complaints performance for 2013/14. There are short reports on the local authority and housing networks and on the further education complaints handling advisory group. There is also an update on the most recently implemented model complaints handling procedure in the Scottish Government, Scottish Parliament and associated public authorities in Scotland sector.
We laid two detailed investigation reports before the Scottish Parliament today, both about the NHS. We also laid a report on 81 decisions about all of the sectors under our remit. All the reports can be read on our website at www.spso.org.uk/our-findings.
Case numbers
Last month (in April), we received 475 complaints. In addition to the five full investigation reports we laid before Parliament, we determined 450 complaints and of these we:
• gave advice on 329 complaints
• considered 84 complaints at our early resolution stage
• decided 37 complaints at our investigation stage.
We made a total of 87 recommendations.
Overview
Investigation reports
One of today’s two detailed investigation reports about the NHS sets out very serious matters raised in a complaint about a surgical operation on an elderly man that ended in his paralysis (case 201204510). There were multiple failings - in clinical treatment, in the lack of necessary surgical equipment, in acquiring consent, in nursing care and in record-keeping. The report highlights my great concern that the board’s own investigation did not address the medical staff’s failures in assessment and communication. The staff’s action or lack of action resulted in a significant personal injustice. With the help of the recommendations I have made, the board as a whole and the individuals involved must reflect on how this situation arose and ensure that these failings are not repeated.
The other report (case 201203602) is about the death of a young man with a history of mental health problems and drug and alcohol abuse. The investigation highlighted the gap in provision for patients who present to NHS services with both substance abuse and mental health problems. My recommendations included that the board concerned develop a protocol for dealing with such patients who arrive at A&E, and I would urge other boards to read the report and consider whether there is learning there for them as well.
NHS complaints handling
This month’s overview focuses on complaints handling in the NHS. From the outside, it may seem that delays and administrative errors in complaints handling are minor issues. This, however, is to misjudge the enormous emotional toll that poor complaints handling can exact. People complaining about the NHS are often bereaved, or aggrieved because they feel that they or their loved one have been unnecessarily harmed. They are in in search of answers that will move them towards completing the grieving or the recovery process. In this context, delays and mistakes in the handling of their complaints can cause significant additional distress and create distrust.
There are several examples of poor complaints handling in today’s reports. In one of the detailed investigations (case 201203602), the parents of the young man who died did not receive a full reply to their complaints until some two months after they complained, and it took over three months to arrange a meeting that they had requested meanwhile. It then took the board more than two months to respond fully to the issues they raised. In another case, an advocacy worker complained to us on behalf of a client who had received no reply after complaining about his care and treatment (case 201304213). For about 15 months she tried to make his complaints or receive updates on them. We found that the board only responded directly to four of her 15 contacts. In another instance, we found mistakes in a board’s response to a complaint about the care and treatment of a woman who died in hospital (case 201300802). And although the woman’s daughter told the board that they had written to her at the wrong address, it was three months before she received a reply to her complaint, as they used the same address again.
There are also examples of poor complaints handling in relation to prison healthcare. In one example we found that even after a prisoner told a manager that she had not received a response to her complaints, she still did not get a reply (case 201204664). Her complaints were logged but not responded to, contrary to the NHS complaints handling guidance. We also found that some complaints information was inappropriately held in her medical records.
Poor complaints handling also represents a massive missed opportunity for health professionals and governance teams to learn from the mistakes that happen and to put things right. I am, therefore, very pleased with the outcome of the Scottish Health Council (SHC)’s recent review of NHS complaints handling, which recommends a role for the SPSO in supporting improvement. We have been asked to lead on the development of a more succinctly modelled, standardised and person-centred complaints process for NHSScotland, in collaboration with the public, NHS boards and the SHC. There are further recommendations relating to the e-learning modules we have developed with NHS Education for Scotland and other direct training we have provided to the NHS. We are currently considering the report and the way in which this can best be taken forward. The SHC’s report is at:
http://www.scottishhealthcouncil.org/publications/research/listening_and_learning.aspx
Read my Overview and summary of today's investigation reports here (PDF), or via the links below.
s
"… due to the lack of an assessment of [Mr A’s] mental health, there is no way to know whether he was mentally fit for discharge on that day. The fact that his parents’ fears were realised three days later suggests that he may not have been."
Clinical treatment; psychiatric assessment; hospital admission/discharge; complaints handling
Lothian NHS Board (201203602)
> Read full report (PDF)
> Read summary (PDF)
"…there were multiple serious failings, which not only led to a significant personal injustice to Mr A, but also suggest systemic failures. ... the Board failed Mr A at every level and provided him with an unacceptable standard of care and treatment."
Care of the elderly; clinical treatment; consent; nursing care
Lothian NHS Board (201204510)
> Read full report (PDF)
> Read summary (PDF)
Complaints Standards Authority
Local government
The local authority model complaints handling procedure (CHP) requires councils to report annually on their complaints handling performance. The requirements for this are set out in ‘SPSO performance indicators for the Local Authority Model Complaints Handling Procedure’ which was developed in partnership with the local authority complaints handling network.
There are a number of ways in which a council may publicise their 2013/14 performance, and it is for each council to decide which is most appropriate for them. We are not prescriptive about how they do this. Councils may, for example, elect to publish the information on their website, and/or include it in their annual report. We understand that the timescales required to publish an annual report mean that the information may not be in the public domain until later in the year, but by also publishing the complaints performance information on their website, councils can ensure that the data is publicly available as early as possible. The information will help to facilitate continuous improvement in complaints handling, and benchmarking of performance.
The next meeting of the local authority complaints handling network takes place on 20 June 2014, in Glasgow. The theme of the day will be ‘Service improvement/good practice’. The network will consider examples of complaints that have led to service improvement, and good practice in complaints handling, with a view to sharing this information across the sector.
The network is run by the sector for the sector and is open to all complaints handlers, managers and senior managers across it. Those who regularly attend the meetings recognise its contribution to adding value. If you are interested in becoming involved, please contact the CSA team directly at CSA@spso.org.uk.
Housing
The model CHP for registered social landlords (RSLs) also requires them to report on their performance in handling complaints. The requirements are set out in ‘SPSO complaints self-assessment indicators for the housing sector’, developed in partnership with HouseMark, the Scottish Housing Best Value Network and the Chartered Institute of Housing. The indicators complement and build on the Scottish Social Housing Charter’s annual return on the charter indicators and will provide important information when RSLs report to their tenants, as complaints outcomes can provide clear evidence of listening and responding to tenants’ needs.
As with the local government sector, there are a number of ways in which an RSL may choose to publicise their annual performance. These include publishing the information on their website to ensure that the data is publicly available at the earliest opportunity, and including the information in their annual report. Again, this will help to facilitate continuous improvement in complaints handling and benchmarking between RSLs.
The next meeting of the housing network is planned for June. As with the local authority complaints handling network, the housing network is run by the sector for the sector and we would encourage those who may be interested in attending to contact the CSA team directly at CSA@spso.org.uk.
Further education
We continue to work closely with Scotland’s Colleges Quality Development Network and sector representatives. The next meeting for the FE complaints handling advisory group is also planned for June, where we will seek to agree detailed terms of reference for the group, which will then be presented to the Quality Development Network Steering Group. The advisory group will also consider the priority areas for the sector and the key deliverables they can work towards over the next year.
Again, the FE complaints handling advisory group is run by the sector for the sector, and we encourage representatives who are keen to join or to learn more about the group to contact the CSA team directly at CSA@spso.org.uk.
Model CHP for the Scottish Government, Scottish Parliament and associated public authorities in Scotland
All organisations in this sector should now have implemented, and be fully compliant with, the model CHP for the Scottish Government and associated public authorities sector. Our engagement with organisations continues to be positive as we provide advice and respond to operational queries arising during the initial phases of operating the model CHP.
We have taken assurance of compliance with the model CHP from the self-assessment and compliance returns from organisations. We will monitor compliance both through the complaints that we are asked to consider and through our CSA activities. Where appropriate and where required we will liaise with organisations directly to support them in addressing any areas of non-compliance.
We continue to be available to all organisations in this sector for advice, and to respond to operational queries. If and where there is a need for additional support we encourage organisations to contact the CSA directly at CSA@spso.org.uk.
NHS
The Scottish Health Council’s report ‘Listening and Learning - How Feedback, Comments, Concerns and Complaints Can Improve NHS Services in Scotland’ recommended that the CSA should lead on the development of a more succinctly modelled, standardised and person-centred complaints process for NHS Scotland. We are considering the report and the way in which this and other SPSO-related recommendations can best be taken forward. We will liaise directly with NHS stakeholders as we look to develop the next steps in relation to this work.
For this and previous updates and further information, visit our dedicated website www.valuingcomplaints.org.uk
Jim Martin, Ombudsman | 21 May 2014
