Formal Complaint Adult Social Care
Quarter 4 2021/22
Concern:
Relative of a service user raised concerns following a service user placement at a residential home in relation to:-
- Lack of information regarding the financial aspect of the placement.
- That a Continuing Healthcare Assessment was not completed prior to the placement.
- That the placement was unsuitable.
- That the treatment of the service users spouse in relation to the safeguarding allegations was poor.
Response:
A full investigation report was completed which identified:-
That the service user and spouse were fully informed with regards to the financial aspects of any placement prior to the placement being identified and that they had capacity to understand the information provided. Information regarding charges for the placement were discussed following the placement and the spouse declined the offer of a financial assessment.
The placement was arranged as an emergency respite placement at the service users request and therefore staff were unable to complete a CHC assessment prior to the placement. Prior to the request for an emergency respite placement there was no indication that the patient was eligible for CHC funding.
The placement was identified as suitable, based on the service user presenting and known needs in the community as reported by the service user and spouse. Following the placement into 24 hour care, the service user displayed behaviours which staff members were unaware of, the service user was reassessed and it was identified that the service users needs would be best met in a nursing home placement. Due to COVID there was a delay in an alternative placement being sourced by the Local Authority.
There was no evidence that there was any maltreatment of the service users spouse in relation to safeguarding referrals. Actions as a result of the safeguarding allegations were communicated in an open, transparent and caring manner, with evidence in the records that staff members were trying to ensure that both the service user and spouse were supported in the community and the service user and spouse were encouraged to accept additional support.
Learning:
No learning action identified, although apologies were offered to the spouse if at anytime they felt that staff members treated him unfairly.
Formal Complaint BeeU
Quarter 4 2021/22
Concern:
Relative of a service user raised concerns about the following areas:-
- There was a lack of communication by Crisis Resolution Home Treatment (CRHT) Bee U staff with family/guardian of young person referred into services.
- Young person had been triaged by telephone and assessed as low risk (shortly afterwards she was admitted to hospital following self-harm with suicidal intent).
- Mental Health Act Assessment (MHAA) was vigorously pursued by CRHT Bee U team.
- Poor communication between family and social care and the Trust.
- Family wanted psychological support therapy for their young person.
Response:
A full investigation report was completed which identified:-
The findings did show there could have been better communication between services and the family guardians/young person who was deemed to be gillick competent.
There was a lack of openness and honesty when working with the family and the plans to pursue a MHAA.
Social care staff and health staff had different views around the element of risk posed and how this should have been best managed.
There were lengthy delays in completing the MHAA and this was due to a lack of discussion between Social Care Advanced Mental Health Practitioners and Heath staff in CRHT BeeU service. The psychological assessment and therapy was delayed as service user was in crisis and it was not considered conducive to work on her psychological issues at the time of her contact in crisis.
Learning:
Work between Health and Social Care to be improved as a result of senior managers from both organisations to hold regular meetings to understand how both organisations can work together to provide a more positive experience for the service and their family/guardian which should involve a dialogue with the family /guardian young person if deemed gillick competent.
Formal Complaint CAMHS
Quarter 4 2021/22
Concern:
Concerns were raised regarding the CAMHS team and Children and Young People Autism Service (CYPAS) for autism assessment in relation to:-
- The CYPAS did not following NICE guidelines when assessing the patient.
- Medical history and family history was not included or considered as part of the assessment process.
- Communication was poor.
- Assessment findings were not shared face to face or sensitively.
- Question why the patient was not suitable for support from CAMHS and that the suggested referral to another organisation were inappropriate.
Response:
The investigation identified that the assessment completed by CYPAS was in line with NICE Guidance and that all medical information, family history and information provided by the family was considered as part of the assessment. It was acknowledged that the guidance was not fully met because there was not a single point of contact or a care coordinator allocated. The investigation acknowledged that the experience of care would have been improved if these were in place.
Due to COVID the assessment findings could not be discussed face to face and therefore the findings of the assessment were discussed in a telephone call. It was noted in the records that this was a distressing call for the family and changes to the process have since been identified to ensure families and clinicians are supported when outcomes are provided.
Following review of the referral to CAMHS it is identified that the patient did not meet criteria for CAMHS intervention, and was appropriately signposted to alternative services. The investigation acknowledged that the rationale for this decision making was not clearly explained in order for the family to understand the clinical rationale for the decision making.
Learning:
The following recommendations were made as a result of the investigation:-
For CYPAS service to provide an overarching care coordinator and single point of contact for each family
CYPAS and CAMHS to provide an explicit rationale as to why signposting is required and clinically informed.
For CYPAS to review their risk assessment and management process
For CYPAS to develop a robust intervention offer for children being assessed for autism. This should include of the interventions, resources and signposting evident during care pulled into one integrated intervention plan
Formal Complaint CAMHS
Quarter 4 2021/22
Concern:
Concerns were raised regarding the CAMHS team in relation to the following:-
- The diagnosis given to the patient.
- The quality of the assessment completed prior to the diagnosis being given.
- Poor communication and conflicting advice being given.
- The style of questioning used during the assessment.
- Staff absences within the team impacting on care.
Response:
The investigation concluded that clear rationale had been given to support the diagnosis, the correct processes had been followed and the consultant acted appropriately during the assessment. All medical information, family history and information provided by the family was considered before giving the diagnosis.
It was identified that the families’ expectations could have been better supported if the team had produced a clear care plan, in line with Trust standard practice.
There were occasions when communication was below the standard expected by the Trust, particularly during times of staff absence. A full handover of the patients care did not take place when a member of staff left the team resulting in a gap in services which had been offered to the family. A particularly high level of staff sickness negatively impacted on the standard of communication with the patient and their family.
Learning:
The following recommendations were made as a result of the investigation:-
A caseload review to take place prior to staff leaving their roles ensuring a full handover of tasks. The team leader designed a checklist template to be used.
The importance of attendance at MDT meetings to be reiterated to staff to ensure that significant information is shared regarding progress in a patients care and treatment
Discussions to take place with Family Therapist prior to the service being suggested to families to ensure they are suitable
All staff to be reminded of the importance of good communication and any change in roles or impending departures from the Trust to be shared with families at the earliest opportunity with reassurance offered around the handover of care
Formal Complaint CAMHS
Quarter 4 2021/22
Concern:
Concerns were raised with regards to the service received by the CAMHS service, the concerns related to:-
- Delay in meaningful interventions.
- CAMHS delay, decline to share information with social services.
- Overall support provided.
- Management of concerns.
- Communication.
Response:
The investigation identified that the service user received appropriate care and support from a Youth Worker with regards to the reported low mood. Following an escalation in behaviour due to a personal matter, the service user had multiple agencies providing support. The investigation acknowledged that once the Youth Worker was aware of other agency involvement, this could have been explored further to identify if the service user required any additional emotional support and escalation to the CAMHS MDT.
Following the relative requesting further CAMHS involvement, CAMHS were conscious of the number of agencies involved and therefore were linking with these agencies to identify who was providing what support in order to identify if there was a role for CAMHS. Following concerns raised with the management team a further assessment was arranged with a clinical psychologist and it was identified that the service did not have any mental health needs at that time and her needs were being appropriately met by the other agencies involved and the patient was discharged from the CAMHS service.
The investigation acknowledged that the CAMHS did not attend a meeting with social services due to capacity and demand on the service and apologies were offered for this. It was acknowledged that verbal update was provided to the meeting on behalf of the service. A further chronology was requested for the next meeting, however the family withdrew from the process and therefore the next meeting was cancelled and the chronology was no longer required.
The investigation also identified following the relative raising concerns with the operational management team that there could have been more timely communication with relatives.
Learning:
The following recommendations were made as a result of the investigation:-
Team leader to ensure that there is a clear pathway to escalate complaints and that patients/relatives should be informed of potential timescale for response from the service
Report findings to be discussed with Youth Worker in 1:1 supervision to identify any personal development needs.
PALS Concern 0-19 Service
Quarter 4 2021/22
Concern:
Parent shared their concerns regarding possible traits of Autism Spectrum Disorder (ASD) with the health visitor (HV) who agreed to make a referral in April 2021. The young person was referred to a Paediatric Consultant in August 2021 as the results of the Ages and Stages Questionnaire (ASQ) form indicated behavioural and social ASD traits over any delays in growth/development as of April 2021. Parent believes the child should have been referred to CAMHS Autism Service not the Paediatric Consultant.
Response:
At the appointment with the health visitor the parent consented to a referral to the community paediatrician which is in line with NICE guidance, due to concerns that were raised following further assessments which took place using the ASQ and SE questionnaire.
In line with NICE guidance the child did score fairly in fine motor skills, hence why a referral into the Community Paediatrician was made.
Learning:
The team to have further learning in when to refer to the Community Paediatrician and when to refer to CAMHS.
HV Service approached the CAMHS (ASD team) to complete a piece of work to improve links and communications, and to produce guidance to further support healthcare professionals referring into the service.
The CAMHS (ASD Team) is a service provided by another organisation and is not a service provided by the Midland Partnership NHS Foundation Trust (MPFT) who provide HV services across Staffordshire.
Guidance has been shared with the HV team around NICE guidance for ASD and further learning has taken place to understand symptoms of ASD. This will also be shared across all HV Teams within MPFT where appropriate.
All guidance is to be used in conjunction with professional judgment and individual assessment.
Team Leads discussed enquiry and agreed that every referral received would be reviewed into the triage centre for CAMHS, and would be either accepted or rejected at source, before it is sent to the individual team to be placed on the waiting list for assessment.
Formal Complaint Community Mental Health
Quarter 4 2021/22
Concern:
The relative of a service user who had sadly died as a result of suicide expressed concerns regarding the decisions made in his relatives care. A full investigation had been completed in line with Trust policy, however the relative expressed the following concerns as a formal complaint.
The relative requested further clarity on the decision making of the Multi-disciplinary team who had reviewed the service user and granted her request to be discharged.
The relative expressed concern that the service user had not been detained under a section of the Mental Health Act (MHA) 1983.
Response:
A full investigation report was completed which identified:-
The report gave assurances that the Multi-disciplinary team had taken into account a variety of factors when determining a suitable management plan for the service user. These included the events that had led to the admission, the progress during the admission, and the available support in the community. With these factors in mind, and after completing a clinical review, whereby it had been determining that the service user had capacity to make this decision, her request was discharge was facilitated.
The report provided information about the Mental Health Act 1983, this included information about the criteria in which a person is considered detainable under this legislative framework. There is evidence within the report which indicates that the service user did not meet the criteria for detention.
Learning:
The service identified that some improvements could be made in the way in which they complete their documentation. These were included as part of an action plan to ensure this learning is embedded into practice.
Formal Complaint Community Nursing Service
Quarter 4 2021/22
Concern:
A relative raised concerns with regards to a patients end of life care, reporting that the appropriate equipment and medication were not in place/administered.
Response:
The investigation identified that appropriate equipment in place to ensure their comfort at end of life, however following the family reporting that the patient was more comfortable on a different mattress the mattress was ordered for next day delivery.
All appropriate end of life medication was in place on the patient’s return home and the district nurses attended as required to support the family and ensure the patient’s pain was managed.
Learning:
It was identified that a bereavement visit for the family was not arranged following the patient’s death and the team leader was requested to review the process for arranging bereavement visits to ensure these are completed in a timely manner.
PALS Concern South Alliance Out of Hours Community Nursing
Quarter 4 2021/22
Concern:
Unable to contact the out of hours’ community team in an emergency and are only able to leave a voicemail message and wait for a call back.
Response:
In March 2021, referrals into the out of hours’ community team were via a mobile phone. Due to the poor phone signal in parts of South Staffordshire, calls received were diverted to a landline where a message could be left by the caller. This was then accessed by the nurse on duty and was done approximately every 20-30 minutes. There was no one to answer the call at times; however contact would be made by the nurse on duty following any messages left. It has been recognised that this is not acceptable practice and that an alternative process was needed.
Learning:
The service have made changes to their contact systems and since March 2021, have implemented a 24 hour telephone system that allows all calls received into the service to be answered by a call handler and managed from the first point of access. They will ensure that all of the appropriate information is taken from the caller and this information is then passed to a nurse coordinator for triage. They will then liaise with the patient or relative to arrange a visit.
Formal Complaint Home First Team
Quarter 4 2021/22
Concern:
When the patient was discharged from a local nursing home where she had been recuperating from a hospital stay after fracturing her neck of femur, she was referred to Home First for short-term assessment and rehabilitation. The patient’s son complained that his mother, the patient, had only been seen by the Home First Physiotherapist on a few occasions and that visits were then stopped without this being discussed with him and without a referral being made to the community physiotherapy service as had been initially agreed. The son complained that the service was aware he had Lasting Power of Attorney for health and welfare and as such he should have been involved in any decision-making as his mother did not have capacity in this regard due to her dementia. The son felt that the lack of referral of his mother for further community physiotherapy took away an opportunity for her mobilisation to improve and that she quickly deteriorated as a result.
Response:
The Trust advised that the patient had been referred to the Home First team for four double-up care calls a day. She was allocated for assessment and it was noted during this that the son held Power of Attorney for Health and Welfare. The son was present during the assessment and advised that his mother was able to mobilise with her rollator frame from the bedroom to the living room. The plan at that time was to encourage this mobilisation with care support workers on every allocated double up care call. Within a couple of weeks it was noted that the patient’s mobility fluctuated and she was unable to retain information due to her mental capacity. The need for long-term domiciliary care was discussed and a referral to Adult Social Services to support this was made. A couple of week’s later it was recorded that care agency staff had been unable to transfer the patient to stand from the bed and they requested a further Home First physiotherapy assessment.
A Home First physiotherapist attended the patient’s home with an Occupational Therapist to undertake the assessment in the presence of the patient’s son. The notes reflected that the patient walked from her bedroom approximately five metres with her rollator and with supervision from staff. She was noted to be unsteady but did not show signs of pain. In accordance with the plan she was visited the following week by the Physiotherapist and Occupational Therapy Technical Instructor in the presence of the patient’s son. It was noted that the patient mobilised approximately three metres with her rollator and with staff supervision, although she was unsteady. The plan was to continue with double up care calls and that care support staff would mobilise the patient where possible during the calls.
The Physiotherapist considered that the patient was not engaging well with treatment and was very unlikely to be able to retain information and follow instructions due to her dementia. Any mobility was therefore likely to be minimal and the patient was discharged.
The investigation found that insufficient details about the decision not to refer the patient to the community physiotherapy service were recorded and the son had not been involved in discussions about this. The son did not therefore have an opportunity at the point of discharge to raise his concerns, ask questions and be involved in the decision-making process.
Learning:
The Team Leader picked up issues relating to record-keeping and communication with the staff member concerned directly through one to one management supervision to ensure that a similar occurrence did not happen again. In addition, all Home First staff members were reminded through their monthly team meetings and one to one management supervision that carers with lasting Power of Attorney for Health and Welfare should be communicated with and have opportunity to be fully involved with care and decision making regarding their family member where the patient does not have capacity.
Formal Complaint Integrated Mental Health Team
Quarter 4 2021/22
Concern:
Patient complained about the attitude and approach shown towards her by a member of the community mental health administrative staff during her telephone call to the service. Patient said that the administrator’s tone was intrusive and inconsiderate and that the administrator was not interested in information shared by the patient about her support dog and how this would help her to find the confidence to attend sessions, telling her that the call was not an emergency.
The patient added that the administrator took an extraordinary amount of time to find her details on the system and then ended the call abruptly, having informed the patient that an assessment letter was in the post. The patient felt that the administrator should have transferred her to the duty worker in order that her queries could have been answered appropriately.
The patient felt that telephone calls should be routinely recorded and that if this call had been recorded then details of the exchange could be easily verified.
Response:
The response reiterated information previously provided by the Patient Advice & Liaison Service (PALS) when an informal concern was raised with them which stated that details of the conversation were not recorded on the patient’s records as they should have been. As the patient was able to provide the exact time of her call, telephone records showed that the patient’s call was received by the Access Team and transferred to the team administrative hub at the time stated.
It was confirmed who the administrator was to whom the patient spoke to and the administrator had been asked for their recollection of the conversation. They recalled that the patient referred to her plans to move location with her dog and that as such advice was given that the team could not provide support relating to housing or pets. The administrator said that they were unaware the dog was a support dog. The administrator did not recall a request from the patient to speak to the duty worker although transfer to the duty worker would only usually happen where an urgent need is indicated to ensure that the line remained free for that purpose.
The Trust advised that the administrator involved was on sick leave at that time and it was not possible to ascertain why it had taken a while to find the patient’s details on the system. However, it was explained that this can happen due to system/network delay or through inadvertently inputting incorrect details. The Team was not aware of this being a wider problem based on service user and staff feedback.
Due to the member of administrative staff being on sick leave during the investigation it was not possible to obtain their response regarding why the call may have abruptly ended. There was no indication however that the patient was considered to be unreasonable or abusive.
With regard to the request for telephone calls to be recorded it was explained that this functionality was disabled at the time whilst service managers looked to adapt this system so that callers could choose whether they wanted their calls to be recorded or not.
Learning:
The administrator had reflected on the patient’s experience when asked about this following the patient’s contact with PALS and they appreciated that they may have inadvertently appeared as though they did not wish to help the patient based on the patient’s feedback. The administrator stressed that this was not their intention and offered personal apologies for how their manner was perceived.
With regards to record-keeping, the administrator was reminded during routine one to one management supervision of the necessity and importance in logging all telephone conversations on patient records. This would be monitored through one-to-one supervision.
In terms of concerns that the telephone call ended abruptly, the administrator and team staff were reminded that calls should only be terminated in such a way when they are experiencing abuse or unreasonable behaviour and in those instances the caller should be warned that the staff member intends to hang up before taking this course of action.
It was reiterated that if the patient’s dog was a registered support dog that this could be brought along to all future appointments.
Apologies were offered to the patient for the issues and distress she experienced as a result of her contact with the service and that she had not had the option to ensure her telephone call was recorded at that time.
Formal Complaint Older Adults Inpatient Ward
Quarter 4 2021/22
Concern:
The family of a service user raised concerns following the care their relative received whilst an inpatient, these included the following concerns;
- Family expressed their concern that the inpatient staff had not given full consideration to their relative’s physical health when making prescribing decisions.
- The family wanted to ensure that the concerns they had raised on behalf of their relative regarding side effects was taken into account by the prescribing clinicians.
- That a staff member had spoken to a family member using inappropriate phrases which had caused the family member distress.
- The family requested an explanation regarding actions taken by a pharmacist.
- The family expressed concern that the inpatient ward manager had prioritised the ward staff over their relative.
- The family expressed frustration that the inpatient staff had referred to one of the family members as intimidating.
- The family had been requested to contact the inpatient ward at designated times for information on their relative, however there were times when their call went unanswered.
Response:
A full investigation report was completed which identified:-
The family were provided with assurances that all aspects of their relatives full physical and mental were taken into consideration when making prescribing decisions. Evidence was shared that the clinical team consulted with a variety of colleagues to discuss the treatment plan.
The report confirmed that the concerns raised by the service user’s family regarding medication were noted within the clinical records. These concerns were taken into account by the clinical team which in turn assisted in the clinician decision making relating to the medication regime.
The report included apologies for the unintentional distress that a staff member’s articulation of a complex presentation has caused.
An explanation was provided regarding the actions of the pharmacist which were in line with relevant policies and guidelines.
The report explained that the Manager had conveyed to the family that in order for her to ensure that the very best care is provided to all the inpatients on their ward it is her role to ensure that the staff have all of the things they require in order to perform their role to the best of their ability. The report offered its apologies if this sentiment was not articulated as well as it could have been and for any unintentional distress it may have caused.
The report clarified that the staff had not described the family member as intimidating, however it is acknowledged that at times the relationship between the staff and the family was at times fraught. Apologies were again offered for any unintentional distress caused.
The report gives the rationale for the request from the inpatient staff for telephone calls at pre-arranged times, however it also recognised that at times these calls were not always successful due to the clinical activity. Apologies were offered for any unintentional distress caused.
Learning:
No learning action identified, although apologies were offered to the family for any unintentional distress caused by the issues above.
PALS Concern Minor Injuries Unit
Quarter 4 2021/22
Concern:
A service user who had contacted the Minor Injuries Unit (MIU) prior to attending was informed that the service was open. However, on arrival at 4.40pm (shortly after the telephone conversation), was informed that the service was closed. The Service user was redirected to a different hospital. The opening times on the internet stated that they were open until 8pm.
Response:
The Minor Injuries Unit is open from 9am-5pm seven days per week, however, the last admission is 4.30pm to enable triage prior to assessment/treatment. It was identified that, when making contact to check opening times, the service user spoke with the main hospital reception, not the MIU reception and that the information provided was inaccurate.
On review of the website the opening hours had been updated to reflect the current opening hours. However, ‘Google’ still stated the previous opening hours.
Learning:
The main hospital reception staff have been informed that any enquiries relating to the Minor Injuries Unit should be forwarded to the MIU reception desk to ensure that accurate information is provided and they have been informed of the correct opening hours. The Communications Team contacted Google to request that the opening hours are updated.
A review will be completed to identify how we can record how many people are redirected to the other services due to capacity or service opening times. This will identify the current demand of the service. The impact of the reduced opening hours will also be reviewed.
Integrated Sexual Health Services (ISHS)
Quarter 4 2021/22
Concern:
Service user experienced extreme difficulty in contacting the service to make an appointment, long waits to get through, being directed to website to book an appointment which had already been attempted. Staff are unhelpful. Service user unhappy to have received a letter from the Trust Security Lead.
Response:
Team apologised for the difficulties experienced. Explanation provided that there are only a finite amount of appointments and once these have gone the team is not able to offer an appointment until more become available which is the reason why the team may ask to call back another day. The team has tried to diversify the service to increase capacity through online services such as STI testing, oral contraception and some treatments which can be posted to individual’s home or location of their choice.
With regards to the staff member, the service lead apologised for how the receptionist came across on the day and that the manner and tone were not supportive and appeared robotic in nature.
Service lead acknowledged that a letter was sent as a result of service user’s behaviour towards the receptionist. Whilst the team appreciate that service user was not happy with the letter received and that as stated service user’s behaviour was out of frustration from his experience and that he did not feel that he should have received a letter of this nature. Staff are encouraged to report where they feel they have experienced verbal or physical abuse or feel threatened and as a result the Trust will send letters to advise service users that this is not acceptable and will not be tolerated. On this occasion, following the incident, the Trust Security Lead, felt that this had occurred and service user’s behaviour towards the receptionist was not deemed acceptable which resulted in the letter being sent. Team were sorry for how the letter has made service user feel but we are unable to apologise for sending the letter or revoke this.
Learning:
To improve online booking system by changing the message to be clearer to advise when there are no appointments available. Line manager to be alerted to concern and asked to monitor staff member by listening into calls and arrangements to be made for staff member to re-attend the services customer service training as well as complete a reflection with her line manager to show growth and learning. Concerns to also be shared with the wider customer service team within ISHS for wider learning. Explanation provided that it is not possible to monitor calls as this is not the current policy.