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Handling Comments, Concerns, Complaints and Compliments Policy 

Post Holder Responsible for Policy:
Head of Customer Care
Directorate Responsible for Policy:
Quality Directorate
Contact Details:

Salisbury District Hospital

01722 336262

Date Written:
February 2010
Date Revised:
December 2014
Approved By:
Operational Management Board
Date Approved:
23rd December 2014
Next Due for Revision:
December 2017
Date Policy Becomes Live:
27th April 2010

Version Information

Version No. Author Review Date Description of Changes
Head of Customer Care
December 2014
Advocacy Services
Health Watch
Duty of Candour
Removal of template letter appendices

Table Of Contents

Staff Information
Process for monitoring compliance, effectiveness and risk management
References and Associated Documents
Equality Impact Assessment



1.1      Background

This policy details the protocol for dealing with comments, concerns, complaints and compliments received about any aspect of the care, treatment and service provided by Salisbury NHS Foundation Trust. It has been reviewed in accordance with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

The important principle behind complaints reform is that all health and social care organisations work together, conducting joint investigations. This is to ensure co-ordinated handling and to provide the complainant with a single response that represents each organisations final response. The new provisions will cover all complaints received in the NHS and Adult Social Care, including primary, secondary and tertiary health care.

In the patient-centred environment of Salisbury NHS Foundation Trust, patients/relatives/carers are encouraged to express comments, concerns, complaints and compliments about the treatment and services that they receive in the knowledge that:

Ø  They will be taken seriously.

Ø  They will receive a speedy and effective response.

Ø  Things will be put right and appropriate remedy used.

Ø  Their views will inform learning and improvements in service delivery.

Ø  There is a system for taking action to address the full range of problems, which occur from minor difficulties to major failures in treatment and care.

Ø  There will be no adverse effects on their care or that of their families.

NB:     It is a disciplinary offence for any member of staff to retaliate against a complainant or their family because they have made a complaint.  

1.2      Definitions

It is vital that the NHS takes account of the views of its patients/relatives/carers, listening to and learning from the  ‘4 C’s’: comments, concerns, complaints and compliments to:

Ø  Tell us what is working;

Ø  Help identify potential service problems;

Ø  Help identify risks and prevent them from getting worse;

Ø  Highlight opportunities for staff improvement;

Ø  Provide the information we need to review our services and procedures effectively.

A complaint is an expression of dissatisfaction about a service offered by the Trust. It may be made by a patient or a person on behalf of a patient or visitor and a formal investigation is undertaken. A concern is usually where the patient or a person on behalf of the patient is requesting further information about the patient’s treatment or care. Comments are usually requests for further information such as appointment times.

A compliment may be expressed by a person who is happy with any part of a service they receive. All compliments received by the Chief Executive’s office or Customer Care Department are acknowledged and shared with the staff/department named and recorded on Datix (risk management system). Many more compliments are received directly by wards/departments.

1.3      Aim

At Salisbury NHS Foundation Trust the management of patient/public dissatisfaction is an important part of the governance framework by ensuring that information about complaints and their causes are an integral part of the system that ensures safe, high quality care and which is constantly improving.

The Trust’s vision for a successful complaints procedure is one that meets the need of our patients/relatives/carers, staff and the organisation and follows the six principles of good complaint handling as set out by the Parliamentary and Health Service Ombudsman:

Ø  Getting it right

Ø  Being customer focused

Ø  Being open and accountable

Ø  Acting fairly and proportionately

Ø  Putting things right

Ø  Seeing continuous improvement

1.4      Staff groups affected

Every member of staff employed by Salisbury NHS Foundation Trust has a responsibility to implement this policy.

1.5      Exceptions

There are no exceptions to Salisbury NHS Foundation Trust’s commitment to learning from comments, concerns, complaints and compliments, it is therefore expected that all staff will comply with this policy by dealing with comments, concerns, complaints and compliments in line with this policy. Investigations must be carried out in an open and fair culture to ensure honesty when reporting back to complainants.




The Trust has a responsibility to establish a complaint procedure in line with the statutory requirements and take steps to publicise the arrangements.  The arrangements must be accessible and ensure that complaints are dealt with speedily and efficiently and that complainants are treated courteously and sympathetically.

2.1      Who might complain?

Complainants may be existing or former patients using the Trust’s services and facilities, as well as relatives/carers.  Members of hospital staff and other health professionals including the General Practitioner may also complain about aspects of a patient’s care or raise it through the Raising Concerns Policy “Whistleblowing”.  If the person complaining is not a patient, but is complaining on behalf of a patient, it is important to check that the patient knows about the complaint.  The complainant must be told that, in order not to be in breach of patient confidentiality, any matters relating to the patient’s care and treatment can only be answered with the patient’s consent. (This does not mean that the matters raised cannot be investigated, but means that the Trust’s response will not divulge any information about the patient’s care and treatment).

Relatives/carers or others complaining on behalf of patients will be sent an acknowledgement letter and consent form for the patient to sign and asked to return it to the Customer Care Department. The patient will sign to confirm their agreement to a reply being sent to the person who made the complaint or directly to themselves. If the patient is unable to act for him or herself, the Trust will take reasonable steps to ensure that the complainant is an appropriate person to receive information. In any event, if there is no signed consent from the patient as to what personal information can be passed on, there is a greater limitation on the content of the Trust’s response.

Where a complaint is made on behalf of a patient who has died, it is important to check that the person making the complaint is the deceased patient’s next of kin. Where this is not the case, the consent of the next of kin will be sought in writing and they will be asked to complete a consent form. In doing so the Trust will offer the next of kin the opportunity to review the complaint that has been made.

Children and young people who are competent to consent

If children are competent to give consent for themselves, consent should be sought directly from them. The legal position regarding ‘competence’ is different for young people aged over 16 than under 16.

Young people aged 18 and Over

Once a person reaches their 18th birthday they are deemed to be a competent adult capable of consenting or refusing treatment unless, following assessment, they are deemed unable to make informed decisions for themselves.

Children aged 16 and 17

A person who is the age of 16 is assumed to have the same capacity as an adult to consent to treatment in accordance with the Mental Capacity Act 2005.  As such, they do not need parental consent for medical treatment or interventions unless, following assessment, they are deemed to lack capacity.  Medical staff also have a duty of confidentiality to such patients and should not disclose information to parents without the person’s consent. 

If a complaint is made on behalf of a 16 or 17 year old, unless there is clear medical evidence that they lack capacity, then their express authority should be obtained before responding to the complaint as it will involve disclosing confidential patient information.

Children under the age of 16

Children under 16 can consent to medical treatment if they fully understand what is being proposed.  It is up to the treating clinician to decide, after assessment, whether the child has the maturity and intelligence to fully understand the nature of the treatment, the options available, any risks involved and any potential benefits. A child who has such understanding is considered ‘Gillick competent’ (a standard which is based upon UK case law).

The parents cannot overrule the child’s consent when the child is judged to be Gillick competent. Children under 16 who are not Gillick competent and very young children cannot either give or withhold consent. Those with parental responsibility need to make the decisions on their behalf.

If a complaint is made on behalf of a child who is under the age of 16, unless there is clear medical evidence that they have been assessed and still are Gillick competent, then no authority from the child will be needed to respond to a complaint made by those with parental responsibility. If however there is clear evidence that the child is Gillick competent, then their express authority should be obtained before responding to the complaint as it will involve disclosing confidential patient information.

2.2  Time limit for making a complaint

The timescale in which a complaint can be made is 12 months from the date on which the matter occurred, or the matter came to the notice of the complainant. The Trust will have the discretion to investigate beyond this time, especially if there are good reasons for a complaint not having been received with the 12 months and it is still possible to investigate the case effectively. This decision will be taken locally and where it is decided not to investigate, the complainant will have the opportunity to approach the Parliamentary and Health Service Ombudsman.

2.3  What people can complain about

People will be able to use this policy and procedure about any matter reasonably connected with the exercise of Salisbury NHS Foundation Trust’s services for patients.

2.4  What people cannot complain about

Ø  A complaint made by an NHS body about the functions of Salisbury NHS Foundation Trust.

Ø  Staff working within, or contracted to, Salisbury NHS Foundation Trust cannot use the arrangements to complain about employment, contractual or pension issues.

Ø  Complaints that have already been investigated under the complaints regulations.

Ø  Complaints arising out of the alleged failure to comply with a data subject request under the Data Protection Act 1998.

Ø  Complaints arising out of an alleged failure by an English NHS body to comply with a request for information under the Freedom of Information Act 2000.

2.5  Disciplinary action

A complaint can be investigated even if disciplinary action is being considered or taken against a member of staff, provided the organisation has regard to good practice around restrictions in providing confidential/personal information to the complainant.

The Trust believes it is important, wherever possible, to ensure the potential implications for patient safety and organisational learning are investigated as quickly as possible, to allow urgent action to be taken to prevent similar incidents arising. However, although the complaints handling arrangements will operate alongside the disciplinary arrangements, the two arrangements will remain separate.

2.6  Cases involving legal action

On receipt of a complaint where legal action is being taken or the police are involved, the Government will expect discussions to take place with the relevant authority, e.g. legal services, the police, or the Crown Prosecution Service, to determine whether progressing the complaint might prejudice subsequent legal or judicial action. If so, the complaint will be put on hold, and the complainant advised of this fact. If not, an investigation into the complaint should take place. Again it is important to ensure the potential implications for patient safety and/or organisational learning are investigated as quickly as possible to allow urgent action to be taken to prevent similar incidents arising.

2.7  Serious Incidents (see Serious Incident Immediate Response policy)

A Serious Incident (SI) is an incident which has occurred in relation to NHS funded services. The SI is a situation in which one or more individuals (patients, staff, visitors, contractors) are involved in an event which is likely to produce significant legal, media or other interest. This may have resulted in permanent serious harm, unexpected or avoidable death, or where actions of health service staff are likely to cause significant public concern. This extends to include incidents that may indirectly affect patient safety and the organisation's ability to delivery ongoing healthcare.

Such events include:

·         Unexpected or avoidable death

·         Allegations of abuse

·         Adverse media coverage

·         Data loss and information security

·         In-hospital development of grade 3 or 4 pressure ulcer

·         Failure of a screening service that has actual or potential consequence for clinical outcomes

·         Child protection

·         Suicide or serious self-harm

·         Homicide

·         Rogue staff

·        Events that affect multiple patients e.g. rogue staff, outbreak of infection such as legionella, incorrect interpretation of specimens

·         Large scale theft or fraud

Events also include the core set of 'Never Events' which include:

·         Wrong site surgery

·         Retained instrument post-operation

·         Wrong route administration of chemotherapy

·         Misplaced naso-gastric or orogastric not detected prior to use

·         In-patient suicide using non-collapsible rails

·         In-hospital maternal death from post-partum haemorrhage after elective  caesarean section

·         Intravenous administration of mis-selected concentrated potassium chloride

If a complaint is received and the key points are being investigated under the serious incident investigation, the complainant is kept informed and a longer timescale is agreed to respond. The Head of Risk should keep the complainant informed of the progress of the investigation. If the person has raised issues that are not being investigated under the serious incident investigation, then they will be investigated under a complaint investigation.

2.8 Roles and Responsibilities

Chief Executive

The Chief Executive is the designated responsible person whose duty it is to ensure overall compliance with the Statutory Instrument. The Trust will have a designated Head of Customer Care to whom the Chief Executive will delegate the day-to-day management of the process and whose role is to oversee the complaints procedure.

The Chief Executive will sign all complaint acknowledgement letters within three working days of receipt of the complaint. A copy of the Trust’s leaflet ‘Comments, Concerns, Compliments and Complaints’, which explains how the complaint will be handled will also be enclosed. The response letter will be signed by the Chief Executive, and in his absence, responses will be signed by the Deputy Chief Executive.

Head of Customer Care

The appointed Head of Customer Care has the delegated responsibility to manage the complaint procedure on behalf of the Chief Executive. The prime responsibility is to oversee the complaints handling procedure, provide guidance and support, and to provide the Trust with an overview of its complaints.

The Head of Customer Care is readily accessible to the public.  Complainants may refer complaints directly to the Head of Customer Care if they do not wish to raise issues with the staff directly involved in their care.

In relation to complaints received about other NHS bodies or Social Services, the consent of the complainant shall be sought prior to transferring the complaint to that organisation. In the case of complaints that are a mixture of health and social care issues, it will be agreed with the complainant, which organisation will lead and co-ordinate the final response.

Any complaints that involve a sudden unexpected death, serious harm or potential safeguarding issues, should be escalated to the Head of Customer Care who will discuss the management of the complaint with the most appropriate Head of Service/Lead Clinician.

The Head of Customer Care will co-operate with the requirements of the Parliamentary and Health Service Ombudsman (PHSO) by providing information, files and copies of relevant medical records if required.

Customer Care Staff

Customer Care Staff are responsible for trying to resolve concerns/complaints when the issue if brought to their attention. If the issues cannot be resolved quickly then they will co-ordinate the concerns/complaints procedure, ensuring compliance with the complaint regulations, agreeing a plan with the complainant for the management of the complaint.

Any complaints where there has been a sudden unexpected death, serious harm or potential safeguarding issues, should be escalated to the Head of Customer Care immediately.

The Customer Care Staff will contact the complainant to discuss the complaint at the outset and explore the feelings of the complainant and identify their preferred outcome - what they hope to achieve from the process if this has not already been established; identify and explain any consent issues to the complainant and assess what further action might best resolve the complaint e.g. a meeting with staff.

The Customer Care Staff will prepare the acknowledgement letter for the Chief Executive to sign within three working days of receipt. The acknowledgement will indicate that a written response from the Chief Executive for complaints or relevant manager for concerns will follow within an agreed timescale and will include a leaflet about the Trust’s Comments, Concerns, Complaints and Compliments Procedure, which also gives information about local advocacy services and the PHSO.

When a complaint is received by e-mail, the Customer Care Staff will acknowledge the complaint and ask the sender to supply an address so that all future correspondence can be in writing. It is not possible to be certain that the sender is who they appear to be, that the message will be read by them and that they understand or accept the risks. Whilst we understand the need for people to communicate by e-mail, to ensure security of information, the Trust must positively identify the named individual and address. (Acceptable use of Email and SMS Text Messaging policy).

Verbal complaints will be acknowledged with a written record of the conversation sent to the complainant. The complainant will be asked to confirm if the record clearly captures the issues they want investigating or if they wish to add or amend the information.  

Ø  The Customer Care Staff will record all relevant information about the issue on Datix and set up the agreed response timescale alerts.

Ø  Track complaints and send reminders to facilitate the meeting of deadlines and keep the complainant informed of any delays.

Ø  Telephone/e-mail the Investigating Manager one week before the final deadline to find out if there are any problems with the investigation and to offer assistance by contacting the complainant and agreeing a longer timescale, giving the reasons for the delay.

Ø  Record the conversation and set the new timescales on Datix.

The Customer Care Staff will check completed response letters for content, format, grammar and spelling, before forwarding to the Head of Customer Care. After sign-off by the Chief Executive, the Customer Care Staff will send the signed letter of response to the complainant and a copy to all staff named in the letter.

Helpdesk Managers

Helpdesk Managers (HDM) are responsible for manning the Helpdesk in accordance with the Helpdesk rota. The shifts are either 9.00am–1.00pm or 1.00pm–4.30pm. If the HDM cannot attend their designated shift, it is their responsibility to find a replacement/swap and inform the Customer Care Staff who will be covering for them in order that the rota can be updated on the Intranet.

HDM’s are responsible for dealing with comments and concerns face-to-face, by e-mail or by telephone. If the complainant wishes to make a formal complaint, the HDM can write down the complainant’s complaint on the Record of Discussion form (Appendix A) and refer it to the Customer Care Team to co-ordinate. If the HDM is dealing with the complainant face-to-face, they should give a copy of the leaflet to the complainant.

HDM’s should complete a Record of Discussion form for all concerns and complaints dealt with in order that any themes arising can be addressed. Comments or compliments can be recorded on the Helpdesk log.

Any complaints where there has been a sudden unexpected death, serious harm or potential safeguarding issues, should be escalated to the Head of Customer Care immediately.

At the end of the HDM’s shift they should e-mail their Record of Discussion forms, whether they have completed the matter or not to so that the Customer Care Staff can log the information on Datix. The HDM should take any outstanding concerns with them to resolve and keep the complainant updated. The HDM must record all their actions, including dates and people who they have discussed the case with, and when it is resolved they should e-mail it again to so that Datix can be updated and the case closed. If the PHSO is asked to review a case that the Trust has dealt with, it is very important that a full audit trail of actions taken can be shown.

Directorate Management Team (Investigating Manager)

Directorate Management Teams have the responsibility to undertake an investigation into all complaints, ensuring that the complainant’s concerns are fully addressed, and are available within the agreed deadlines.

The Investigating Manager will undertake a preliminary assessment of how best to investigate the complaint. Formal complaints should be thoroughly investigated in accordance with Adverse Events: An Organisation Wide Approach to Investigation, Analysis, and Learning policy.

Provide support to staff involved in an investigation, particularly those named, and make sure they are aware of the contents of the complaint and response. If a named member of staff has left the Trust, the Investigating Manager has the responsibility to ensure all efforts are made to obtain their comments, particularly if harm has been alleged. If the complaint involves a junior member of staff, the Investigating Manager must obtain a senior review as well as obtaining comment from the junior member of staff involved. The draft complaint response letter needs to be shared and agreed by all named in the response letter and by those who have contributed to the investigation.

If admissions of error are to be made, the draft response must be shared with the Head of Litigation. If the complainant is explicitly requesting compensation/ recompense, findings of the investigation must be shared with the Head of Litigation.

If harm is alleged to have been caused, Investigating Managers must assure themselves of the evidence when they read the medical records.

Ensure that agreed actions arising out of investigations are implemented across appropriate teams/departments and to ensure that the Directorate fosters an ethos of learning in order to minimise future occurrence. 

To ensure improvements arise out of complaints, Action Plans (Appendix B) must be completed and monitored following the investigation of all complaints. The information from the Action Plan will be recorded on Datix and timescales set for follow-up. The Customer Care Advisors will e-mail the Investigating Manager or person responsible for implementing the action for an update/closure. Complaints should be shared with staff within each ward/department by the manager for learning purposes.

All Staff

All managers have a responsibility within the complaints handling procedure.  It is part of the role of the manager to ensure that staff are fully assisted and feel fully supported throughout the handling of any complaint.

Staff should ensure that complainants, having made a complaint, are assured that it will not prejudice the patient’s future treatment and care. The Trust policy and procedure for handling complaints is considered as part of the ward/department induction. 

Further information on how to deal with comments, concerns and complaints is available at Appendix C.

Front line staff will distinguish those serious issues that, even if raised verbally need to be brought to the attention of senior managers within the Trust.

Non Executive Director

An appointed non-executive director will be responsible for reviewing a sample of complaints on a quarterly basis as an important assessment of the quality of investigations.

2.9 Safeguarding Adults

The Trust has in place systems and processes to promote the safeguarding and wellbeing of patients. These are reflective of local and national guidelines. It is important that when a complaint is received, consideration is given as to whether it may meet the Safeguarding Adults threshold and this must be done in a timely manner in line with the Safeguarding Vulnerable Adults/Adults at Risk Policy.

Before commencing a complaint investigation, Customer Care Staff will review the complaint for potential safeguarding adult issues. If there are safeguarding concerns these should be escalated to the Head of Customer Care and the complaint will be referred to the Trust Adult Safeguarding Lead. They will consider the complaint and confirm to the Head of Customer Care whether there are safeguarding issues that require referral to the appropriate social care, learning disability or mental health team. This may mean that the formal complaint investigation has to be delayed although it should be remembered that the two investigations can run in parallel if it is agreed that this would not compromise the safeguarding investigation. 

2.10 Meetings

As part of the local resolution process and in agreeing with the complainant how they wish their concerns to be handled, consideration will be given to arranging a meeting with hospital staff. However, this will be discussed with the relevant members of staff before it is agreed with the complainant.

Once a meeting has been agreed the complainant will be asked to provide a list of questions to form an agenda so the meeting can be structured with the most appropriate staff in attendance. Meetings will take place in a sensitive venue. Complainants requiring support will be advised to contact their local Advocacy Service. A letter will be sent to the complainant giving details of the meeting and who will be attending.

Staff should attend a pre-meeting to discuss the case. The meeting will have a chair/facilitator and someone to take the minutes. Following the meeting with the complainant, if necessary, staff will meet to discuss the outcome and any further actions that need to be taken to achieve local resolution for the complainant.

The minutes will be circulated to all staff members involved in the meeting for checking the clinical content before they are sent to the complainant.

2.11  Parliamentary and Health Service Ombudsman (PHSO)

The PHSO investigates complaints about the National Health Service and is completely independent of the NHS and the government.  The PHSO will consider cases where the complainant is not satisfied with the Trust’s efforts to resolve their concerns at a local level. The complainant has to send their complaint to the PHSO no later than a year from the date when they became aware of the events, which are the subject of complaint.  The PHSO can sometimes extend the time limit, but only if there are special reasons.

The PHSO can investigate complaints about hospitals or community health services which are about:

Ø  a poor service;

Ø  failure to purchase or provide a service a complainant is entitled to receive;

Ø  mal-administration - that is administrative failures such as unavoidable delay, not following proper procedures, rudeness or discourtesy, not explaining decisions or not answering the complaint fully and promptly;

Ø  complaints about the care and treatment provided by a doctor, nurse or other health care professional;

Ø  other complaints about family doctors (GPs) or about dentists, pharmacists or opticians providing a NHS service locally.

The PHSO cannot look into:

Ø  complaints which one could take to court or an independent tribunal - unless the PHSO does not think it reasonable for the complainant to do so;

Ø  personnel issues such as appointments of staff, pay or discipline;

Ø  commercial or contractual matters, unless they relate to services for patients provided under a NHS contract;

Ø  properly made decisions an NHS authority or other body or individual providing NHS services has a right to make, even if the Complainant does not agree with the decision;

Ø  services in a non-NHS hospital or nursing home, unless they are paid for by the NHS;

Ø  complaints about government departments, such as the Department of Health;

Ø  complaints about local authority departments, such as social services.

The PHSO will decide whether or not an investigation will be carried out.  If the PHSO cannot look into a complaint or decides not to, the complainant will be told why.  If the PHSO decides to investigate, the complainant and the Trust will be sent a statement of complaint, which sets out what matters the PHSO, will look into. The complainant and relevant hospital staff may be interviewed by the PHSO’s investigator. At the end of the investigation, a report will be sent to the complainant and the Trust. If the complaint is found to be justified, the PHSO will seek for the complainant an apology or other remedy.  Sometimes that may include getting a decision changed, or a repayment of unnecessary costs to patients or their relatives/carers. The PHSO does not recommend damages (compensation). The PHSO may also call for changes to be made so that what has gone wrong does not happen again.  Where the Trust tells the PHSO that it will make such changes, the PHSO checks that it has done so.

Following receipt of the PHSO’s draft report, this will be circulated to the relevant staff involved in the case for their comments. The Trust must confirm to the PHSO that the content is accurate and state whether it accepts the PHSO’s decision.

Further to receipt of the final report, if recommendations are made the Trust must convene a meeting of the relevant senior staff to review the recommendations and carry out the necessary actions. Clear action planning must be carried out. It is likely that the Ombudsman will wish to review actions taken as a result of their recommendations three months later. The Head of Customer Care will oversee this process.

A complaint to the PHSO represents the final stage in the procedure for pursuing a complaint. The PHSO’s decision on a complaint is final.

2.12 Healthwatch

Healthwatch's sole purpose is to understand the needs, experiences and concerns of people who use heath and social care services and to speak out on their behalf. People who want to make a complaint about a particular service can contact Healthwatch to find out how to get help with making their complaint.


Staff Information


3.1      Statutory Duty of Candour

All Trusts have to identify that an incident causing moderate or major harm has happened and tell the patient about it swiftly and honestly. Trusts will also have a duty to support the patient by allowing a member of the family, carer or a healthcare professional that the patient has confidence in to be present when they tell the patient what has happened. Ongoing support and treatment to reduce the harm must be provided. This might be from a different clinical team or hospital if the patient wishes.

Further guidance is available in the Trust’s Adverse Event Reporting Policy and the Adverse Events Supporting Staff/Being Open Policy. The duty, which will be monitored by the Care Quality Commission (CQC), will apply to all NHS organisations.


Complaint correspondence will be kept separate from health records, subject to the need to record any information, which is strictly relevant to their clinical management in the patient’s health record. No complaint correspondence is to be filed in the patient’s health record.  This instruction covers the initial letter of complaint and the final letter of reply, as well as internal correspondence.  The master files of all statements and correspondence of meetings are held by the Customer Care Department.

The minimum recommended period for retaining a complaint file is presently eight years from the date on which action was completed. For complaints about children and young people the file must be kept until the patient’s 25th birthday. Files must be disposed of under confidential conditions. (Records Management – NHS Code of Practice Part 2 (2009) Department of Health)

3.2  Statements

With an increasing number of complex queries and complaints, it is becoming more common for staff to be asked to provide statements as a result of a complaint/claim/untoward incident. When writing a statement, it is important to remember that, although the majority of statements will go no further, a statement may be copied to the complainant, PHSO, the Coroner or used as evidence in defending a legal claim. Please remember, however, that the Trust indemnifies its entire staff and will be responsible for any complaint and claim made. (Appendix D)

3.3  Mediation

Some complaints are difficult to resolve, particularly when there is a breakdown in a relationship between staff and patients/relatives/carers. In these cases mediation can be used.

Mediation is a process that complements the Trust’s formal arrangements for dealing with complaints. It offers early assistance before problems escalate into major issues for all concerned.

The mediator’s role is purely to mediate between the parties to restore communication. The mediator is not expected to get involved in the investigation of the complaint. The process and principles used by the mediator are clearly set out in the Trust’s policy Mediation Scheme.

To request a Mediator, you can e-mail or telephone 01722 336262 extension 2743.

3.4  Advocacy Services

If someone wants to raise concerns or make a complaint it is important to let them know what support is available. There are a number of advocacy services available depending where the patient lives. These services are free, independent and confidential and will listen to a person’s concerns about their NHS treatment. Advocates can help people write effective letters to the right people; prepare them for and go to meetings with them; contact and speak to third parties if they wish them to and help people think about whether they are happy with the responses they receive from NHS organisations.

3.5      Persistent and Unreasonable Complainants

Persistent and unreasonable complainants are those that raise the same or similar issues repeatedly, despite having received a full response to all the issues they have raised. If following a review of the complaint the complainant is persistent or unreasonable in their manner of engaging with the Trust, it may be appropriate to apply a degree of restriction on their frequency and mode of contact. This would include complainants that:

Ø  Refuse to accept the remit of the process to be undertaken as described to them.

Ø  Request actions that are not compatible with the process or place unreasonable demands on staff.

Ø  Change the basis of the concern or complaint or introduce trivial or irrelevant information and expect these to be taken into account when they have already agreed to a plan and specific issues to be responded to.

Ø  Make excessive telephone calls or send excessive numbers of e-mails or letters to staff.

Ø  Submit concerns or complaints about the same issues as have previously been appropriately and fully considered and responded to.

Ø  Fail to engage with staff in a manner which is deemed appropriate: e.g. repeatedly using unacceptable language; refusing to adhere to previously agreed communication plans or behaving in an otherwise threatening or abusive manner on more than one occasion, having been warned about this.

Ø  Repeatedly focus on conspiracy theories and/or will not accept documented evidence as being factual.

The Head of Customer Care in agreement with the Chief Executive will determine the point at which a complainant will be considered to be persistent and unreasonable. Below are some possible courses of action that may help to manage complainants who have been designated as persistent and/or unreasonable.

Ø  Placing time limits on telephone conversations and personal contacts.

Ø  Restricting the number of calls that will be taken or made.

Ø  Requiring contact to be made with a named member of staff.

Ø  Requiring contact to be made through a third person, such as an advocate.

Ø  Limiting the complainant to one mode of contact e.g. in writing only.

Ø  Requiring any personal contact to take place in the presence of a witness.

Ø  Refusing to register and process further concerns or complaints about the same matter.

Ø  Informing the complainant that future correspondence will be read and placed on file, but not acknowledged.

Ø  Advising that the organisation does not deal with correspondence that is abusive or contains allegations that lack substantive evidence. Request that the complainant provide an acceptable version of the correspondence or make contact through a third person to continue communication with the organisation.

Ø  Asking the complainant to enter into an agreement about their conduct.

Ø  Advise that irrelevant documentation will be returned in the first instance and (in extreme cases) in future may be destroyed.

Once a restriction is put in place, a letter should be issued by the Chief Executive to inform the complainant about the decision; what it means for their future contact with the organisation; how long those restrictions will remain in place; and what they can do to have their position reviewed.

3.6  Private patients

This procedure covers any complaint made about staff or facilities relating to private health care on Trust premises but does not cover the private medical care provided by a consultant outside her/his NHS contract.

3.7  Other agencies

If the Trust receives a written complaint that involves another agency, for example, the Police, the Trust will work jointly with an agreed point of contact, to ensure all matters are fully investigated.


Process for monitoring compliance, effectiveness and risk management


4.1      Monitoring

The Head of Customer Care will be responsible for the monitoring of individual complaints against agreed timescale and responsibilities, in liaison with the Directorate Management Teams.

The Head of Customer Care will produce quarterly summarised reports of complaints received to the Trust Board that will include qualitative and quantitative analysis of key issues found in complaints. The report will include action taken to improve services as a result of complaints. These reports will also be shared with the Commissioners and at the Governor’s meetings. The conclusions and recommendations outlined in a PHSO’s final report, together with any action to be taken by the Trust as a result of these investigations, will also be included.

An annual trustwide report card is produced and presented at the Clinical Governance Committee incorporating the information and analysis from across incidents, comments, concerns, complaints and claims, identifying cross cutting issues for the organisation. The Clinical Governance Committee reports into the Trust Board. 

A quarterly KO41(A) return will be completed and returned to the Health and Social Care Information Centre.

Complaint data both in terms of specific issues/actions and more general trends arising out of complaints should be used in improvement work and executive walks.

Complaints Management Questionnaire

A complaints management questionnaire will be sent to each complainant on conclusion of the complaint unless it is excluded under the exceptions, which are as follows:

Ø  The complainant has contacted the PHSO (as it is felt that if they have done so they have already demonstrated their dissatisfaction with the complaint process).

Ø  The complaint is re-opened and still under investigation.

Ø  The complaint is subject to an ongoing clinical review.

Complaints provide a unique insight into the complainant’s experience of our services and often highlight where service improvements can be made. It is very important to us that complainants not only feel able to raise their concerns, but are happy with the actions that we take as a result.

4.2      Training

Customer Care and Complaints

All staff should know how to react and what to do if someone makes a complaint.  The Trust provides staff training in customer care, complaints management, conflict resolution and difficult conversations.

Root Cause Analysis

Root Cause Analysis (RCA) training is provided by the Risk Management Team.

Additional information is available from the National Patient Safety Agency (NPSA) on

Incidents, Complaints and Claims – managing investigations and supporting staff

This session provides a detailed session around Root Cause Analysis, information regarding complaints and the writing and submission of statements.  

4.3  Publicity

Leaflets informing patients and visitors of the Trust’s Complaints Procedure will be displayed throughout the Trust. The Complaints process is also publicised on the Trust’s website. 

4.4  Translating and Interpreting

The Trust recognises that on occasions complainants may experience difficulties in pursuing their complaint due to language or communication barriers. The Customer Care staff will ensure that appropriate support is made available to complainants.

4.5  Special Needs

The Customer Care staff will ensure that wherever possible the individual needs of complainants are identified and met. This will include meeting the needs of people with learning disabilities, physical disabilities or communication problems such as hearing or visual impairment.

Patients can apply for a Salisbury Care Card which will alert staff to their particular need.


References and Associated Documents


5.1 Sources of information


Data Protection Act (1998) –

Being Open – communicating patient safety incidents with patients and their carers, (2009) National Patient Safety Agency

NHS Constitution 2013

Ombudsman’s Principles, (2009) Parliamentary and Health Service Ombudsman

Records Management – NHS Code of Practice Part 2, (2009) Department of Health

Statutory Instrument (2009) The Local Authority Social Services and National Health Service Complaints (England) Regulations –


Health Service Ombudsman -

Care Quality Commission -

NHS Litigation Authority –

Root Cause Analysis (National Patient Safety Agency) –

5.2 Associated Documents

Acceptable use of Email and SMS Text Messaging Policy

Adverse Events: An Organisation Wide Approach to Investigation, Analysis and Learning       

Mediation Scheme

Raising Concerns Policy “Whistleblowing”

Serious Incident Immediate Response Policy


Equality Impact Assessment

The policy Equality Impact Assessment can be found in Appendix F.







Record of Discussion/Telephone Conversation


Customer Care Department Action Plan


Dealing with Comments, Concerns and Complaints Information for Staff


Guidance for Staff on Preparation of Statements


Helpdesk Manager Checklist


Equality Impact Assessment


















































Page Last Updated: 06/11/2015 15:55 
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