Formal Complaint Adult Social Care
Quarter 1: 2022/23
Concern:
Relative raised concerns about lack of information provided by her mother’s Social Care Team. She said that her mother was transferred to a nursing home for 24 hour care after discharge from hospital but that neither she nor her mother were told of the need to self-fund this placement after Covid-19 funding ceased in April 2022. She complained therefore that unnecessary costs had been incurred, without her having opportunity to consider or make alternative arrangements beforehand.
Response:
The Trust responded, stating that records indicated funding may have been discussed during a visit to the home by the social worker, with which the daughter was involved. However, details of what was discussed were not clear from the records and this took place whilst the service user was already incurring costs, the costs being for 16 days in total.
It was agreed that both the relative and service user had not been informed that the placement would be self-funding in good time before this commenced and it was agreed that the Trust would settle the payment direct.
Learning:
Social care teams are regularly reminded of the importance of clear records, including information shared with service users, families and carers about charges that may be incurred and available options.
PALS Concern AHP Referral Centre
Quarter 2 2022/23
Concern:
Service users and carers are attempting to contact the AHP referral Centre to arrange an appointment with therapy services. Service users are unable to get through and the message states that they are in queue position 20. This then encourages the service user to wait on the phone as the queue positions become lower; however after 45 minutes the call automatically terminates. Service users have been raising this with PALS and Experience as it is causing additional stress and they are unaware on how they can contact the service to arrange their appointment.
Response:
There has been an increase in demand and the service have reduced staffing levels with vacancies available. The service managers have been escalating the concerns to the senior leadership teams and this will be added to the Trust risk register. Apologies are being provided to service users and carers and where possible a member of the team is making direct contact to arrange an appointment.
Learning:
The AHP Referral Centre have raised this feedback with our Health Informatics Service (HIS) who have made the following changes to the automatic voicemail. This is to ensure service users and carers are aware of the current delays when they make contact;
Introduction when calling 0300 123 0991
Welcome to the Therapy Referral Services, part of Midlands Partnership NHS Foundation Trust. Calls are recorded for training and monitoring purposes.
Please be advised that we are experiencing a high volume of phone and email queries. You may be waiting up to 45 minutes for your call to be answered. If you have not been connected to one of our agents after this time, your call may be disconnected.
If you have been referred from the GP, please allow at least seven working days before contacting the referral services to book your appointment, as the team will be unable to process your referral before this time.
If you would prefer not to wait in the call queue, you can contact us via email on NIMSadmin@mpft.nhs.uk Please ensure to include your full name, NHS number or date of birth, postcode and full details of your enquiry.
PALS CLD ASD Telford
Q3 2022/23
Concern:
Parent attended an appointment to begin the Autistic Assessment process. The doctor arrived 10 minutes late and advised that the appointment had already been cancelled, due to another colleague who was joining the appointment was off poorly. Parent claims that they were not informed of cancellation via letter/telephone and found the doctors attitude unacceptable.
Response:
Team apologised for the poor communication. Due to the postal strikes the team made the decision to send a new appointment date via text and not post. Unfortunately, the admin staff had not checked for a reply to the text message nor did they follow up with a phone call.
Outcome:
A new process is now in place to ensure that admin staff are checking to see a reply is received for text messages that are sent.
Operational Lead has met with the staff member to discuss the concern and apology afforded for the way she had purported to have been as this is not the experience the service would want anyone to have.
PALS BeeU Shropshire - ASD/ADHD Pathways
Quarter 3 2022/23
Concern:
Parent wished to raise an official complaint on behalf of their 10 year old child regarding the service they have received. Parent said that YP was assessed by the ASD Pathway in October 2021 who confirmed had a diagnosis of ASD. Following this they understood that a referral was made to the ADHD Pathway to review case in November 2021; however when family contacted services in summer 2022 for an update, was told all the paperwork had been reviewed in December 2021 and it was deemed that YP did not fit the ADHD criteria. Subsequently the ADHD Pathway had removed YP from the waiting list and closed the referral without their knowledge.
Outcome:
Following review it was found that there was no evidence to suggest that the ADHD Pathway had the opportunity to review the case, as it was not documented. It was deemed that the last progress note which indicated that the ADHD Pathway will contact the family if a referral is accepted, was too open ended. This allowed the referral to sit closed for a year with no sharing with the family that this had not happened, leaving both the family and our partner agencies feeling frustrated with BeeU. Team acknowledged that family’s experience of service had not been good enough and the ADHD Pathway were asked to review historical and updated information to see whether an assessment was needed. Assurance was given to parent that BeeU were reviewing processes and looking at movement between pathways to be more seamless.
PALS Concern - CAMHS West
Quarter 2 2022/23
Concern:
Mum called on behalf of her 14 year old son who is going through the transgender process. She said earlier this year they saw a new mental health practitioner as his usual therapist has been off sick.
Mum said during the appointment the practitioner miss-gendered her son on more than one occasion which made him feel uncomfortable. She also questioned him about his medical choices and ongoing treatment with trans-identity.
Mum explained that her son has been in gender therapy since the age of 9 and is happy with the therapy and treatment he receives.
Mum explained they have declined any further appointments with this therapist as she made her son feel worse and had the audacity to question him about his gender when she was not in the capacity to do so.
Response:
Enquiry shared with Service Manager about staff member's conduct and breach of the Transgender Inclusion Policy.
Learning:
Mum updated that the team has identified the breach of policy, and that our actions will be to:
To discuss with staff member conduct and breach of the Transgender Inclusion Policy.
To reaffirm the Transgender Inclusion Policy with the staff member in a form of education. Share policy within the team to refresh the team around the appropriate ways to address a young person who identifies as transgender.
Formal Complaint Children’s & Young People’s Autism Service
Quarter 1 2022/23
Concern:
Parent raised a complaint that their daughter had been given insufficient and inappropriate support for ther Autistic Spectrum Condition and Selective Mutism. She said that following there daughter’s referral to the service she had not received good communication about waiting times and that she needed to chase this up. She said that the session work provided was the unsuccessful and the wrong approach, with the decision about a way forward being predetermined, regardless of parents thoughts and feedback. The parent considered that her daughter should be seen by a specialist in Selective Mutism but this did not happen. Parent felt that the service did not effectively engage with her daughter and that parent was not invited to be involved in Multi-disciplinary team (MDT) meeting discussions. When the parent asked for a copy of minutes of the MDT meeting, these were not provided.
Response:
The Trust agreed that waiting time from referral to intervention was much longer than the Trust would like to see and that parent's frustrations were understandable.
It was recognised that the support sessions to help the young person with anxiety were unfortunately not successful, although this was considered to be that despite best efforts to encourage communication through various methods, the young person did not feel able to engage with the practitioner. Without being able to successfully complete this support to deal with the anxieties that caused the Selective Mutism it was not possible to commence Speech & Language Therapy support. A meeting had been held with the parent to discuss concerns and the investigation found that these were listened to and considered. It was reiterated to the parents that the young person may benefit from a trusted communication partner either from her home or school environment to be able to engage with the service. The service remained of the view that session work on her anxieties which caused her Selective Mutism needed to be successfully completed before SALT support could be progressed.
As this did not resolve matters it was appropriately suggested that MDT would discuss this case further to agree a way forward. MDT felt that the appropriate decision had been made and did not recommend a change to the approach.
Learning:
Additional staff have been recruited and work continues to ensure improvements in waiting and treatment times. It was confirmed that as a result of parents concerns all future initial letters would advise parents/carers that the next time the service will be in contact is when an appointment is available. Families are now encouraged to contact the service direct if there are any changes that they need to discuss or if support is required.
With regard to the MDT meeting, it was considered appropriate that minutes were not recorded as discussions took place about several patients during each meeting. For this reason and due to the volume to be discussed it was also appropriate that parents and carers did not join the meetings. Records however did not identify which members of staff were in attendance at a particular MDT as would be expected and the team were reminded of the importance of this and confirmed that such detail is now logged. Apologies were relayed to parent.
PALS Children's 0-19 Newcastle
Quarter 4 22/23
Concerns
Mum concerned about the lack of consistency in the information regards to weaning babies with allergies and to express her concerns about the lack of communication between professionals and teams.
Team reviewed the enquiry and formulated the below response:
Team Lead reviewed the videos incorporated into the latest toolkit.
Response:
Discussions took place with staff involved in making the video, to discuss concerns and the content of the video. It was decided that out of the two videos available for the 0-19 service to share, that the Cows Milk Protein Allergy (CMPA) video would be removed from the toolkit as this is more specialist advice that should not be shared by the 0-19 service, but advice is given from the Dietician.
Dietician at UHNM has confirmed that Mum has an appointment on 2nd May 2023.
Mum is happy with the resolution from the Newcastle 0-19 service perspective.
Mum has commenced weaning following some basic advice from the Dietician at the time of being contacted to say that the referral had come through to the wrong department.
Learning:
The 0-19 service to share with the wider team, that the Cows Milk Protein Allergy video would be removed from the toolkit as this is more specialist advice that should not be shared by our service, but advice is given from the Dietician.
Dieticians to be invited to deliver some refresher training to ensure staff provide consistent advice, and where required signposting back to GP early on to ensure that the Dietician referral can be completed in a timely manner, allowing sufficient time for appointment.
Team to ensure that GP has correct information to make referral.
Ensure staff are aware of CMPA and the guidance around weaning a baby with CMPA.
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.
Community Paediatrics (Staffs)
Quarter 4 2023/24
Concern:
Parent asking why Community Paeds have not made a referral to CYP Autism and how the service plan to rectify the situation and ensure that her son will not be prejudiced by this error.
Response:
CYP Autism Lead spoke with mum to confirm that there was misunderstanding with the Doctor who has come from a different area, and he thought he had submitted the referral but had not sent it. CYP Autism have linked in with the paediatric service and the referral has now been received along with a teacher liaison form. The referral has been triaged immediately and accepted for assessment; the referral has also been backdated to October. Mum has been informed that the team are looking at about 18 months to commence the assessment. In the interim, mum has been provided with resources to support whilst they await their appointment.
Learning:
Learning for paeds - to ensure any new Doctors coming into the service are aware of the process for making a referral. This will be included as part of paediatrics local induction and training planning.
Community Paediatrics & Audiology (Staffs)
Q2 2022-23
Concern:
Parent frustrated that the referral for autism assessment has been rejected despite the high cast score from both home and school.
Following the rejected assessment, family has received no communication from paediatrics. Attempts to contact the service have failed, each time going to answerphone resulting in messages left but no return call from the service.
Response:
Team reviewed the enquiry and formulated the below response:
1. Family contacted to explain that the paediatric service currently have long waits for reviews. The letter from the Children and Young Persons Autism Service would have been sent to them directly from the Autism team and community paediatrics would not have any part in the decision to accept or reject a referral. The referral would have been supported by all the required information, including questionnaires.
2. Team to send out Connors questionnaire for school/parents to complete.
3. Organise school observations for young person by nurses to ensure that the team capture the issues around ADHD and other behaviours to be able to further assess concerns around ADHD.
4. Organise for young person to be seen by community paediatrician, following receipt of school reports/questionnaires.
5. If significant outburst of aggressive behaviour or anger issues are noted at home/school young person will require urgent referral to CAMHS for review of oppositional behaviours as paediatrics wouldn't have expertise to diagnose/treat such behavioural/mental health issues.
Learning:
Team have now recruited to vacancies and implemented a phone rota to ensure calls are answered.
CRHT Shropshire
2023-2024 Q4
Concern:
Complainant contacted PALS to advise after speaking with the team they felt the staff member was unhelpful and unsympathetic, causing them to feel worse about their condition. Complainant felt disheartened by the lack of empathy and personalised care provided by mental health services. And highlighted how they felt like a statistic rather than a person in need of assistance.
Response: It was acknowledged that callers to the service should feel heard and not made to feel that the practitioner is unhelpful or unsympathetic towards them. Team leader spent time advising changes to procedure over the past two years and complainant was thankful to have clarification on which service to call out of hours and the potential process of support following this, i.e signposting to services such as the sanctuary or the access team requesting support from their designated clinician, who would then refer to CRHT for follow up if appropriate.
Learning:
Concern was raised in the next CRHT team meeting and in supervision with staff members. This was used as a learning opportunity to improve practice within the team and prevent similar situations arising in the future.
Crisis Team South Staffordshire East
Q4 2023/24
Concern:
A concern was raised by a family member regarding the care their mother received when contacting the Crisis team for support. The family member was unhappy that they overheard a conversation between staff members during the telephone call. This comment had caused the service user distress and that she felt she was unable to contact the service for support.
Response:
The service manager spoke with the service user directly to discuss the concerns raised and provided their sincere apologies from the team. The service user had stated she had no concerns relating to the care and treatment from the team other than the comment made when contacting for help. The service user was assured that it would be raised with the wider team to ensure that staff members are not sharing information or comments with other staff.
Learning:
All staff are to be reminded of the Trust’s values and behaviours when supporting our service users and carers and to treat all people with the upmost dignity and respect.
Grange Ward
Q4 2023/24
Concern:
Complainant contacted PALS to advise that during their inpatient stay, prescription charts were not kept up to date and there were delays with medication due to low stock on the ward, which resulted in delayed pain relief.
Response:
The ward manager confirmed that prescription charts last 28 days and should be rewritten on the 27th or 28th day. The ward manager provided their apologies to the service user that it was not identified the prescription chart was not updated in a timely manner.
In regard to medication, it was confirmed that liquid paracetamol is not a medication which the ward stock and is only dispensed on request. The ward manager provided assurance to the service user that staff would be reminded to check medication stock and ensure the required medications are ordered more promptly.
Learning:
All staff were reminded during a team meeting on 27 March 2024 that prescription charts should be rewritten on 27th or 28th day.
All staff were reminded during a team meeting on 27 March 2024, to check medication stock regularly and order required medication in advance.
Formal Complaint Dental Service
Quarter 1 2022/23
Concern:
The patient reported that she had been provided with inappropriate advice with regards to pain relief, which resulted in her taking an accidental overdose and being admitted to hospital.
Response:
The investigation identified that the patient was advised to alternate medication every 3 hours, however the patient had misunderstood and was taking paracetamol and ibuprofen every 3 hours, resulting in the overdose.
Learning:
Although there were handwritten notes available regarding the telephone conversation with the patient, the full details of the conversation had not been included on the electronic patient record. The staff member was reminded of the Trust policy regarding record keeping.
Formal Complaint - Dental Service
Quarter 1 2022/23
Concern:
The patient reported that she had been provided with inappropriate advice with regards to pain relief, which resulted in her taking an accidental overdose and being admitted to hospital.
Response:
The investigation identified that the patient was advised to alternate medication every 3 hours, however the patient had misunderstood and was taking paracetamol and ibuprofen every 3 hours, resulting in the overdose.
Learning:
Although there were handwritten notes available regarding the telephone conversation with the patient, the full details of the conversation had not been included on the electronic patient record. The staff member was reminded of the Trust policy regarding record keeping.
Formal Complaint Integrated Mental Health Team
Quarter 1 2022/23
Concern:
Patient raised concerns regarding the delay in care from the mental health team. Patient reported that 7 months after her initial assessment she still did not have a care plan.
Response:
The investigation identified that although a plan of care had been discussed and agreed with the patient her care plan had not been updated in a timely manner to reflect the plan of care agreed and the patient had not been provided with a copy of her care plan.
Apologies were offered to the patient and a review appointment was arranged to ensure the care plan was completed with the patient and that the patient was provided with a copy of her care plan as a matter of urgency. The investigation also identified that the care plan written was not completed on the current care plan documentation.
Learning:
The following learning actions were identified:-
The investigation findings were discussed with the staff members involved in the patient care as part of their one to one supervision to identify any personal development needs in relation to care planning.
The Trust standards regarding care planning were reiterated to the wider team, to remind staff that care plans should be produced collaboratively with patients, that patient should be provided with a copy of their care plan and the correct documentation to use for developing a care plan.
PALS Concern Mental Health Access Pathway East and West
Quarter 2 2022/23
Concern:
A service user raised concerns about how his care was managed by the Access service. The service user feels that the text message prompts do not provide any indication on what a service user needs to do if they are unable to take the phone call. Service user has also raised concerns that from contacting the service he received a letter and the wording of the letter was poor, where it mentions that if a service user does not return their contact within a certain time frame they would close the referral. Service user feels that ‘the wording is very poor from a department that should be putting their arm around a patient, not pushing them away’.
Response:
Apologies were provided to the service user as it would not be our intention to cause any further distress. The findings identified that the service user only received the first text message prompt to state that a call handler would be making contact within ten minutes. It is normal practice to then send a 2nd message and attempt to make contact again; however this did not take place.
Learning:
The service manager will be reminding all staff to ensure a second text message is sent to service users or carers as the text message service has been successful and the answer rates have increased. The service manager has also confirmed that she will review the template letters and the content.
PALS Concern Integrated Mental Health - Shropshire
Quarter 1 2022/23
Concern:
Mental Health Assessment appointment attended and service user seen by a Senior Mental Health Nurse. Concern related to a lack of informed consent about students being present in the meeting, and the conduct of the staff member during.
Response:
Quality Lead met with service user to discuss concerns and apologies given for the distress caused. Review of care plan completed and agreed changes to support service user’s wishes and progress.
Learning:
It was agreed that there would be changes to service processes in relation to;
1. If students are shadowing clinicians that the service user is to be asked permission, before the student is present, so the service user can be honest with the clinician.
2. The pathway have an assessment template, and staff have been encouraged to follow this for a consistent approach.
PALS Concern Intensive Life Skills Shropshire
Quarter 1 2023/24
Concern:
Service user in crisis unable to access mental health services. Numerous attempts made to contact mental health services with no call back.
Response:
Service user had previously been under ILS services. A discharge care plan (CPA) review was completed with the service user at the time of closure of case. Which service user was involved in and a copy was also sent to their GP. Within this discharge review it was indicated if service user required additional mental health support they can contact the ILS pathway directly for this, to access top up 1:1 sessions. Alongside this service users also has the option to engage with monthly ILS consolidation group sessions online if they wished and would not need to be open to the service to access these.
Within ILS they have this top up and consolidation offer in place for all service users who have worked with ILS and completed treatment, to support a quick re-access to mental health support, within the first two year period following discharge.
It was established that service user had accessed a top up session previously and would have been able to do so again. However it is noted when a referral was received by Shropshire Access, service user was directed to the Community Interventions Pathway (CIP) East. It was not picked up by CIP East until nearly 3 months later that referral should have been sent to ILS.
Learning:
Further to contact with the Access team, referral should have been directed to ILS. It is recognised that also when picked up by CIP East it was not initially recognised that this error had occurred and correct process was not followed, in line with ILS opt-in processes.
Services would urge all service users who are able to opt-in, to contact ILS directly in the first instance, if they require further assistance. However Shropshire Intensive Life Skills (ILS) Pathway Lead has provided the ILS self-referral guidance and a flow chart to the Access Team. This is hoped to ensure that those service users who chose not to self-refer directly to the ILS Pathway are able to access an ILS top up and consolidation offer if this has been agreed. In addition this will support referrals received via this Access function and refresh/ establish processes within the newly formed service structures.
PALS Concern Brocton House, St Georges Hospital
Quarter 1 2023/2024
Concern:
PALS and Experience Facilitator attended a patient forum at Brocton House on 21 June 2023. Patient’s raised concerns regarding the cleanliness of the communal toilets and how the toilets were stained. The cleanliness of bedrooms was also raised.
Response:
The ward manager offered their apologies and confirmed that housekeeping have attempted to clean the toilets and bedrooms; however the stains were not able to be removed.
Learning:
The PALS and Experience Team escalated this matter to our Facilities and Estates Team who visited the ward on 26 June 2023 to investigate the concerns further. The following actions were completed during this visit;
Estates visited the ward and checked the toilet standards within the communal areas
One toilet was found to be in need of an additional deep clean. Additional refresher training was undertaken at the time by the Assistant Facilities Manager, to Housekeeping staff now working on the ward
Cleanliness of bedrooms were reviewed and further training and awareness was given to new starters on how to remove some of the harsh staining
The ward should see some visible improvement within these areas and supervisors will be auditing as required.
PALS Concern Brocton House, St Georges Hospital
Quarter 4 2022/23
Concern:
Relative had raised discrepancies in information given from the ward of how things would work in the community. Relative was informed that the service user would be seen by a Doctor within six weeks following discharge; however this never took place. There was also no discharge letter shared with the GP and therefore the GP was not aware that medication was required in the community. When the discharge letter was shared with the GP, the incorrect dosage of medication was documented.
Response:
The ward manager offered their apologies that the discharge letter was not sent in a timely manner. The manager provided assurance that it is clearly evident within the nursing records that the dose of medication was increased independently and this was not reflected on the GP summary care record.
Regarding information given about support provided by the community mental health team, it is the wards responsibility to ensure that a 72hr follow up is arranged prior to discharge. Any further appointments would be co-ordinated by the community mental health team. The ward manager offered apologies that the relative was incorrectly advised that the patient would be reviewed by a community Doctor/GP within six weeks.
Learning:
There is some learning for the team that will be discussed with the relevant professionals with regards to ensuring accurate information is documented in discharge letters. Discharge letters are to be sent to the GP within 7 days, as per NICE guidelines and trust policy.
Ward staff will be reminded to ensure that accurate information is provided, regarding support on discharge.
PALS Dame Carol Detox Service (DCDS)
Quarter 4 2022/23
Concerns:
Service user complains about the poor experience of his care and treatment at DCDS in October 2022 which included:
Communication concerns between DCDS and the community service REACH.
Changing of admission dates.
Communication between the service user and DCDS.
Facilities namely temperature of the room was cold and the worn mattress.
Medication – nurse refused service user Ibuprofen
Staffing Dr lacked empathy with addiction
Infection Control – another patient developed shingles
Not awoken for observations and observations only taken half hour after medication.
Response:
1. All service users are commenced on a detoxification regime, and the starting amount will depend on a number of factors and will then be reduced over a period of time. Symptomatic relief is offered and is available throughout the detoxification period.
Service user questioned whether he would be allowed in Detox whilst on Diazepam? REACH advised not allowed. DCDS are very clear that they will offer a methadone detoxification while maintaining someone’s diazepam medication.
2. The intention of providing provisional dates was to help service users prepare for their detoxification. DCDS do acknowledge that the dates being postponed can lead to anxiety and have therefore now changed their procedures and individuals are now only informed of their admission date a month prior to admission.
3. During certain times of the day it is not possible to answer calls due to clinical activities. It has therefore been agreed that an answer phone would support communication with service users and the community services. The team have been reminded of the importance of calls being undertaken and the quality of the calls and accuracy of information.
4. The mattresses are all under 9 months old, mattress audits are completed monthly in line with the Trusts infection and prevention control policy and visual checks on the mattresses are made between each admission, therefore DCDS do not agree that they are worn.
DCDS are sorry that the problem with the shower and the radiator came up and acknowledge this would be very uncomfortable for someone detoxing. The fault was reported immediately and it was resolved the next day. Unfortunately service user was unable to move rooms as the unit was full to capacity on that evening.
5. Throughout service user’s stay he was prescribed the maximum permissible dose of both Paracetamol and Ibuprofen.
Service user’s diazepam was prescribed to be given at 12 noon and 6pm, on one occasion the diazepam was given early at 9.00 a.m. This was an error in that it should have been given at 12.00. On all other occasions it was given at 12.00. The Dr states the timings for the diazepam were agreed with service user on admission as his full Methadone dose would be given at 9am.
Nurse B and service user agreed on a reduction of 5mg every two days. However, the following day methadone was reduced a further 5ml. The DCDS opiate standard operation procedure, states “The rate of methadone reduction should be no more than 5mg daily, however if the detox is commenced on a high dose they may be able to reduce at greater dose at the start of the detox. The regime should be tailored according to the COWS score. “
Unfortunately service user was given incorrect information by a team member that his reduction plan was every other day.
The clinical Lead has dedicated time booked in to discuss the impact.
DCDS regret that service user felt unsupported in relation to his sleep. In the notes he is only recorded as not sleeping on the night of 7th October 2022. Staff are diligent in recording service users not sleeping. However it is recognised that the unit’s capability in this regard could be improved and that service user not being written up for any sleep medication was regrettable. Promethazine had been added in to the stock medications procedures but it had been unable to be sourced from our suppliers and this may account for this not being written up.
Inclusion are reviewing the policy in light of service user’s complaint and are now intending to use Clonidine, to support with sleep and anxiety when individuals are reducing from a relatively high dose.
REACH questioned the use of Lofexidine. Lofexidine was a medication that was used in both community detoxes and in patient units, it was used instead of, not as well as an opiate substitute and it helped to relieve some of the symptoms of withdrawal but not eradicate them all. Lofexadine has not been available in the UK since October 2018 and therefore DCDS does not use Lofexadine.
6. The DCDS Dr has worked in a lot of different settings and locations, and has a wide range experience of working in addiction.
We are sorry you felt like this, we do understand that coming in for a detox can be anxiety provoking and can make people feel unsafe, we try to work with individuals to support them during this time. We are sorry this was not your experience.
7. There was another service user that had a rash on their foot - this was not diagnosed as shingles or any illness requiring formal treatment.
8. Night time observations did take place, daytime observations were taken in advance of medication being given i.e. COWS being completed and a range of PRN medication given when needed. Staff try to conduct night time observations as unobtrusively as possible and minimise disturbance depending on the risk level of the service user. DCDS definition of Observations include BOTH observation of the service user through the night AND undertaking Physical & Psychological checks including blood pressure, COWS score etc. These are normally conducted during the day and only undertaken at night if there are health risks that indicate they are required.
Learning:
• Team to improve communication/learning with community drug and alcohol services.
• Ensure accuracy of information when taking calls.
• Team agreed that an answer phone would support communication with service users and the community services.
• Prescribed medication to be administered on time.
• Management to discuss with staff member upon return from leave the importance of providing accurate information re reduction plan.
• Inclusion services are reviewing the policy in light of service user’s complaint and are now intending to use Clonidine, to support with sleep and anxiety when individuals are reducing from a relatively high dose.
Willow Ward - Low Secure Unit (LSU)
Quarter 4 2023/24
Concern:
Service user wrote to complain about the repeated mistakes that are happening with the prescribed Nicotine Replacement Therapy (NRT) on numerous occasions; staff nurses are writing the lozenges on the inhalator sheet without looking.
Learning:
This concern has been addressed with the qualified nurses on Willow. The NRT folder has been updated and made clearer. Folder now includes separate sections for inhalator and lozenges.
Service user was satisfied with the response and mentioned how the folder "seems better" and that there have been no further issues since.
Laurel Ward – Shropshire Care Group
Q4 2022/23
Concern:
Concerns were raised by family about service users unsafe discharge from ward.
Response:
The investigation found that family had been liaised with regarding discharge plan and in agreement. At the point of discharge, service user’s mental state was clinically assessed to be stable, and deemed to no longer require inpatient admission to support their needs.
Learning:
The following learning was identified as a result of a review of the care;
-Case taken to clinical leads meeting
-To be discussed with Redwoods site manager to identify any other learning to take forward
PALS Concern – Sexual Health Services, City of Leicester
Q1 2022/23
Concern:
Receptionist had poor communication skills, was extremely rude and showed no respect or empathy towards service user. Receptionist had asked what the appointment was for, service user did not feel comfortable discussing with the Receptionist; Receptionist informed service user she would look on her records. Service user concerned that the receptionist should not be looking in her health records.
Response:
Apology afforded if the service user felt she did not receive a caring service when speaking with the switchboard. Explanation provided on the process when patients call the service switchboard. The team run several specialist clinics each day across Leicester, Leicestershire and Rutland in addition to a selection of online services. Therefore, it is imperative that staff ascertain the reason for any requested appointment as a face-to-face appointment is not always necessary. If it is established that an attendance is necessary it is important to ensure that this appointment is with the most appropriate clinician to avoid any delays in care or treatment and unnecessary additional appointments.
To book an appointment our switchboard staff need to ensure that any patient attending the service has a medical record on our electronic system. Their access to these records is very limited and they would only be accessing the demographic section to book an appointment. There may have been some confusion in the conversations today about this access and the terminology used by our staff.
Assurance afforded that the team do not have access to the clinic notes that the clinicians write and they would not need to look at this section to make an appointment. Our staff have received guidance and training in relation to assisting callers with their requests and how to manage these, and also about accessing our electronic patient record system, restricted and unauthorised access and GDPR regulations.
Learning:
Team Lead to ensure that concern regarding some of the terminology and style experienced by the service user are raised and addressed at the team meeting. Nurse has made contact with the service user and an appointment has been arranged.
PALS Concern – Sexual Health Service Leicester
Q2 2022/23
Concerns:
The receptionist's attitude was poor and unprofessional, being rude and unreasonable.
It took a long time to get an appointment. Staff shortage as a result of sickness and leave were reported.
They were encouraged to seek treatment elsewhere Nottingham, Birmingham or elsewhere in the East Midlands.
Response:
Service apologised for how the receptionist came across and that their manner and tone were not supportive. As a result of this feedback we will share this experience with our receptionist staff members to discuss the concerns that have been raised. All staff have their calls monitored by their line manager and are listened into on a quarterly basis and assessed. They annually attend the services customer service training and have regular update training delivered throughout the year as part of the monthly team meeting agendas. Staff that are identified by patients where behaviours have not been as expected are asked to repeat customer service training and to complete a reflection session with their line manager to show understanding of the complaint and to support with growth and learning.
Team only have a finite amount of appointments and once these have gone they are unable to offer an appointment until more become available which is why service users are asked to call back on another day or try an alternative pathway. For example online STI testing.
The team receive approximately 5000 calls per month and see over 5000 people across all clinics with 80 percent of all appointments being seen at Haymarket Health, situated within the Haymarket Shopping Centre. The service also have clinics in Loughborough as well as Rutland and other peripherals across the County. Team have tried to diversify the service to increase capacity through online services such as STI testing, oral contraception, Emergency Hormonal Contraception (EHC) and some treatments which can be posted to a patient’s home or a location of their choice. Team also offer telephone appointments for certain conditions or where repeat treatment is required that allows for medication to posted to an address of choice or available for collection at one of our sites.
The team have had a high sickness rate and number of COVID related isolation in the last 12 months. Along with the wider NHS they have found it difficult to recruit, leaving vacancies for consultants and nurses, but they have diversified recruiting speciality doctors and band 5 development nurses (moving to band 6 on completion of 18 month training programme).
Once appointments are full there is a triaged system in place to ensure that the team pick up emergency or high risk individuals (e.g. severe pain, symptomatic GU, Emergency contraception, PEPSE, Sexual Assault, High risk individuals). Those that are low risk will be signposted to alternative provision within LLR (e.g. GP, Pharmacy or online). It is not our practice to signpost to another sexual health service with the East Midlands region and we will ensure this is shared with staff to avoid this happening in the future.
Learning:
• Online booking service now has a new message to make it clearer when no appointments are available.
• Staff member received additional training as well as receiving regular assessment by her line manager.
• Concern shared with the wider team.
•Team have recruited 2 new staff to assist with the telephones to support with answering calls to help with the waiting times.
Concern, Specialist Care Group, Sexual Health Burton (Branston Clinic)
Q3 2023/24
Concern:
Concern raised about standards of practice/ hygiene in the service and in response to this the following steps have been put in place.
Learning:
• Patient Survey Form – to be used to give consistent reassurance that the practices remain in line with guidelines.
• The Infection Control team to provide an additional update specifically regarding the importance and relevance of hand hygiene in additional to decontamination and cleaning methods. This will also incorporate a practical session on the correct technique.
• Two staff members to retake their Infection Prevention & Control mandatory training.
• Team to order hand sanitizer that have a pump-action mechanism.
• Coat hooks to be reinstated to backs of toilets doors.
PALS Concern North Integrated MSK Service (NIMS)
Quarter 1 2023/2024
Concern:
Service user contacted PALS and Experience to chase MRI results, due to the length of time it is taking to receive the results and any treatment.
Response:
Operational Lead advised enquirer has been contacted. Clinician apologised for the delay and informed of the results. Enquirer has been referred to the Orthopaedic Hip Team at UHNM and will receive a copy of the referral letter by post.
Learning:
Correct process for recording the request was not followed correctly which resulted in medical secretaries not knowing the request had been completed. Therefore the results were not looked for so the service were not aware the results had been received in February 2023. Feedback has been provided to the clinician as learning.
PALS Concern North Integrated MSK Service (NIMS)
Quarter 4 2022/23
Concern:
Service user raised concerns for the NIMS service due to lack of communication and delay in referral to the required service.
Response:
The service manager acknowledged that there have been some unnecessary delays in the service users care pathway, in referring to the appropriate service. It has been agreed that the service user should not have been put in a position where they felt that they had to chase their referrals or to receive information from the team. Assurance was provided that the referral had been completed with the hope that there is no further delays and a satisfactory management of ongoing symptoms can be achieved.
Assurance was provided that the concerns outlined are taken seriously and will be addressed with individual staff members and any learning shared with the wider team including clinicians, the medical secretary team and the triage team. Extended apologies were provided for any distress caused and confirmation that all actions would be completed to reduce the risk of this situation happening again.
Learning:
All staff to be reminded that all conversations need to be recorded in clinic letter documentation and any investigations ordered as soon as possible.
Triage staff to be reminded that referrals, where it has been identified that patients have already had recent contact with the service, need to be sent back to the original clinician, to be reviewed. Referrals can be reopened and clinicians are able to contact patients directly to discuss their needs. Also, should there be a clinical need to request a face to face or telephone appointment, this can also be completed at this time.
Reinforce Standard Operating Procedure to medical secretary team, to ensure that any onward referrals are actioned by another member of the team in the absence of the original clinician.
Long COVID Service
Q3 2023/24
Concern:
Complainant contacted PALS to advise that they attended a Long COVID workshop group. The group were asked to add their name for the online session and the service user is a very private person and used an initial as ‘D’ as they did not wish to share their full name with the group. The Facilitators of the workshop then shared the service user’s full name to all participants during the session.
Response:
The service manager spoke with the two clinicians who facilitated the workshop. Reassurance was given that the staff take patient confidentiality and privacy seriously and they do not use patient names or surnames unless the patient has used it within their guest name displayed on the screen or openly disclosed in the chat.
By reflecting on the events of that evening, the team have identified lessons learned. Moving forward, at the beginning of the session, the staff will ask the participants if it is acceptable to verbally call them by the guest screen name that they have chosen for themselves, or the name they put in the chat section. If a participant is using a name not on the attendance register, we will ask them to email us with their actual name separately to maintain their privacy and confidentiality.
Learning:
Staff to ask participants if it is acceptable to verbally call them by the guest screen name that they have chosen for themselves, or the name they put in the chat section. If a participant is using a name not on the attendance register, we will ask them to email us with their actual name separately to maintain their privacy and confidentiality.
PALS Concerns Haywood Hospital Ward 1/Specialist Pelvic Health Team (SPHT)
Quarter 1 2022/23
Concern:
A relative of a service user raised concerns that her father had been discharged from Haywood Hospital and no referral had been made to the Specialist Pelvic Health Team (SPHT), despite the ward stating this had been completed. The relative contacted the SPHT several months later to follow up the referral, however, she was informed no referral had been received.
Response:
The response from the ward was that a referral had been completed and it was later identified that the same form is used for both supply of products and referral for an assessment. For a referral there is an additional box to complete which wasn’t completed on this occasion and led to relatives having to follow up the referral which caused delays.
Learning:
A meeting was held between the Matron at Haywood Hospital and the Specialist Pelvic Health Team and it was agreed to improve communication between the two services to avoid further issues and for a quality visit to be undertaken to identify if any improvements can be made. A quality visit will be completed for the Specialist Pelvic Health Team which will be led by our Chief Nurse, to identify if a new process is required.
PALS Concern Podiatry Service
Quarter 1 2022/23
Concern:
Service user has not been receiving notifications of their appointments and has identified that sometimes appointments are sent by email which appear in ‘spam’ rather than ‘inbox’ and on occasion appointments details have not been shared with the service user causing this to result in a ‘Did Not Attend’ (DNA) and discharged from the service.
Response:
Apologies were provided and it was explained that emails arriving in ‘spam’ can be due to a person’s email settings and how the content of an email can pick up sensitive words where it will be relayed to ‘spam’ rather than inbox. During the review it was identified that the clinician had sent two appointments by letter to the home address. This was documented on the clinical system; however there was no evidence of the letter attached to the records. The service user had advised that these letters had not been received.
Learning:
All staff have been reminded that when a service user does not attend an appointment, this should be followed up with a telephone call to identify the reason and to arrange a further appointment. If letters are being sent to service users, the letters should always be uploaded to the clinical system as good record keeping. It should be advised that if a person DNA’s three times, they would be discharged from the service and a new referral from the GP would be required.
Case Study – Talking Therapies ST&W (IAPT)
Q3 2023-24
Concern
Service user received no support or promised documentation following assessment some months prior. Feels let down by service as declared it had taken them a long time to find the courage to self-refer and to ask for help and then nothing.
Outcome: It was established that the assessor acknowledged that they did not send out the required information to the service user as agreed.
Learning:
To reduce the risk of this happening again, a check list is now in place to ensure that all required actions are completed following assessment. Enquirer was accepting of this.
Talking Therapies ST&W (IAPT) also agreed that service user would be allocated to a therapist for video consultation, which is the shortest wait time of 3-4 weeks approximately. It was agreed that should service user not find the online therapy helpful, they could be moved back to the wait list for face-to-face appointments at the same stage as where they would have been.