Learning from Complaints and Concerns

You said, we acted

You as patients and families said	We as a Trust acted
No aftercare service available.	A gap in the aftercare was identified and has been resolved by a new aftercare leaflet.
Waiting times are too long	·       An insourcing provider has been introduced to support reductions in waiting  times; this continues to be reviewed across services to identify where additional capacity may be required ·       Funding has been secured to support weekend clinics in Gastroenterology; a capacity and demand model has been submitted to the Executive Team, and the associated risks have been added to the Trust Risk Register for monthly review
Communication with patients and families is poor	Communication continues to be a  theme, with targeted improvement work underway to address system factors.   •       Cases will be discussed in the team to explore communication processes and identify system‑level learning. •       Staff focus on communication processes and opportunities for system‑level learning. •       Mechanisms to be explored supporting follow‑up plans and timeframes to patients
Waiting to be discharged takes a long time	Discharge planning training is being delivered to ward staff by the Lead Discharge Planning Nurse to strengthen understanding of processes, improve communication with patients and families, and support safe and timely discharge.

 

What happened?
Patient had a c-section delivery and following this all was well and mum and baby were discharged home. On day three  following discharge the patient noticed discharge at the c-section wound site so called the hospital for advice. She was advised to attend the hospital where her wound was checked and antibiotics were prescribed.  

On the third day of taking the antibiotics the patient was still in pain and felt unwell in herself so called the hospital, where again she was asked to come in. 

On attending the hospital, she felt she was listened to by the consultant and was told that as she had had a c-section she would of course be in pain. The consultant sent her home. The following day she was more unwell and had a temperature, was breathless and could not walk properly. The patients husband called the  hospital and they again requested she attend.

 

Outcome
On attending and having further checks carried out, including a blood test, where it was found that the patient had high infection markers and there was fluid around her gallbladder and on her lung resulting in an inpatient stay until she was well enough to return home to her family and newborn baby. Her previous visit to the hospital had not shown a clinical need for a blood test.

 

Learnings
As a result of this complaint, an information leaflet was being produced to provide guidance on recovery from a c-section for patients.

Better communication could have helped the patient understand why further test had not been completed initially and this has been taken onboard by the consultant.

Improved communication would also have informed the patient that there are wards that would have allowed her to keep her newborn baby with her during her admittance.

What happened?
The husband of the patient/NOK had contacted PALS regarding their family's concern on the treatment and cancellation of the procedure for the mother/wife who was in constant pain. The care and condition of the patient had made the husband depressed and expressed thoughts of harming himself. 

PALS had contacted the Service Manager who had reviewed the concern. It was identified that the patient had been referred to  Leicester Infirmary Hospital as URGENT due to the complexity of the required procedure. The Service Manager and the Matron had initially provided the response and spoken to the NOK explaining that NWAngliaFT was unable to action the concern as the referral is now with Leicester Infirmary Hospital. The NOK and the patient had made multiple follow-ups with PALS and the service, including requesting assistance from the MP for immediate action and logging a formal complaint despite knowing about the referral to Leicester Infirmary Hospital.

 

Outcome 
PALS had raised the concern on safeguarding for the NOK with the Safeguarding Team. The GP (consent acquired) had been informed and supported the NOK.

The Service had made multiple emails to Leicester Infirmary Hospital  for  follow-ups on the referral.

PALS had assisted the NOK to contact Leicester Infirmary Hospital' PALS about the patient's referral. 

The Divisional Complaints Team had provided the same response, explaining that NWAngliaFT was unable to require Leicester Infirmary Hospital  to immediately perform the procedure as the hospital has their own waiting list and procedure. 

The NOK had been provided with copies of all follow-up emails to Leicester Infirmary Hospital and the acknowledgement that the referral had been received, and being actioned.

 

Learnings
1. Responsibility to raise safeguarding concern is not limited to patients, but also for NOK/family members/carers.

2. Communication and cooperation assist in the immediate resolution of concerns.

3. Service to patients and family members extend beyond patient timeline of care and treatment in the Trust.

This outcome has had a profound positive effect on my wellbeing. After months of anxiety, frustration, and loss of trust in her care, she now feels safe and supported. She wishes to acknowledge the role that your team — and particularly the escalation of her concerns — played in reaching this stage.'

I just wanted to thank you and the complaints team for helping me. It really does mean a lot. I saw the consultant today, who went above and beyond and understood my frustration, we now have a plan going forwards with my care, as there is an issue. I am pleased that my complaint has been resolved.'

'Firstly, it is most encouraging that the results of you enquiry will be shared with other departments as a learning point. This was foremost in our minds to ensure other families are spared further trauma at an already traumatic time. I would like to thank everyone for their time.'

'My complaint was handled quickly and thoroughly. I believe the people concerned will learn from it so as to avoid others going through a similar thing in the future . Thankyou'

'I was not offered a pre-investigation meeting which has resulted in areas of my complaint being misinterpreted. If a complaint is going to be delayed, this needs to be adequately communicated to the patient by the investigator - which may include communicating multiple times to ensure the patient feels it has not been forgotten.'

I'd like to say a huge thank you for all of her help! Again, I cannot thank you enough and I'm elated to finally see light at the end of a very long tunnel. You don't realise how much this means to me! 

I would like to thank you all once again for taking the time to meet with me, and for providing a space in which I could reflect on and share some of my experiences. I sincerely appreciated the opportunity to be heard, and I acknowledge the apology offered during the meeting. I'd particularly like to thank the consultant for their continued kindness and empathy — it meant a great deal to feel that my concerns were being taken seriously.