Following the inquiry into patient care at Mid Staffordshire NHS Foundation Trust, Robert Francis recommended that NHS trusts should publish information about upheld complaints on their website. As part of our commitment to share information and improve learning, Mersey Care NHS Trust publishes upheld complaints every month on our website.
Every year the trust receives approximately 500 complaints from service users, relatives and carers in both local and high secure services.
If a complaint is received which relates to one specific issue, and substantive evidence is found to support the allegation made, the complaint is recorded as ‘upheld’.
If a complaint is made regarding more than one issue, and one or more of these issues are upheld, the complaint is recorded as ‘partially upheld’.
Where there is no evidence to support any allegations made, the complaint is recorded as ‘not upheld’.
Sometimes it’s possible to resolve a complaint by arranging a meeting with the complainant and those involved in the care of the service user, for example, the consultant psychiatrist, team leader or service manager. Other times, it’s more appropriate to formally investigate a complaint, after which a response letter is sent to the complainant from the Chief Executive.
It is the responsibility of the Complaints Department to identify any trends or themes within particular services, on certain wards etc., to see what action can be taken by the trust to prevent the same issues recurring in the future.
You can view our upheld complaints below.
The following complaints were closed and upheld in September 2023:
Personal Recs
Information was incorrectly recorded.
Appointment
Appointment delayed.
Staff Attitude
Staff member spoke inappropriately.
The following complaints were partially upheld in September 2023:
Clincial Care
Questioned if appropriate care received from the nurse.
Clinical Care
Patient raised concerns about processes not being followed.
Staff Attitude
Attitude of the nurse did not meet expected standards of the patient.
Clinical Treatment
The team did not understand part of the diagnosis, therefore appropriate support not received.
Clincial Treatment
Unhappy with how pressure ulcer was managed.
Communication/info
Unhappy with care and treatment.
Clinical Treatment
Patient felt unfair assessment for CHCPatient felt unfair assessment for continuing healthcare.
Appointments
Patient unhappy with length of time waiting for appointment.
Communication/info
Communication with patient was poor.
Clinical Treatment
Lack of clinical input.
The following complaints were closed and upheld in August 2023:
Communication
Family members were not contacted when patient was transferred.
Clinical Care
Received referral but no action taken.
Clinical Care
Trust Policy was not adhered to with regard to the appropriate treatment.
The following complaints were partially upheld in August 2023:
Communication
Team should have picked up that the patient's pain medication may be causing her symptoms.
Medication
Electronic patient record entry confirms there was confusion by the inpatient team about what dose the patient was prescribed.
Care and Treatment
Communication strategies had not been discussed with the relative and if previously agreed, may have reduced concerns.
Clinical Care
No care plan developed during period of care.
Clinical Care
Staff could have communicated better with patient.
Appointments
Had had not been notified of appointments.
Communication
Poor communication with service user.
Appointments
Team did not communicate with patient.
Clinical Care
Nurse failed to examine the patient in pain which resulted in them being admitted.
Communication
Lack of contact from nursing services.
Clinical Care
Referral incorrectly signposted.
Staf Attitude
Clinic behind schedule for the appointment and therefore the appointments were late.
Appointments
Appointment delayed.
Appointments
Patient travelled to appointment and was advised it had been brought forward and they had therefore missed it.
The following complaints were closed and upheld in July 2023:
Communications/Care and Treatment
Patient was not receiving holistic care.
Care and Treatment
Nurses did not identify what their role was or what the process was that needed to be followed.
Personal Recs
Incorrect info held on records.
The following complaints were partially upheld in July 2023:
Leave
Patient leave was suspended.
Staff Attitude
Staff member acted inappropriately.
Care and Treatment
Medical review needed to manage symptoms at home was not completed correctly.
Staff Attitude
Staff member spoke inappropriately about another person.
Care and Treatment
Poor recording in clinical records, documentation, and staff attitudes.
Care and Treatment
Level of care could have been better.
Medication
Side affects of medication.
The following complaints were closed and upheld in June 2023:
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Personal recs Information was incorrectly recorded |
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All aspects of clinical treatment The reviewer also found a missed opportunity to attend and complete a full mental health assessment |
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Personal Recs The reviewer found that the standard of timely and effective communication to the family following the breach and follow up of the breach with was not of the standard expected from the Trust. |
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All aspects of clinical treatment Delay in package of care delivered |
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Communication/info Nurse Assessor had previously met the patient historically but did not meet her on the day of assessment. No communication of changes to representatives. |
The following complaints were partially upheld in June 2023:
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Communication/ info It is recognised that the doorbell for the ward was out of action, awaiting Patient felt she was over sedated this was not substantiated. |
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All aspects of clinical treatment There was conflicting information on both checklists completed. However the team communicated well about any changes with the family. |
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Attitude of staff The reviewer advised that The MHP concerned has reflected on their practice and whilst there was no evidence in the clinical records that the pt's concerns and presentation were treated any differently than others in the department, first impressions count, and this can impact on the reputation of the Trust |
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Admission/discharge/transfer The reviewer was unable to find any information within the clinical record to indicate that safeguarding advice had been sought or any documentation in relation to agreed actions to safeguard. |
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Attitude of staff Patient stated that an appointment was not offered but at the time they had not requested an appointment. Review of clinical documentation does appear to be limited in attempts to persevere with the patient’s engagement in conversation. |
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All aspects of clinical treatment Lack of support provided at times, however the medical review was comprehensive. |
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All aspects of clinical treatment The communication between the teams seems to have been ineffective. The reason for this breakdown in communication has been reviewed to minimise the risk of this occurring in the future, however staff did follow process. |
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Communication/info Info recorded should not have been, procedures followed |
The following complaints were closed and upheld in May 2023:
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Appointments-Delay/cancelled Reason for rejection of the referral not stipulated within the letter. |
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All aspects of clinical treatment due to the fact the assessment practitioner did not formally assess capacity although they did document 'lacking insight'. |
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Communication/Info Service did not communicate with service user in the format requested |
The following complaints were partially upheld in May 2023:
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Patient privacy and dignity The reviewer found that correct procedures around escalating concerns were not followed but found no evidence to support the other aspects of the complaint |
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Communication/Info Service aware of needing a specific appointment time and did not facilitate. However, communication preferences were considered. |
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All Aspects of clinical treatment Poor communication with the family identified however correct process followed. |
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Communication/info There is no evidence of face to face consultation, however the reviewer concluded the service user was sign posted correctly and communicated with regularly. |
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Appointments – Delay/cancelled One appointment was cancelled, however attempts were made to contact the service user. |
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Attitude of staff There have been occasions when appointments have been changed and times when the patient was expecting to contact him has not happened or this has been a different person |
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All aspects of clinical treatment The reviewer found that nursing staff should have considered constipation as a cause of agitation, that response times were not of the expected standard and communication with the family could have better, however correct documentation was provided. |
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Attitude of staff Safety management completed but did not receive a full comprehensive assessment. |
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All aspects of clinical treatment Discharged following non attendance at OPA even though informed they could not make the date however service did sent the referral to another service appropriately. |
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Non clinical No evidence incorrect documentation was sent. no clear recording of conversation had with service user |
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All aspects if clinical treatment The reviewer found that one aspect of the complaint as partially upheld in terms of lack of meeting emotional needs. The reviewer found all other aspects of the complaint not upheld. |
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Attitude of staff Staff member acknowledged the conversation was awkward, however did offer to call back at more convenient time |
The following complaints were closed and upheld in April 2023:
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Communication / Care and Treatment failed to deliver the correct feed on the agreed delivery dates. |
The following complaints were partially upheld in April 2023:
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All aspects of clinical treatment Poor communication and record keeping, it is not routine to complete a detailed wound care form however the reviewer found in this case it would have been helpful to of done this to substantiate the clinical decision. |
The following complaints were closed and upheld in March 2023:
- Care and treatment. Concerns about lack of information with family and patient complained of pain and staff ignored. The reviewer has not been able to evidence within the records that any family were invited to six reviews
- Diagnosis. Unhappy been misdiagnosed by two different doctors and medication dosage has been documented incorrectly. The discharge process was a key element to concerns both in terms of the service user’s view on readiness for discharge and the way in which planned medication changes were managed post discharge
- Staff attitude. Concerns raised about attitude and behaviour of staff. The impact of the family’s experience was explained to the staff nurse in full for her to reflect on this and consider it in future practice. This will be discussed regularly and monitored during regular one to one management supervision
- Care and treatment. Waiting time for psychological services. Informed at an earlier date unlikely to be admitted for treatment. Apologised and explained that the community mental health teams are unable to send electronic prescriptions directly to pharmacies in the community. The reviewer is hopeful this will be improved in future as primary and secondary care work together in a more collaborative way
- Documentation. Disagreed with information in discharge papers shared with GP, also disagrees with diagnosis. Diagnosis should be formally reviewed on balance with learning from this complaint and information available to the clinical team at the time of assessment
- Care and treatment. Unhappy with treatment from team, appointment being late, attitude of staff. Due to the staff member running late and not having prepared for the session before hand, there was a lack of understanding of the patient’s medical history.
The following complaints were closed and partialy upheld in March 2023:
- Staff attitude. Staff to liaise affectively going forward
- Clinical care. Community mental health team offer of care, routine appointments with a psychiatrist and duty contact did not meet needs
- Access delay. Missed opportunity to investigate blood pressure results in more detail. discharged before being assessed by the clinic
- Care and treatment. Consideration could have been given to remain on the caseload for lengthier period to reassess pain following GP intervention
- Care and treatment. Poor documentation and no seating plan
- End of life care. There was delay in the nurses responding to messages left on the answerphone
- Care and treatment. Poor communication
- Care and treatment. Lack of engagement and not enough documentation
- Care and treatment. The reviewer found that staff should be reminded of the importance of positive attitudes towards those who utilise our services
- Care and treatment. Better communication needed
- Staff attitude. Poor level of cleanliness on the ward
- Care and treatment. Failure in the communication between the Trust and the family within the 72 hour process
- Care and treatment. Review information given to patients in timely manner going forward with regard to application of medication
- Care and treatment. The team to ensure they have everything in place and also that they have the district nurse contact numbers going forward
- Care and treatment. Improved communication with patients and families going forward.
- Referral. Referral should have been sent there is no evidence to support this had taken place
- Care and treatment. Referral not sent when advised it had been.
The following complaints were closed and upheld in January 2023:
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Physical health care. Son is unhappy that the plan to check his mother's blood pressure wasn't followed when doctor went on leave. This complaint evidences a break down in communication between the multidisciplinary team and the patient family
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Confidentiality. Received letter from team which was unsealed and open which caused distress. Reduced administrative support has a palpable, negative effect on service delivery. In this instance it has contributed to a deterioration in a service user’s mental health
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Care and Treatment. If assessed appropriately why was no definitive action implemented
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Medication. Patient wishes to change the format of her medication from tablets to liquid. Lack of documentation of open dialogue and co-production.
The following complaints were closed and partialy upheld in January 2023:
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Care and treatment feels let down by the team. Poor communication
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Care and treatment. Mother raised concerns around lost property, assault, lack of communication and care and treatment. Need to review process
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Care and treatment mum not happy with care and treatment received from Walk In Centre. Assessment was not given, this was due to the high number of patients
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Patient injury received meal on a broken plastic tray. Food container was compromised. Unproven that the patient accidentally choked
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Communication. Not contacted by services when he was feeling suicidal. Improvements were required to the Psychology Step 4 SOP
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Assessment. Parents concern around the ND Pathway and the assessments completed. The assessment should not have been recommended for a child who is nonverbal staff not aware of referral restrictions around third sector providers. Several instances where communication with parents could have been improved
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Patient Injury. Received meal on a broken plastic tray. The food container was compromised, unproven that the patient accidentally choked.
The following complaints were closed and partialy upheld in February 2023:
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Care and treatment. Numerous issues raised regarding the ward. Lack of contact at the point of admission and inviting them to attend care reviews
- Confidentiality. Mother unhappy that breached her confidentiality. The reviewer found that the lack of communication from the service contributed to the situation
- Staff attitude. Issues raised about staff attitude and behaviour on ward. Staff should be working collaboratively when locking in and ending night time confinement.
- Bed not available. No bed available, patient at home and a fire being started accidently which as caused her to go into temp accommodation. Incorrect information shared at the bed management meeting
- Care and treatment. There was lack of monitoring and reviews when new to service
- Staff attitude. Issues raised about staff attitude and behaviour on ward. The importance of staff working collaboratively when locking in and ending night time confinement.
The following complaints were closed and upheld in December 2022:
- Prescribing of medication. Evidence of the error in prescribing.
The following complaints were closed and partialy upheld in December 2022:
- Poor care and treatment. Concerns regarding medication and lack of communication with family
- Lack of care and treatment. Failings in communication with the family but staff did follow process in relation to care and treatment delivered
- Unhappy with discharge from service. Telephone communication agreed to confirm discharge was not made
- Poor care and treatment on the ward, patient assaulted. Evidence of poor care and treatment
- Poor care from ward and trying to discharge too soon. Evidence that processes were not followed fully following discharge
- Medication stopped too quickly. Clinical decision in relation to medication, Trust Values also shared with staff member following review
- Lack of communication with service user. Clinical records indicate attempts were made to contact patient but did find lack of follow up.
The following complaints were closed and upheld in November 2022:
- Form given to wrong patient. Patient form contained incorrect results and documented on incorrect clinical record
- Poor treatment provided. Further appointment could not be facilitated
- Lack of treatment provided. Appointment was not available
- Unable to obtain appointment. Experienced difficulties in getting an appointment due to issues with telephone line
- Lack of communication from team. Difficulties in contacting team, staff reminded of Trust Values when speaking with service user, carers
- Lack of equitpment provided. Insufficient equipment at appointment.
The following complaints were closed and partialy upheld in November 2022:
- Concerns raised around care and treatment. Lack of support provided, adaptions to support service user prior to his appointment
- Disagreement over information kept on record. Staff member reminded of use of language within clinical notes
- Unhappy with side effects of medication. Medication provided was appropriate for service user
- Confidentiality breach. Letter was not sent direct to GP
- Poor staff attitude. Staff reminded staff member reminded of Trust Values
- Cancelled appointment. Cancelled appointment and letters not signed due to these being printed from the clinical system
- Discharge took place too early. Discharge planning process was not followed in line with expected practice
- Not enough info in assessment. Insufficient assessment.
The following complaints were closed and upheld in October 2022:
- Concerns around communication within the team. Relative should have been sent copies of patient’s correspondence and was not on a number of occasions
- Concerns around care and treatment from the team. Miscommunication from the team which resulted in no re referral
- Issues around referrals to District Nurses.There was a delay in receiving the referral and a delay in medication provided.
The following complaints were closed and partialy upheld in October 2022:
- Poor treatment from the team. Service user did receive numerous input/ opportunities; however staff did not look into the issue of waiting for psychology
- Family have raised issues about the care received by our services before family members death. Miscommunication/lack of continuity but staff had followed all processes in place and liaised with the service user
- Poor care received before family member passed away. Reviewer found that some of the patient records were poorly recorded.
- Medication and prescribing concerns. The reviewer found there was lack of communication at times and lack of documentation
- Care and treatment were poor as well as staff attitude. Due to the environmental layout privacy was compromised but staff followed protocol in applying the registration /booking in process
- Difficulty booking appointment. Established delays did occur when answering the phone due to team capacity
- Poor communication. The reviewer found that process was followed but was a lack of communication at times with the family.
- Staff behaviour. Allegations should of been documented on incident system
- Lack of care and treatment. Delay in obtaining an appointment due to team capacity.
The following complaints were closed and partly upheld in September 2022:
- Several concerns about the district nursing team were partially upheld because of a lack of communication with family
- Concerns about the care and treatment were partially upheld after it was found the patient was
seen within the planned time and appointments were booked and cancelled several times
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Another family had concerns about medication and contact from the team, which was partially upheld and a review of duty system began
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A family raised concerns about patient's care and treatment which was partiallly upheld due to a lack of communication with the family
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Unhappiness with the outcome of a referral to ASD/sensory service was partially upheld and services are to ensure they include clear information about what to expect and the opportunity to discuss these with parents/families
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Delays in receiving therapy caused a complaint to be partially upheld about the care and treatment being received from several teams
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Patients complaint about current staffing levels was partially upheld after activities were unable to take place because of it
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Another complaint about staffing levels affecting patient care was partially upheld because there was a short period where activities could not take place becuase of staffing levels
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Patient's complaint about being assaulted by another patient was partially upheld because it did not trigger a safeguarding referral but this has now been shared with the safeguarding team
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Complaint about care and treatment was partially upheld as arrangements for therapy sessions were not arranged via normal process and the Trust apologised for issues with therapist
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A service user raised concerns regarding the ending of treatment with Talk Liverpool, whcih was partially upheld due to a lack of correspondance
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Patient was transferred to another ward and the family were not informed. Their complaint was partially upheld because there was no consent to share this information with parents..
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Patient's complaint was partially upheld because they were unhappy that information had been shared with employer
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Patient raised various concerns about his stay on the ward which was partially upheld because he was unable to visit the gym because of reduced staffing
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A complaint was partially upheld due to a lack of communication with family and the appointment was arranged during school time
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Patient was concerned they had not been assessed properly and as a result developed medication induced bipolar disorder, a complaint which was partially upheld because completed biopsychosocial assessment was limited.
The following complaints were closed and upheld in August 2022:
- A complaint was upheld about the conduct of a district nurse after it was found staff did not follow Trust values and there was a lack of communication with the family. An apology was given
- Another complaint was upheld aftger staff did not recognise in the last weeks of life or respond to the family in relation to the decline in function which delayed referrals, with insufficient information, to support the patient at home
- There was a compaint about the complaints process which was upheld after it took longer than expected. An apology was given..
The following complaints were closed and upheld/partly upheld in July 2022:
- A complaint was made about staff following a review. It was found the consultant did not communicate appropriately with the patient and had recorded inaccurate information and missed details
- There were several concerns about the district nurse team which were partially upheld due to lack of communication with family
- One patient's care and treatment from the team was reported and partially upheld as they were seen within planned time of four months while appointments were booked and cancelled several times
- A complaint was partially upheld concering medication and contact from the team
- A patient's family raised concerns about their care and treatment which was partially upheld
- A patient complained about the outcome of their referral to Autism Spectrum Disorder/sensory service which was partially upheld
- Another patient raised concerns about their care and treatment received from several teams which was partially upheld due to the delay in receiving therapy
- There wsa a partially upheld complaint from a patient who was unhappy with current staffing levels
- Another complaint about staffing levels affected patient care, including no Skype visit for parent. This was again partially upheld due to no therapeutic input for the patient.
- A complaint was partially upheld after a patient reported they had been assaulted by another patient.
The following complaints were closed and upheld/partly upheld in June 2022:
- Thnere was a complaint about access delay over a GP's referral which was upheld
- A further complaint about missing property was upheld
- There were concerns about a member of staff terminating a call
- A parent's complaint was partially upheld because a Health Visitor was supposed to refer her son in March 2020 to an eye specialist
- Concerns about a father's concerns access to services was partially upheld
- A patient's complaint that a district nurse had refused to see them at home was partially upheld. This followed the introduction of Mersey Care's reduction of violence of aggression policy however this was not consistent thoughout the patient journey
- A patient's daughter complained that the visiting clinician lacked humanity and empathy, which was partially upheld
- The Hospice staff complained that a service user was admitted without any communication or paperwork from the district nursing team, which was partially upheld
- A patient's complaint regarding several issues relating to a stay on the ward was partially upheld
- A complaint was partially upheld from a patient concerned about a reduced service being offered.
The following complaints were closed and upheld/partly upheld in May 2022:
- A patient's son raised concerns regarding the treatment his mother received and that she was discharged, even though her records stated she was housebound. The complaint was upheld and it was found that staff did not communicate with her GP and did not follow standard procedures following a failed visit
- A complaint was made that their daughter had been given a COVID-19 vaccine without consent, which was upheld because parental consent was not in place at the time the vaccination was administered
- A shaver could not be located
- There was a complaint about the attitude of a locum consultant on the ward. It was found there were failings and the locum agency is taking this forward
- A complaint was partially upheld about communication regarding care and treatment
- Another complaint was partially upheld due to a lack of communication with the patient while not all information was shared at handover
- There was a partially upheld complaint regardign a patient's concerns around her dignity and respect. It was found incorrect information had been included in her discharge plan
- A patient was unhappy with the services offered, which was partially upheld because of a lack of communication with the patient
- A complaint was partially upheld about care and treatment because there was a lack of communication and a delay in therapy
- A patient's complaint about being discharged too soon was partially upheld
- Another complaint from a patient about being discharded inappropriately was partially upheld
- A parent complained their child was weighed and measured without their consent. This was partially upheld because of a lack of communication from the service with the family.
- A complaint from a patient about their life on the ward was partially upheld because of access to acticvities due to the pandemic.
The following complaints were closed and upheld/partly upheld in April 2022:
- Property blinds were damaged. The Trust made an ex-gratia payment.
- Complaint was made about staff attitude in giving information to children by our Child and Adolescant Mental Health Services
- A complaint about breach of GDPR was partially upheld
- There was a complaint about contacting district nurses out of hours or on bank holidays that was partially upheld
- A patient complained after a blood test left her arm swollen and sore, which was partially upheld
- A complaint was partially upheld by a patient who had to wait for an appointment and was then seen by a clinician unknown to them
- The wife of a patient was unhappy a care plan not approved by her has been added to her husband's record, which was partially upheld
- A Mum was unhappy because there was a lack of treatment available to help with her son's eating, which was partially upheld
- Parents were concerned their son was not being seen or assessed by services, which was partially upheld.
The following complaints were closed and upheld/partially upheld in January 2020:
- A service user reported that items of property went missing whist they were an inpatient. The Trust has apologised that the correct procedure was not followed and an ex-gratia payment has been offered.
- Service user raised concerns about the care she received from the District Nurse Team, following surgery.
Treatment Rooms are to look into developing regular Safety Huddle meetings to improve the remote working arrangements of staff within this service and help with continuity of care. Staff are to attend a learning session for holistic assessment and pain assessment. The recording of information on templates as opposed to free text will be introduced to support appropriate record keeping, including any changes to wound management.
- Service user raised concerns about the care he received from the Hospital Liaison Team.
The service user has received an apology and we have confirmed that the referral pathway is currently being reviewed.
- Family member raised concerns about the care a service user received when she moved into the area.
A breakdown in communication was identified. Norris Green Hub now has permanent administration cover. It has also been recommended that anybody in a similar situation will be allocated a care coordinator to act as a point of contact during the transfer of care process and ensure that the required documentation is competed and received in a timely manner.
- Family member raised concerns that a service user was allowed off the ward unescorted, without their knowledge and subsequently attempted to take his own life.
The Trust have agreed to consider informing next of kin/family when leave is agreed, with service user’s consent. Staff should also ensure that leave cards are provided consistently when a service user utilises leave.