Category and description

Complaint review outcomes

Property

Patient raised concerns regarding missing property items. 

Upheld - Reviewer found that property had been given and placed in the storeroom by staff. Unable to locate, agreed to reimburse.

Clinical Care

Relative raised concerns patient care and treatment.

Partially Upheld - reviewer found that the CPA took place outside expected time frame and there was lack of communication with the NOK.

Clinical Care

Concerns raised by patient regarding treatment, communication, discharge and medication.

Partially Upheld – Reviewer found lack of communication with the family; family were also not invited to attend MDT.

Appointments

Patient unhappy with length of time awaiting therapy. Also, regarding communication and attitude of staff.

Partially Upheld - Reviewer found patient has been on waiting list for 2 years. However, the reviewer could not ascertain any documentation that the lead met with the patient to conclude their work.

Clinical Care

Relative unhappy that patient has been in A&E for significant period due to bed not being available.

Partially Upheld – Reviewer established that patient was waiting for a bed and slept in a chair for 2 days in the HUB.

Clinical Care

Relative is unhappy with the care and treatment being provided to the patient.

Partially Upheld – Reviewer found Practitioner was carrying an additional discharge plan belonging to another patient which could have potentially resulted in a breach of confidential data.

 

the reviewer found that In line with the Trust's complaints procedure, the Practitioner should have provided the complainant with their name, designated position and contact details for the PALS/Complaints Service

Clinical Care

Patient raised several concerns regarding care received.

Partially Upheld

The reviewer found miscommunication between patient and teams. However, from records can see that patient was offered several contacts that were declined.

Personal Records

Member of the public receiving mail for a patient.

Partially Upheld

The reviewer found that the complainant received correspondence to their home address after contacting the Trust to request that the address be corrected. The address has been removed on the clinical system

Property

Patient raised concerns regarding missing property.

Partially Upheld

Reviewer established that on ward transfer no property list was taken. Also, no property disclaimer was completed.

Clinical Care

Relative unhappy with care provided to patient.

Partially Upheld – Reviewer ascertained that relative was under significant stress due to this and apologise for contributing. However, found staff had acted professionally.

Clinical Care

Relative unhappy with care provided to patient.

Partially Upheld – Reviewer ascertained that there had been a lack of continuity in patients care and lack of communication.

Non-Clinical

Relative unhappy regarding the drug dog within service as always is turned away which causes her anxiety.

Partially Upheld –

The reviewer found that it is possible that the drugs dog could respond to certain prescribed medications upon the skin. Unfortunately, when the dog gives a positive indication, it is impossible to ascertain if it is for legal or illegal drugs and given that the visitors are attending a High Secure Mental Health Unit, the safety and security of the environment and patients therein is paramount

Category and description

Complaint review outcomes

Clinical Care

Relative raised concerns of care provided by team.

Upheld - Reviewer found that there had been a breakdown in communication and fast track CHC would have been appropriate.

Clinical Care

Relative raised concerns regarding patient failing on two occasions.

Upheld - The reviewer found that patient had raised concerns regarding standing/walking and staff should have taken forward to establish any falls risk during initial assessment. 

Clinical Care

Relative raised concerns patient care and treatment.

Upheld - The reviewer found that there was lack of communication and appointment should have been removed.

Communication

ICB raised concerns regarding patient medication and documentation.

Upheld – Reviewer found staff did not documented medication in care home-controlled drugs resister and there was a delay in requesting medication from the GP.

Clinical Care

Relative states that patient has not received the var she feels, and this resulted in the patient’s health deteriorating.

Partially Upheld - Reviewer found several issues in relation to processes and communication issues.

Clinical Care

Relatives raised concerns that patient was discharged against family wishes.

Partially Upheld - Reviewer found issues with staff communication with the family and documentation.

Clinical Care

Relative unhappy with how patient was treated by staff

Partially Upheld - Reviewer established that patient passed away and the team did not contact the family to offer condolences in a timely manner. 

Clinical Care

Patient raised several concerns relating to treatment and lack of access for therapy.

Partially Upheld - Reviewer ascertained that the patient was due a call back which did not take place and was not provided with outcome in relation to therapy.

Communication

Relative unhappy that patient was not looked after nor his property correctly.

Partially Upheld – Reviewer found that staff did follow process through rapid review however, no safeguarding referral was made. Property list was completed but was a delay in locating property.

Clinical Care

Patient unhappy with care plan and advised was not involved when this was created

Partially Upheld – Reviewer established due to high number of calls care plan was implemented with a 15 min call limit. However, this was not discussed and agreed with patient.

Clinical Care

Patient feels that she has not had continuity of care and is not happy with treatment received.

Partially Upheld – Reviewer found that patient had been seen by 8 different medics due to inconsistent locum cover. Reviewer also established delay in referral.

Communication

Patient raised several concerns regarding care, staff attitude and communication.

Partially Upheld

The reviewer found that there was background noise during phone call

Clinical Care

Relative is unhappy with care patient received.

Partially Upheld

Reviewer found that care provided was correct however, communication with the family fell below standard.

Staff Attitude

Patient disagrees with being places in seclusion and lack of facilities.

Partially Upheld

Reviewer established that patient experienced delay in being provided with toilet paper.

Appointments

Patient experienced a significant delay in receiving an appointment.

Partially Upheld – Reviewer ascertained that patient had requested no contact with CMHT which was adhered to. However, there was sensitive information provided to GP regarding complaints raised by patient.

Personal Records

Patient feels that they have been discriminated against by referral being made to children’s services.

Partially Upheld

Reviewer found that there had been issues with appointments and safeguarding referral was not discussed which caused distress.

Clinical Care

Patient states that staff have not been trained in activities and no OT available on the ward.

Partially Upheld

Reviewer advised that had been difficulties regarding activity co-ordinator post.

Clinical Care

patient is unhappy that he has been given injections since 2022, he was not able to see a second option doctor and he was placed in seclusion for 7 weeks.

Partially Upheld

The reviewer found that a SOAD (second opinion appointed doctor) request was completed on the 9 May 2022, but SAOD was not completed until Completed 28 June 2022

Property

Relative advised that patient is not receiving any parcels due to dogs responding to these. Also advises lack of communication regarding this.

Partially Upheld

This matter is assessed as partially upheld as the delays do occur in the mailroom

Admission/Discharge/Transfer

Patient raised around care & treatment, cancelled appointments, & discharge letter received.

Partially Upheld

Reviewer found lack of documentation within clinical notes regarding information sharing.

Category and description

Complaint review recommendations

 

 

Upheld - Reviewer found

 

 

 

use of inaccurate weight for height measurement, this had an impact on clinical decisions

.

 

 

Clinical Care - Relative raised concerns about care provided to patient.

Upheld - Reviewer found lack of communication and lack of information provided by team.

Clinical Care - Relative raised concerns regarding how patient has been managed by the service.

.

Upheld - Reviewer found that the patient was not taken through appropriate pathway.

Clinical Care - Relative unhappy with monitoring and treatment her mother has received.

Partially Upheld - Swabbing guidance needs to be more informative and robust around storage and follow up. That clinical photography was not always completed.

Clinical Care - Relative raised concerns regarding lack of support and care and treatment her mother received.

Partially Upheld - Reviewer established that there was a negative experience and staff had not followed plan in place.

 

Clinical Care – Relative raised concerns regarding end-of-life care received.

Partially Upheld - Reviewer found staff had not followed policy.

Attitude of staff/Clinical Care - patient unhappy about lack of compassion and treatment.

Partially Upheld - Reviewer found that there was lack of communication and due to this lack of understanding of what the patient wished for.

Clinical Care - Patient unhappy with diagnosis.

Partially Upheld - Reviewer established that a different cause was not considered.

Clinical Care - Patient raised concerns regarding care and treatment received.

Partially Upheld - Reviewer ascertained that there was lack of documentation.

Clinical Care - Relative

unhappy with care provided  to her child.

Upheld - Reviewer found

 

 

 

use of inaccurate weight for height measurement, this had an impact on clinical decisions

 

Category and description

Complaint review recommendations

Appointments

Relative unhappy with delay in patient receiving appointment

Upheld

Reviewer found that patient had been lost to follow up. An appointment was arranged asap.

Property

Patient raised concerns in relation to amount of time it has taken to receive property items from stores.

Upheld

Reviewer found that property was delivered but not processed in timely manner due to staff pressures

Property

Patient raised concerns regarding the process of parcels.

.

 

Upheld

Reviewer found that due to bank holiday there was volume of packages that team could not process in timely manner.

Property

Patient is unhappy with delay to it takes for orders to be processed through patients cash.

Upheld

The reviewer established significant backlog in relation to processing orders within patient cash.  

Discharge Arrangements

Relative raised concerns regarding the lack of support and rushed discharge of patient.

Partially Upheld

Reviewer established that there was a lack of evidence that Care Act assessment was made which delayed support.

Staff Attitude

Relative raised concerns regarding the attitude of a staff member.

Partially Upheld

Reviewer found that staff member had made an inappropriate comment, and this was not in line with Trust values.

Clinical Care

patient is unhappy with the decision making regarding a referral to safeguarding

Partially Upheld

Reviewer ascertained that patient was not advised of the safeguarding concern.

Staff Attitude

Patient states that the Phlebotomist was inappropriate at the appointment

Partially Upheld

Reviewer established that staff member had been loud and had not considered the environment she was working in.

Clinical Care

Patient unhappy with care provided by dentist

Partially Upheld

Patient did not receive an oral examination and no documentation to show that dentures were also examined during this appointment.

Staff Attitude

Relative unhappy with the attitude and communication style of two of the health visitors

Partially Upheld

Reviewer found that staff were late attending appointment and no apology offered.

Clinical Care

Relative raised concerns regarding Care & Treatment, Diagnosis, and Discharge

Partially Upheld

A full review of the patients care record has highlighted some discrepancies in the diagnosis recorded for the patient at various points throughout his admission

Category and description

Complaint review recommendations

Clinical Care

Relative unhappy with care received from the DN team.

Upheld

Reviewer found issues with dressings and that swab for culture and sensitives was not requested.

Aids/Appliances/Equip

Patient raised concerns in relation to the equipment provided and that this caused him pain and discomfort.

Upheld

Reviewer found that the team did not attempt to contact equipment team for advice and matter was not dealt within a timely manner.

Clinical Care

Patient raised concerns regarding treatment, assessment and care planning.

.

Partially Upheld

Reviewer found communication plan could have been more robust.

Personal records

Patient concerned regarding potential breach and care received from the team.

Partially Upheld

The reviewer established there was an error to the clinical system which caused a breach, lack of communication with family members.

Clinical Care

Patient raised concerns regarding the care, treatment, and communication from the team.

Partially Upheld

Reviewer established that there was a lack of support, but patient was provided with information booklets.

Staff Attitude

Relative raised concerns regarding the attitude of a staff member.

Partially Upheld

Reviewer found that staff member had made an inappropriate comment, and this was not in line with Trust values.

Clinical Care

patient is unhappy with the decision making regarding a referral to safeguarding

Partially Upheld

Reviewer ascertained that patient was not advised of the safeguarding concern.

Staff Attitude

Patient states that the Phlebotomist was inappropriate at the appointment

Partially Upheld

Reviewer established that staff member had been loud and had not considered the environment she was working in.

Clinical Care

Patient unhappy with care provided by dentist

Partially Upheld

Patient did not receive an oral examination and no documentation to show that dentures were also examined during this appointment.

Staff Attitude

Relative unhappy with the attitude and communication style of two of the health visitors

Partially Upheld

Reviewer found that staff were late attending appointment and no apology offered.

Clinical Care

Relative raised concerns regarding Care & Treatment, Diagnosis, and Discharge

Partially Upheld

A full review of the patients care record has highlighted some discrepancies in the diagnosis recorded for the patient at various points throughout his admission

 

 

 

 

 

Category and description

Complaint review recommendations

Personal Records

Relative raised concerns regarding breach of his confidentiality.

Upheld - Reviewer found consent was not gained to share personal information.

Clinical Treatment

Relative raised concerns in relation lack of advice/support.

Upheld - Reviewer found failings in relation to Catheter care and lack of communication

Clinical care

Relative raised concerns regarding care provided before patient passed away.

Upheld - Reviewer apologised for the negative experience and has since been reflected that patient would have benefited from an increased visiting schedule. The reviewer also ascertained there were failings in care provided

Clinical Care

Patient raised concerns regarding care provided, and medication issues. 

Partially Upheld - Reviewer found that no beds were available within the division, but this was not communicated to the family and also lack of documentation in relation to medication

Clinical care

Patient raised concerns regarding the care he received whilst an inpatient.

Partially Upheld - Reviewer found miscommunication between ward and family. Also, no evidence within clinical record to support medication was cross referenced against leave prescription.

Policy and Commercial Decisions

Patient raised concerns regarding lack of process and also unhappy with clinical care provided.

Partially upheld - Reviewer found that process is in place but was not communicated to patient.

Clinical Care

Relative unhappy with lack of care provided to patient.

 

Partially Upheld – Reviewer found that patient was referred to incorrect team. Also ascertained that he should have received support following discharge and this was not acted upon.

Clinical Care

Relative is unhappy with the care the patient received for her skin deterioration.

Partially Upheld – Reviewer found lack of documentation regarding concerns identified by GP.

Clinical Care

Patient raised concerns regarding care and treatment provided and diagnosis.

Partially Upheld

Reviewer could not find any evidence that patient was offered an alternative psychiatrist.

Communication

Patient raised concerns that the clinical record had not been read before appointment.

Partially Upheld

Reviewer found that patient requested a change of team that was not facilitated.

Clinical Care

Patient unhappy that the medication has caused significant weight gain

Partially Upheld

Reviewer did see an association between medication and weight gain. The hospital has attempted to mitigate the weight gain providing support, dietitian, and gym access.

Aids/Appliances/Equipment

Patient advised bed had broken and due to this the patient needed to be admitted.

Partially Upheld

Reviewer established that there could have been a delay in response times due to services move to Mersey View.

Appointments

Relative unhappy with the delay in patient receiving an appointment to see his psychiatrist

Partially Upheld

Reviewer found a delay in the patient receiving an appointment.

Communication

Patient was not seen in blood clinic due to admin error and had to wait 6 weeks for another appointment.

Partially Upheld

Reviewer ascertained that staff did not check the system for patients waiting and patient was not seen due to error.

Clinical Care

Relative raised concerns around care and treatment patient received before passing away

Partially Upheld

Reviewer could not find any documentation around rationale for decisions to use pro-heal boot. The reviewer also found lack of communication with the family.

Policy and Commercial decisions

Patient is unhappy with the decision to stop association after 7pm.

Partially Upheld

Reviewer ascertained that staff assumed the time restriction was permanent. This was a miscommunication.

Category and description

Complaint review recommendations

Personal Records

Relative raised concerns regarding breach of his confidentiality.

Upheld - Reviewer found consent was not gained to share personal information.

Clinical Treatment

Relative raised concerns in relation lack of advice/support.

Upheld - Reviewer found failings in relation to Catheter care and lack of communication

Clinical care

Relative raised concerns regarding care provided before patient passed away.

Upheld - Reviewer apologised for the negative experience and has since been reflected that patient would have benefited from an increased visiting schedule. The reviewer also ascertained there were failings in care provided

Clinical Care

Patient raised concerns regarding care provided, and medication issues. 

Partially Upheld - Reviewer found that no beds were available within the division, but this was not communicated to the family and also lack of documentation in relation to medication

Clinical care

Patient raised concerns regarding the care he received whilst an inpatient.

Partially Upheld - Reviewer found miscommunication between ward and family. Also, no evidence within clinical record to support medication was cross referenced against leave prescription.

Policy and Commercial Decisions

Patient raised concerns regarding lack of process and also unhappy with clinical care provided.

Partially upheld - Reviewer found that process is in place but was not communicated to patient.

Clinical Care

Relative unhappy with lack of care provided to patient.

Partially Upheld – Reviewer found that patient was referred to incorrect team. Also ascertained that he should have received support following discharge and this was not acted upon.

Clinical Care

Relative is unhappy with the care the patient received for her skin deterioration.

Partially Upheld – Reviewer found lack of documentation regarding concerns identified by GP.

Clinical Care

Patient raised concerns regarding care and treatment provided and diagnosis.

Partially Upheld

Reviewer could not find any evidence that patient was offered an alternative psychiatrist.

Communication

Patient raised concerns that the clinical record had not been read before appointment.

Partially Upheld

Reviewer found that patient requested a change of team that was not facilitated.

Clinical Care

Patient unhappy that the medication has caused significant weight gain

Partially Upheld

Reviewer did see an association between medication and weight gain. The hospital has attempted to mitigate the weight gain providing support, dietitian, and gym access.

Aids/Appliances/Equipment

Patient advised bed had broken and due to this the patient needed to be admitted.

Partially Upheld

Reviewer established that there could have been a delay in response times due to services move to Mersey View.

Appointments

Relative unhappy with the delay in patient receiving an appointment to see his psychiatrist

Partially Upheld

Reviewer found a delay in the patient receiving an appointment.

Communication

Patient was not seen in blood clinic due to admin error and had to wait 6 weeks for another appointment.

Partially Upheld

Reviewer ascertained that staff did not check the system for patients waiting and patient was not seen due to error.

Clinical Care

Relative raised concerns around care and treatment patient received before passing away

Partially Upheld

Reviewer could not find any documentation around rationale for decisions to use pro-heal boot. The reviewer also found lack of communication with the family.

Policy and Commercial decisions

Patient is unhappy with the decision to stop association after 7pm.

Partially Upheld

Reviewer ascertained that staff assumed the time restriction was permanent. This was a miscommunication.

Category and description

Complaint review recommendations

Personal Records

Relative raised concerns regarding breach of his confidentiality.

Upheld - Reviewer found consent was not gained to share personal information.

Clinical Treatment

Relative raised concerns in relation lack of advice/support.

Upheld - Reviewer found failings in relation to Catheter care and lack of communication

Clinical care

Relative raised concerns regarding care provided before patient passed away.

Upheld - Reviewer apologised for the negative experience and has since been reflected that patient would have benefited from an increased visiting schedule. The reviewer also ascertained there were failings in care provided

Clinical Care

Patient raised concerns regarding care provided, and medication issues. 

Partially Upheld - Reviewer found that no beds were available within the division, but this was not communicated to the family and also lack of documentation in relation to medication

Clinical care

Patient raised concerns regarding the care he received whilst an inpatient.

Partially Upheld - Reviewer found miscommunication between ward and family. Also, no evidence within clinical record to support medication was cross referenced against leave prescription.

Policy and Commercial Decisions

Patient raised concerns regarding lack of process and also unhappy with clinical care provided.

Partially upheld - Reviewer found that process is in place but was not communicated to patient.

 

Clinical Care

Relative unhappy with lack of care provided to patient.

Partially Upheld – Reviewer found that patient was referred to incorrect team. Also ascertained that he should have received support following discharge and this was not acted upon.

Clinical Care

Relative is unhappy with the care the patient received for her skin deterioration.

Partially Upheld – Reviewer found lack of documentation regarding concerns identified by GP.

Clinical Care

Patient raised concerns regarding care and treatment provided and diagnosis.

Partially Upheld

Reviewer could not find any evidence that patient was offered an alternative psychiatrist.

Communication

Patient raised concerns that the clinical record had not been read before appointment.

Partially Upheld

Reviewer found that patient requested a change of team that was not facilitated.

Clinical Care

Patient unhappy that the medication has caused significant weight gain

Partially Upheld

Reviewer did see an association between medication and weight gain. The hospital has attempted to mitigate the weight gain providing support, dietitian, and gym access.

Aids/Appliances/Equipment

Patient advised bed had broken and due to this the patient needed to be admitted.

Partially Upheld

Reviewer established that there could have been a delay in response times due to services move to Mersey View.

Appointments

Relative unhappy with the delay in patient receiving an appointment to see his psychiatrist

Partially Upheld

Reviewer found a delay in the patient receiving an appointment.

Communication

Patient was not seen in blood clinic due to admin error and had to wait 6 weeks for another appointment.

Partially Upheld

Reviewer ascertained that staff did not check the system for patients waiting and patient was not seen due to error.

Clinical Care

Relative raised concerns around care and treatment patient received before passing away

Partially Upheld

Reviewer could not find any documentation around rationale for decisions to use pro-heal boot. The reviewer also found lack of communication with the family.

Policy and Commercial decisions

Patient is unhappy with the decision to stop association after 7pm.

Partially Upheld

Reviewer ascertained that staff assumed the time restriction was permanent. This was a miscommunication.