Upheld complaints 2025

Category and description

Complaint review outcomes

Failure to follow procedures - Complainant raised concerns in relation to member of staff not recording telephone conversation.

Upheld - Reviewer found that the staff member had not followed process and did not record the conversation.

Communication - Patient raised concerns regarding CHC and discharge planning.

Partially Upheld – Reviewer ascertained there was a lack of communication and apologised for the distress this has caused.

 Clinical Care - Patient raised concerns in relation to care provided during blood appt

Partially Upheld - Reviewer found that standard of care fell below the accepted standard.

Equipment - Relatives unhappy that the Wheelchair provided to patient was not checked or inspected before being provided to patient to use

Partially Upheld - Reviewer found that wheelchair was damaged when returned and apologised for any distress caused.

Staff Attitude - Relative raised concerns in relation to attitude of staff towards patient when administering medication. 

Partially Upheld - Reviewer found that staff member on reflection should have communicated better with the patient and family.

Clinical Care - Patient raised concerns in relation to communication of staff and overall experience.

Partially Upheld - Reviewer found that patient did not receive the level of service that is expected and apologised for any upset or distress caused.

Staff Attitude - Relative raised concerns in relation to attitude of staff towards patient when administering medication. 

Partially Upheld - Reviewer found that staff member on reflection should have communicated better with the patient and family.

Clinical Care - Relative raised concerns in relation to attitude of staff from doctor. 

Partially Upheld - Reviewer found that there was a delay in patient receiving a bed and apologised for the delay.

Clinical Care - Relative felt that they should be discharged and also requested his medication be reviewed. 

Partially Upheld - Reviewer found that the team did review discharge to a different unit but felt that the time this could not be facilitated for clinical reasons at the time.

Category and description

Complaint review outcomes

Clinical treatment – Relative unhappy that patient did not receive appropriate treatment of medication

Upheld – The reviewer found that referral pathway was not followed and did not follow fully wound infection policy.

Staff Attitude - Patient unhappy with attitude of staff whilst attending therapy session.

Partially Upheld - Reviewer found that staff member did not follow Trust values.

Clinical treatment - Relative raised concerns regarding staff not administering patients’ medication they required.

Partially Upheld – Reviewer ascertained there had been a lack of communication between team and family and issues with responsibility on medication administering.

Clinical Care – Relative upset on how staff dealt with patient’s medication needs and how she was spoken to. 

Partially Upheld - Reviewer found a number of failings that staff did not pick up on.

Category and description

Complaint review outcomes

Clinical treatment – Relative unhappy that patient did not receive appropriate treatment and lack of communication regarding this.

Partially Upheld – The reviewer found lack of communication and a delay in providing equipment

Clinical treatment- Patient is unhappy with lack of care provided and feels better communication is required.

Partially Upheld - Reviewer found lack of documentation and this did not align with best practice standards.

Clinical treatment - Relative raised concerns regarding end-of-life care. 

Partially Upheld – Reviewer ascertained that there had been a lack of communication between the team and family.

Clinical Care - Patient raised concerns in relation to their section. 

Partially Upheld - Reviewer found patient did not have access to personal care items.

Clinical Care –Patient raised concerns regarding not receiving appropriate medication

Partially Upheld - Reviewer ascertained there was a delay in initiating new medication regime.

Clinical Care - Patient raised concerns as feels they have been left without care or support.

Partially Upheld - Reviewer found that there was no phone call or letter to patient following outcome of referral discussion.

Clinical Treatment - Patient raised concerns around detention, personal safety and discharge.

Partially Upheld - Reviewer found that staff could not provide any documentation to assist allegations.

Admission/Discharge/Transfer Patient unhappy with discharge.

Partially Upheld - Reviewer found there was an issue with discharge address

Admission/discharge/transfer

Patient raised concerns that they were not informed of discharge.

 Partially Upheld - Reviewer found that patient was unaware of discussions on discharge and decision. 

Clinical Treatment – Patient unhappy with the treatment provided and did not feel listened to by the team. 

Partially Upheld –Reviewer found the team did not reflect Trust values and did not appropriately support the patient.

Admission/discharge/transfer Relative raised concerns regarding discharge. 

Partially Upheld – Reviewer could find any evidence of any concerns or requests to search being raised. 

Category and description

Complaint review outcomes

Clinical Treatment – Relative unhappy that patient was left without nursing and EOL Care

Upheld – The Reviewer found no written evidence that a referral was submitted, and care package should have been followed up.

Attitude of staff - Relative raised concerns in relation to attitude of staff and communication

Partially Upheld - Reviewer found staff did not show Trust values but provided narrative of their concerns but should have not been asked in the way it was.

Aids/Appliances/Equipment - Relative raised concerns that they were not approved for the patient’s wheelchair. 

Partially Upheld – Reviewer ascertained from the website that it contained incorrect information and misled the family.

Personal Records - Patient raised concerns they information was shared, and confidentiality was breached.

Partially Upheld - Reviewer found that on the clinical records two referrals had been added which caused confusion and due to this incorrect information was shared.

Aids/Appliances/Equipment

Patient raised concerns regarding not receiving equipment.

Partially Upheld - Reviewer ascertained the referral was put on hold awaiting further assessment.  However, this was not followed up.

Clinical Care - Patient raised concerns over care/transfer and lack of communication

Partially Upheld - Reviewer found that there was a lack of communication with the patient

Admission/Discharge/Transfer - Patient raised concerns regarding ward transfer and leave.

Partially Upheld - Reviewer found that paperwork had not been fully completed.

Appointments - Relative unhappy with delay in blood tests being taken and lack of communication.

Partially Upheld - Reviewer found that there was a delay in patient having blood test taken

Clinical treatment - Relative raised concerns regarding care provided and lack of communication.

Partially Upheld - Reviewer found that there had been lack of implementing agreed care and lack of communication.  

Clinical treatment - Relative raised concerns regarding care not being taken seriously and lack of communication

Partially Upheld - Reviewer found that the standard of communication fell below the standard the Trust expects.

Failure to follow procedures – Patient unhappy that their MDT was documented.

Partially Upheld - Reviewer could not ascertain from documentation who attended the MDT.   

Staff Attitude

Patient states that they could hear staff talking about her and did not know process to obtain their medical records. 

Partially Upheld - Reviewer found that the team were not aware of the SAR process.

Admission/Discharge/Transfer – Patient raised concerns regarding discharge and that adjustments were not provided. 

Partially Upheld - Reviewer found that patient had not missed appt but had been cancelled. 

Admission/Discharge/Transfer – Patient raised concerns following discharge and was offered no therapy

Partially Upheld - Reviewer found that patient was unaware of discussions around discharge and decision.  

Clinical treatment - Relative raised concerns regarding patients diagnosis.  

Partially Upheld - Reviewer found that there had been incorrect information shared with the GP.

Clinical treatment - Relative raised concerns regarding patient’s mental state and that the team would not offer inpatient bed

Partially Upheld - Reviewer found that there had been lack of inpatient beds within the Trust.

Clinical treatment - Patient raised concerns regarding treatment provided, communication and transfer of care.

Partially Upheld - Reviewer found that there had been lack of communication with the patient.

Clinical treatment - Relative raised concerns regarding physical abuse and safeguarding concerns.

Partially Upheld - Reviewer found that the patient had been discharged from cardiology

Category and description

Complaint review outcomes

Attitude of Staff

Patient raised concerns in relation to attitude of staff

Partially Upheld - Reviewer found that staff did not show Trust values but provided explanation as why a request could not be facilitated.

Clinical Care

Patient raised concerns that she did not receive correct treatment and due to this was admitted to hospital.

Partially Upheld – Reviewer ascertained from clinical records there had been subtle signs of infection. However, observations were within normal limits.

Clinical Care

Patient raised concerns that they did not receive follow up call and staff did not review clinical records

Partially Upheld - Reviewer found that due to staff sickness call was not returned.

Admission/Discharge/Transfer

Patient was unhappy that referral was not sent.

Partially Upheld

Reviewer ascertained the referral was put on hold awaiting further assessment however, this was not followed up.

Clinical Care

Relative raised concerns over patient being left without medication.

Partially Upheld - Reviewer found on clinical notes that letter was sent with incorrect appointment date for follow up  

Clinical Care

Patient raised concerns regarding teams they are under

Partially Upheld - Reviewer found that meetings had taken place without the patient being involved or informed.

Communication

Patient unhappy with level of detail shared with GP.

Partially Upheld - Reviewer found that further guidance could have been sought from the clinical team regarding sharing detailed clinical information.

Clinical Treatment

Patient raised concerns regarding blood tests that were not taken in a timely manner.

Partially Upheld - Reviewer found that there was an error within the health centre.

Category and description

Complaint review outcomes

Clinical Treatment

Patient raised concerns regarding medication and consultant

Partially Upheld – Reviewer ascertained that there had been a breakdown in communication in relation to medication between team and GP.

Clinical Treatment

Patient raised a number of concerns regarding accessible venues.

Partially Upheld – Reviewer found that team has no permanent base to facilitate mode of therapy and due to these issues with Trust sites used.

Clinical Treatment

Patient wishes to raise concerns in relation to care provided

Partially Upheld – Reviewer found lack of communication and learning from the concerns raised. 

Clinical Treatment

Patient raised concerns regarding care provided and accommodation.

Partially Upheld – Reviewer found audit did identify actions that required completion.

Attitude of staff

Patient is unhappy with attitude of staff and feel this was discriminative

Partially Upheld – Reviewer found that telephone call was terminated before a mutual resolution was agreed.

Admission/Discharge/Transfer

Patient disagrees with what the staff have recorded.

Partially Upheld

Reviewer found that there was miscommunication due to information on webform.

Clinical Treatment

Relative raised concerns in relation to discharge of patient.

Partially Upheld – Reviewer ascertained that family was not involved in relation to discharge.

Clinical Treatment

Patient is unhappy that advised to attend Trust site for treatment when they were not required.

Partially Upheld – Reviewer advised that more detailed referral was not available for the team and staff should have sorted this for clarity.

Clinical Treatment

Relative was concerned that patient did not receive correct care.

Partially Upheld – Reviewer could not find that patient was not assessed appropriately

to manage treatment and escalation. 

Clinical Treatment

Patient was concerned that he was advised he would receive a phone call back and this did not occur.

Partially Upheld – Reviewer could not find any discussion had taken place with patient.

Communication

Patient unhappy that staff would not refer patient and felt they gave false hope.

Partially Upheld – Reviewer ascertained that the patient was not informed regarding bed availability

Clinical Treatment

Patient raised concerns regarding transfer of care and delay in medication.

Partially Upheld – Reviewer acknowledged delays with transfer of care which led to delay in response.

Clinical Treatment

Relative was unhappy stating the patient has been left with no support

Partially Upheld – Reviewer found that due to deterioration of patient at meeting, there was not an opportunity to discuss all concerns.

Admission/Discharge/Transfer

Patient raised concerns with being discharge.

Partially Upheld – Reviewer ascertained discharge was appropriate, but the patient was not provided assurance that this was in collaboration with patient and Psychology services.

Communication

Relative raised concerns regarding meeting that took place in relation to patient.

Partially Upheld – Reviewer ascertained that all family members should have been invited and considered all views.

Category and description

Complaint review outcomes

Clinical Treatment

Patient raised concerns in relation to the care and treatment received when attending WIC.

Upheld - Reviewer found that the patient was not offered earlier appointments and issues with wound care received.

Admission/Discharge/Transfer

Patient raised concerns regarding their discharge from service.

Upheld – Reviewer advised they could not find any supporting evidence that they patient should have been discharged

Non-Clinical

Patient raised concerns in relation to staff members long hair fell on patients face during visit.

Upheld - Reviewer found during the procedure, due to the necessary close proximity, the phlebotomist's lanyard inadvertently fell near patient's face.

Clinical Treatment

Relative concerned with end-of-life care provided to patient.

Partially Upheld

Reviewer ascertained there had been failings as no formalised assessment tool utilised.

Clinical Care

Patient unhappy with nurse refusing to assess them.

Partially Upheld - Reviewer found staff member followed clinical escalation plan however, explanation could have provided to the patient.   

Clinical Care

Patient raised concerns following blood appointment and bruising.

Partially Upheld - Reviewer found that staff member did not apply pressure on withdrawal of needle.

Communication

Relative unhappy with Best Interest Meeting that took place

Partially Upheld - Reviewer found that there was a lack of communication and difficulties around technology during the meeting.

Clinical Treatment

Patient raised concerns regarding care provided.

Partially Upheld - Reviewer found that staff could have communicated more effectively and the family felt rushed at times during appointments. 

Clinical Treatment

Patient raised concerns regarding staff attitude and service overall.

Partially Upheld - Reviewer found that staff member was off sick and this was an administrative error.

Admission/Discharge/Transfer

Patient unhappy that were not provided with their rights under section.

Partially Upheld - Reviewer found that there was no documentation that patient was provided with written information regarding their section.

Clinical Treatment

Patient raised concerns about treatment received.

Partially Upheld – Reviewer ascertained that there had been missed opportunities to discuss pathways with the family.

Category and description

Complaint review outcomes

Patients Property

Relative raised concerns in relation to patient’s clothing that went missing whilst an inpatient.

Upheld - Reviewer found that although patients are responsible for their own property, the property lists were not updated with additional items that were brought in by family members.

Appointments/Staff Attitude

Relative raised concerns regarding behaviour of staff during appointment and issues with contact in relation to appointment.

Partially Upheld – Reviewer ascertained issues with contacting patient and this caused upset/distress.

Clinical care - Relative raised concerns in relation to concerns not addressed whilst patient was an inpatient

Partially Upheld - Reviewer found lack of documentation within patient’s records, and information shared lacked with the team.

Staff Attitude - Patient unhappy with attitude of staff.

Partially Upheld

Reviewer ascertained there had been no offer of reasonable adjustment for patient to attend/via teams’ appointment.

Attitude of staff - Patient unhappy with behaviour of staff whilst attending appointment

Partially Upheld - Reviewer found staff member admitted to speaking about patient within a public area.   

Clinical Care– Patient raised concerns following blood appointment in relation to their arm.

Partially Upheld - Reviewer found that staff member did not provide patient with patient leaflet following appointment.

Personal Records – Relative unhappy with information contained in patients’ records.  

Partially Upheld - Reviewer found that comments could have been written more sensitively within the patient records.

Admission/Discharge/Transfer - Relative raised concerns regarding discharge arrangements for patient.

Partially Upheld - Reviewer found that patients discharge was brought forward by two days and patient unaware until MDT

Communication

Patient raised concerns regarding breaching their confidentiality

Partially Upheld - Reviewer found that information was provided by external agency and not by relative.

Clinical Treatment

Patient unhappy with care received

Partially Upheld - Reviewer found that there were missed opportunities from the clinical team in relation to identifying diagnosis

Clinical Treatment

Relative states that team have not supported the patient or had their needs met

Partially Upheld – Reviewer ascertained that there had been missed opportunities to discuss pathways with the family.

Admission/Discharge/Transfer

Relative concerned that patient was inappropriately discharged.

Partially Upheld – Reviewer found that the team did not contact the family in relation to discharge and were not part of discharge discussions.

Personal Records

Patient states inaccurate information on their clinical notes

Partially Upheld – Reviewer found documentation was not completed and records did not contain information correctly.

Aids/Equipment/Appliances

Patient feels that his accessibility needs have not been met

Partially Upheld – Reviewer felt that although staff had followed process in relation to patients needs, this had not been communicated to the patient appropriately.

Clinical Treatment

Patient wished to raise concerns in relation to medication issues.

Partially Upheld – Reviewer felt that the team should have spoken to the patient in relation to medication however, a medication review was scheduled.

Attitude of staff

Relative unhappy with attitude of clinical team

Partially Upheld – Reviewer did ascertain that contact with difficult and lack of information available.

Attitude of staff

Relative unhappy with attitude of clinical team

Partially Upheld – Reviewer did ascertain that contact numbers were removed from patient kiosk due to risk

Communication

Patient wished to raise concerns regarding the MHA Tribunal

Partially Upheld – Reviewer ascertained lack of documentation on what the patient was advised in relation to appeal.

Clinical Treatment

Patient raised concerns in relation of failure to provide appropriate care and support

Partially Upheld – Reviewer found inconsistent information provided to patient.

Category and description

Complaint review outcomes

Admission/Discharge/Transfer Relative raised concerns in relation to patient’s discharge.

Partially Upheld - Reviewer found that patient was not presenting with acute risk however, in hindsight discharge date could have been deferred until community team could communicate with the family and patient in relation to community management.

Admission/Discharge/Transfer

Complainant raised concerns regarding unsafe discharge and refusal to be accepted by PD service.

Partially Upheld – Reviewer ascertained that staff should have clarified patients living conditions before discharge

Clinical Care

Relative raised concerns in relation to concerns not addressed whilst patient was an inpatient

Partially Upheld - Reviewer found lack of documentation to support actions taken.

Clinical Care

Patient unhappy with the lack of care and support receiving.

Partially Upheld

Reviewer ascertained there had been a gap in provision of care between 23-30 October when no appointments were provided.

Attitude of staff

Patient unhappy with the attitude of staff feeling they were uncaring and rude.

Partially Upheld - Reviewer found that although the trust has a zero tolerance it was found that taking blood can be uncomfortable

Appointments –

Patient raised concerns following appointment and response to carry out actions.

Partially Upheld - Reviewer found that no evidence/records of conversation with patient, this was a missed opportunity to ascertain what occurred as staff member has left Trust.

Clinical Treatment –

Relative unhappy with care provided and lack of communication.

Partially Upheld - Reviewer found that communication and professionalism of staff could have been better.

Clinical Care

Patient raised concerns regarding appointments, medication and care provided.

Partially Upheld - Reviewer found that patient experienced a delay in starting therapy and several occasions phone calls were not returned.

Category and description

Complaint review outcomes

Communication Complainant raised concerns in relation to communication with staff regarding patient discharge.

Upheld - Reviewer found that the staff member had not attempted to contact complainant, this was due to confidentiality however, reviewer found that staff member could have acknowledged contact.

Clinical Treatment

Complainant raised concerns regarding patients lack of support from the team.

Upheld – Reviewer ascertained there was occasions when staff did not seek the support the patients palliative care needs.

Staff Attitude - Patient raised concerns in relation to staff member reading mail whilst not on a PM1.  

Upheld - Reviewer found that staff member did open the card in error.

Clinical Treatment - Relatives unhappy with the care provided to the patient raising a number of in-depth concerns they wish addressed.

Partially Upheld - Reviewer found a number of occasions when staff did not follow process. 

Clinical Treatment - Patient raised concerns in relation to attitude of staff member towards them.  

Partially Upheld - Reviewer found that no evidence of diagnosis was found within review letters. The reviewer also found that there was a lack of communication with the patient in relation to medication.

Clinical Treatment - Patient raised concerns in relation to care and treatment provided

Partially Upheld - Reviewer found that patient had been pre-maturely discharged.

Transport - Patient raised concerns regarding being injured whilst being transported.

Partially Upheld - Reviewer found that patient did sustain injuries due to restraint whilst transporting them. 

Clinical Treatment - Patient raised concerns in relation to care provided.   

Partially Upheld - Reviewer found that there was some information/documentation that requires amending.

Clinical Treatment – Patient raised concerns regarding care and treatment received.   

Partially Upheld - Reviewer found that the patient could have been offered further support and communication regarding discharge would have provided opportunity for patient to ask questions. 

Clinical Treatment – Patient raised concerns in relation to their assessment and request compensation.  

Partially Upheld - Reviewer found that response delayed due to staff sickness and the care team did struggle to engage with patient.

Clinical Treatment- Patient raised concerns in relation to care provided.

Partially Upheld - Reviewer partially upheld due to lack of communication.

Admission/Discharge - Patient raised concerns in relation to discharge from services.

Partially Upheld – an apology was offered for lack of communication by staff.

Appointments - Patient raised concerns in relation to physiotherapy appointment cancelled at short notice.

Partially Upheld - Reviewer found that the appointment was cancelled due to unforeseen circumstances. An apology was offered to the patient.

Category and description

Complaint review outcomes

Failure to follow procedures - Complainant raised concerns in relation to member of staff not recording telephone conversation.

Upheld - Reviewer found that the staff member had not followed process and did not record the conversation.

Communication - Patient raised concerns regarding CHC and discharge planning.

Partially Upheld – Reviewer ascertained there was a lack of communication and apologised for the distress this has caused.

Clinical Care - Patient raised concerns in relation to care provided during blood appt.  

Partially Upheld - Reviewer found that standard of care fell below the accepted standard.

Equipment - Relatives unhappy that the Wheelchair provided to patient was not checked or inspected before being provided to patient to use

Partially Upheld - Reviewer found that wheelchair was damaged when returned and apologised for any distress caused.

Staff Attitude - Relative raised concerns in relation to attitude of staff towards patient when administering medication.  

Partially Upheld - Reviewer found that staff member on reflection should have communicated better with the patient and family.

Clinical Care - Patient raised concerns in relation to communication of staff and overall experience.

Partially Upheld - Reviewer found that patient did not receive the level of service that is expected and apologised for any upset or distress caused.

Staff Attitude - Relative raised concerns in relation to attitude of staff towards patient when administering medication.  

Partially Upheld - Reviewer found that staff member on reflection should have communicated better with the patient and family.

Clinical Care - Relative raised concerns in relation to attitude of staff from doctor.  

Partially Upheld - Reviewer found that there was a delay in patient receiving a bed and apologised for the delay.

Clinical Care - Relative felt that they should be discharged and also requested his medication be reviewed.  

Partially Upheld - Reviewer found that the team did review discharge to a different unit but felt that the time this could not be facilitated for clinical reasons at the time.

Clinical Care - Relative raised concerns in relation to care and treatment being provided to patient whilst an inpatient.  

Partially Upheld - Reviewer found that staff member on reflection should have communicated better with the patient and family.

Clinical Care - Patient raised concerns in relation to care provided, diagnosis, and medication.  

Partially Upheld - Reviewer partially upheld due to the distress that the patient experienced as the reviewer did find that the patient had been offered appointments which were not attended. 

Personal Records - Patient raised concerns in relation to attitude of staff, complaints process and treatment that was outsourced.

Partially Upheld - Reviewer found that communication did fall below the standard provided.

Clinical Care - Patient raised concerns in relation to the lack of aftercare and co-ordination by the team.

Partially Upheld - Reviewer found that standard practice at the time has been changed significantly since. Practitioners are aware of the importance of sharing information with partner agencies.

Privacy & Dignity - Relative raised concerns that the patient was not treated with dignity & respect whilst an inpatient.

Partially Upheld - Reviewer found that communication did fall below the standard provided.

Clinical Care - Patient raised concerns in relation to care and treatment.

Partially Upheld - Reviewer found that patient’s medication was not transcribed, and no medication was transferred with the patient. An apology was provided in relation to this.

Clinical Care – Relative raised concerns in relation to lack of care provided to the patient and issues with delayed appointments and not receiving correspondence.

Partially Upheld - Reviewer found that correspondence had not been received and apologised for lack of communication.

Category and description

Complaint review outcomes

Clinical Care

Patient raised concerns in relation to bruising following blood test

Upheld - Reviewer found in relation to venipuncture procedure this always carries the risk of a level of bruising to puncture sites.

Communication

Relative raised concerns regarding relative being moved at an inappropriate time.

Upheld – The reviewer ascertained that there was a lack of communication which caused distress.

Attitude of staff

Relative raised concerns in relation to staff who visited relative.  

Upheld - The reviewer found there was communication had not been clear and concise in the response.

Communication

Relatives is unhappy with the outcome of a meeting following the death of relative

Partially Upheld - The reviewer found several points of learning identified that fell below expected practice.

Clinical Care

Concerns raised by patient regarding referral for a Specialist second opinion.

Partially Upheld – Reviewer found second opinion process was not communicated appropriately at the time.

Clinical Care

Patient is unhappy with the changes to the service and lack of consultation.

Partially Upheld - Reviewer found that there were difficulties during the transition for group members and staff.

Staff Attitude

Patient raised concerns over attitude of Dr during MH assessment.

Partially Upheld – The reviewer found patient was likely assessed against his will.

Clinical Care

Patient raised concerns regarding relative’s care & treatment.

Partially Upheld – Reviewer found delay in communication.

Communication

Relative raised concern regarding issue with the delivery of his relative’s newspaper. 

Partially Upheld

The reviewer found there had been a delay in the patient receiving newspaper.

Clinical Care

Relative unhappy with care provided and feels she has not been supported.

Partially Upheld

Reviewer ascertained that the staff member should have provided a more urgent response rather than waiting for MDT.