Technically this is part of Clinical Governance however it comes up extensively so needs a page of its own!

Below is the BSUH trust policy:


  • Are part of a ‘vital branch of patient experience’, good source of data about quality of services
  • Use Root Cause Analysis (RCA) techniques to investigate concerns


  • Chief Exec is ultimately accountable for ensuring that the trust’s complaints policy and procedure meets the statutory requirements.  All responses must be signed by the chief exec or a nominated deputy
  • Executive Lead – the person responsible for ensuring compliance with the Complaints Regulations – in BSUH this is the chief nurse, supported by the assistant directors of clinical governance
  • The Board should be informed of complaints and actions, and therefore ensuring the lessons learned are implemented
  • Divisional leads – need to ensure that complaints are appropriately investigated, also need to ensure that members of staff are appropriately supported 

 How complaints are monitored: 

Data including number, response timescale and details of second stage complaints (where the complaint goes to independent review by the Parliamentary and Health Service Ombudsman) are reported in ‘Divisional performance’ updates.

This is reported to Associate Director of nursing

If departments fail to hit timescale they are highlighted to Performance Review Group

Themes and trends are highlighted via Datix system

Action plans reported to associate director of nursing for sign off

Patient safety issues reported via Patient Safety Committee

Complaints board details performance against targets, themes, case studies and leanring


 The Complaints process

 2 Stages

  • Local resolution a) at point of care b) formal complaint with
  • Independent review by Parliamentary and Health Service Ombudsman

Should try to deal with concerns at the time – by the ward or departmental manager

  • PALS can provide information and on the spot help for patients and relatives, can facilitate formal complaints
  • If resolved locally, should be recorded as early resolution on datix system
  • If formal complaint made, can be resolved by
    • early intervention
    • Meeting
    • Formal letter of response signed by chief exec
  • Complaints should be made within 1 year of date when matter occurred or when matter came to the attention of the complainant
  • Complaint can be made by patient or person representing the patient – in this case must have verbal consent at least from patient to respond

Complaint made

Complaints team responds in 3 days – should be by telephone to give complainant further opportunity to explain/clarify

Complaints are graded – using Healthcare commission complaints toolkit risk assessment tool.

 Complaints Team co-ordinates the investigations in BSUH – in other trusts it may be the responsibility of a consultant or senior nurse.

All complainants offered a local resolution meeting – facilitated by complaints team

Complaints team also

  • escalates issues involving patient safety +/- medicolegal aspects
  • Drafts response and sends these out
  • Records datix where appropriate


Complaints received via the media

  • These are not entered into – individuals are advised to contact the complaints department


Requests for financial compensation

There is a specific NHS financial manual about this – this only applies if the complainant does not intend to instruct a solicitor to pursue their claim

Where issues should not be resolved using the complaints process:

Trust staff cannot use the complaints arrangements

Complaints cannot be resolved via this way if the person has instructed a solicitor

If it regards failure to comply with data subject request or FOI act request


If involves a vulnerable adult, should be discussed with Safeguarding lead and chief nurse – if POVA investigation is commenced this will take precident

If all this fails:

Independent Review – by the Parliamentary and Health Service Commissioner (Ombudsman)