Formal complaints

Overview

During 2023/2024 there were 128 complaints received (Stage 1 (77) and Stage 2 (51)). There has been an overall increase of 9% compared to the previous year, which is expected due to services resuming to a more pre pandemic level.

Formal complaints

The chart below provides an overview of the formal complaints received by month over the last 3 years:

Table 1 provides a breakdown of the formal complaints received in 2023/2024 by quarter noting the numbers of complaints, outcomes, percentage that were closed within timescales and the average responses times:

Table 1: Formal complaints outcomes by quarter

Key:

• Q1* - 1 complaint was withdrawn 
• Q1** - 2 were withdrawn, 1 no consent obtained and 1 progressed to SAER (n=12)
• Q2*** - 1 was withdrawn and 2 had no consent obtained (n=8)
• Q3**** - 1 had no consent obtained (n=15)
• Q4***** - 1 complaint was time-barred, 1 complaint had no consent obtained and 1 complaint was still open at the time of reporting
• Q4****** - 1 complaint was time-barred, 1 complaint was withdrawn and 4 were still open at the time of reporting

Stage 1 complaints

53 (68%) Stage 1 complaints were responded to within 5 working days timescales. 2 Stage 1 complaints were withdrawn, there were 4 complaints where consent was not obtained and 1 which was timebarred. There were 17 complaints where an extension was granted for various reasons; all of these were responded to within the agreed 10 working days:

Table 2: Stage 1 complaint response

Examples of reasons for extensions include:

• Consultant off on leave so service manager unable to speak with Consultant until back to see whether change of consultant possible.
• Staff investigating on annual leave and then complex investigation requiring multiple teams input only realised once investigation had come back from others.
• NHS Golden Jubilee (NHS GJ) had to wait to speak with Greater Glasgow and Clyde (GGC) to get authorisation to add patient to list.
• Service Manager unable to speak with complainant despite multiple attempts as no answer on phone.

There were seven Stage 1 complaints that were escalated to Stage 2. The reasons for these included the complexity of the investigation required, complainant unhappy with the outcome of stage 1 complaint, and some were better investigated through the stage 2 process so were escalated and responded to appropriately. Within the Stage 1 complaints, waiting list (n=22) and cancellation of surgery / procedure (n=21) were the highest themes. Staff attitude (n=8) was also in the top 3. Waiting list (n=13) and cancellation of surgery/procedure (n=13) and staff attitude (8) all were in the top 3 in 2022/2023.

Stage 2 complaints

We always aim to provide complainants with their response within timescales, this has evidently been a significant challenge this year, similar to 2022/2023 only 22% of Stage 2 responded to within timeframes as shown below:

Table 3: Stage 2 complaint response

During 2023/2024 there have been many contributing factors that caused delays to Stage 2 responses. The complaints that were received were more challenging and complex. Throughout 2023/2024, the Clinical Governance team have been working alongside the Divisional Management teams, Clinical Leads and Executives Leadership Team with a focus on response timescales. This aims to ensure that the quality of the response remains high, whilst endeavouring to provide complainants with a more timely response to their concerns.

This information is reported monthly at confirming challenge and the Executive Leadership Team meetings to identify areas for improvement. Following on from a period of challenging complaints response performance, a Clinical Governance Improvement Project focusing on the Complaints response system commenced in January 2024. The project is ongoing and is estimated to last up to 9 months.

Our longest response time was 147 days within Quarter 2. This complaint was complex and related to a joint SAER which was undertaken by NHS GGC and NHS GJ. There were also questions raised by the Divisional Management Team and Medical Director which required further investigation, adding further delays to the process. There were 3 fully upheld complaints, 25 partially upheld and 13 not upheld. 2 complaints were withdrawn where the patient passed away and no contact could be made with their family family. The other complaint was withdrawn as the patient wife decided they no longer wished to complain.

During 2023/2024 there was one complaint that was escalated to a Significant Adverse Event Review (SAER). This was upheld. 1 Stage 2 complaint was re-opened for a family meeting to take place. It must be noted that the referrals to the Scottish Public Services Ombudsman remain low (Eight when n=51, investigated complaints, SAER investigations and time barred). This suggests that although the complaint responses were over timescales, the complainants appeared satisfied.

Formal compaint themes

During 2023/2024 the top three highest themes received were Clinical Treatment (n=67), Cancellations of surgery / procedure (n=42) and waiting list (n=42). Over the past five years, Clinical Treatment has been consistently the highest theme. Due to ongoing the impact of the pandemic, it was expected cancellations of surgery/procedure and waiting lists themes would be within the highest categories within 2023/2024. Orthopaedic services had the highest amount of complaints with 14 relating to waiting list and 8 relating to clinical treatment. Cardiac Services and Interventional Cardiology are also within the top 3 services named. Cardiac Services highest was cancellation of surgery/procedure (8) and Interventional Cardiology was Clinical Treatment (6). These 3 are the largest services within NHS Golden Jubilee and were also the top 3 services in 2020/2021, 2021/2022 and 2022/2023. The charts below shows the topthemes comparison for 2022/2023 and 2023/2024. During 2023/2024 cancellation of surgery/procedure had the highest upheld complaints (n=9), with staff attitude (n=5) and patient journey (n=5). Clinical Treatment (n=15) was the highest category in partially upheld complaints. The charts below show a breakdown of all themes via stage 1 and stage 2.

Scottish Public Services Ombudsman (SPSO)

During 2023/2024 NHS GJ had 8 cases referred to the Scottish Public Services Ombudsman which is 15% of all cases. 1 of the cases was not upheld by the SPSO and the other 7 cases were not progressed any further.

Learning from complaints

NHS GJ appreciates all feedback to the Hospital as this helps us improve our services for our patients and visitors. Where complaints are upheld, a full apology is given and learning is identified and shared widely within the teams. Where it is required, this is also shared via the Clinical Governance Service meetings. The following is a summary of some of the improvements to the service from feedback received during 2023/2024: 

• Clear signage to be added to the doors of patients’ rooms, defining that Cardiac Monitoring should never be interrupted.
• Reason for cancellation process to be strengthened to ensure reason for surgery not going ahead is consistently documented.
• Staff attitude to be addressed at upcoming team brief to ensure attidues comply with NHS GJ values.
• Team to review their communication with families to consider ways in which communication can be improved to ensure families are fully informed of a patient’s condition and any changes.
• Staff were reminded to be more mindful of noise and conversations, efforts should be made to create a quiet and comfortable environment particularly during nightshift.

Complaint process experience

During the 2021/2022, 2022/2023 and 2023/2024 the decision was taken to scale back the complaints process experience questionnaires, mainly due to the previous response rates as noted in the annual feedback report (2021 / 2022). We continue to make contact via telephone where possible with all complainants to discuss concerns and fully understand the key issues.

Annual Feedback Report 2023/24