Introduction
Section 1: Understanding the Complaints Landscape in NHS Mental Health Services
Section 2: The Complaints Investigation Process
Section 3: Rights and Responsibilities
Section 4: Responding to a Complaint as a Mental Health Professional
Section 5: Practical Steps and Best Practices
Section 6: Prevention and Future Strategies
- Strategies to Reduce the Likelihood of Complaints in NHS Mental Health Services
Conclusion: Embracing a Progressive Approach in NHS Mental Health Services
References and Resources

Introduction

This article will discuss the NHS Complaints Procedure, including how to respond to complaints, best practice for investigations, and information about why receiving complaints can be turned into a positive force for good.

People who use mental health services are often at the lowest point of their lives when they first come into contact with us. They may be desperately unhappy, scared, without hope or feeling helpless and vulnerable. They then put themselves in the hands of mental health professionals and ask us to help make their lives more bearable and to support them with the challenges they are facing. When they are not satisfied with the care they receive, the disappointment and anger they feel should be understandable to us all. However, they are often also motivated by a concern for those who enter services behind them, or others already using them.

I have always been supportive of people who considered making complaints, whether they are patients, or the people who love them. I advise them that if they have been treated poorly, they deserve an apology but more importantly, complaints can be an engine for change and improvement. People who raise concerns and complaints can shine a light on areas where we are failing, and help us to serve our patients, clients and service users better.

In the complex landscape of mental health services within the NHS, with our reliance on various professionals within our team, as well as a reliance on other teams and services working together, the management of complaints holds a pivotal role. The nature of mental health care, inherently personal and often deeply affecting both patients and healthcare professionals, makes addressing complaints not just a procedural necessity but a cornerstone of quality care and trust-building in healthcare relationships.

A few years ago, I led a complaint investigation regarding an allegation of staff abuse in a mental health inpatient unit and have assisted with other investigations. I have been lucky enough to only have two official complaints made against me personally since I started working as a nurse. One was from the adult daughter of a patient, about whom I had raised a Safeguarding Alert. The investigation found that my documentation demonstrated that her account of events was unlikely to be accurate, and the interviews with the patient painted a very different picture of the care she had received.

The second complaint was made by a service user who was unhappy with my team’s decision not to offer support. When I called him to provide feedback, he was very angry and felt abandoned and ignored. I told him I would send him a copy of my assessment report and said I would support him to make a formal complaint. He told me he was aware of how to make complaints and would be calling PALs as soon as the letter arrived.

This article delves into the complex world of complaints in NHS mental health services, guiding professionals through the maze of processes, rights, responsibilities, and practical steps. I will explore the landscape of complaints, discuss the investigation procedures, explain the rights and responsibilities of all stakeholders, and offer insights into effectively responding to complaints. Furthermore, I will look into practical steps and best practices for handling these challenging scenarios and discuss strategies for prevention and future improvements.

By the end of this guide, mental health professionals will be better equipped not only to navigate the challenging process of handling complaints but also to learn from them, thereby enhancing their practice and contributing positively to the field of mental health care.

Section 1: Understanding the Complaints Landscape in NHS Mental Health Services

Overview of Common Reasons for Complaints in NHS Mental Health Services

Complaints in NHS mental health services are a critical indicator of the areas requiring improvement and attention. Understanding the nature of these complaints provides invaluable insights into patient needs, service gaps, and opportunities for enhancing care quality. Here is a detailed overview of common reasons for complaints based on various sources.

Predominant Causes of Complaints

Poor Communication: The majority of complaints are related to poor communication. In the UK, the three most common complaints to the General Medical Council (GMC) involve issues with investigations and treatment, problems with communication, and a perceived lack of respect for the patient.
Failure in Diagnosis and/or Treatment: This includes cases where there is a failure to properly diagnose or treat a condition, sometimes leading to severe consequences, including deaths.
Inadequate Hospital Discharge and Aftercare: Complaints often arise when patients are discharged without appropriate care plans, sometimes leading to adverse outcomes such as drug overdoses or relapses.
Poor Risk Assessment and Safety Practices: Inadequate risk assessments lead to incidents that compromise patient safety and dignity. In residential or inpatient mental health settings, these risks may be environmental, or relate to access to the means of causing self-harm or harm to others.
Lack of Dignity and Infringement of Human Rights: Situations where patients are not treated with the necessary dignity or respect, including violations of their basic human rights, are a significant source of complaints.
Deficient Communication with Patients and Their Families: Issues arise when there is a lack of clear communication or explanation of actions taken, especially in sensitive situations involving mental health conditions.

Statistical Overview

In the fiscal year 2020-21, the NHS received 170,013 written complaints, averaging about 300.6 complaints per 100,000 people. Among these, the complaints in Hospital and Community Health Services were 83,899.
Clinical treatment was the subject of 26.9% of these complaints, followed by communication issues (18.0%), and concerns about patient care, including nutrition and hydration (12.1%), and values and behaviour (10.6%).

Implications for Mental Health Services

The prevalence and nature of these complaints underscore the need for enhanced communication skills, improved diagnostic and treatment protocols, comprehensive discharge planning, robust risk management, respect for patient dignity, and effective family and patient engagement strategies in NHS mental health services. Addressing these areas can lead to significant improvements in patient safety, patient satisfaction, treatment outcomes, and overall service quality in mental health care.

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The Impact of Complaints on Service Quality and Patient Care in NHS Mental Health Services

Complaints in NHS mental health services significantly influence both service quality and patient care. Understanding these impacts can provide valuable insights into healthcare management and patient relations.

Indicators of Systemic and Individual Failures

System Failures and Individual Shortcomings: Complaints often reflect underlying issues in healthcare systems or individual practitioner failures. They serve as indicators of broader problems either within individual practices or the organization as a whole.

Patient Experience and Expectations

Falling Short of Patient Expectations: The process of making a complaint and its outcome frequently do not meet patient expectations, especially concerning the interpersonal conduct of NHS staff. This gap can lead to dissatisfaction and, in severe cases, legal action, which is costly both financially and in terms of patient well-being.
Psychological Impact on Patients: Complaints are often accompanied by psychological distress for patients, affecting their overall experience and potentially their future perception of healthcare services. I have known many people reluctant to access mental health services due to their previous bad experiences, leading to them delaying seeking support or treatment, and discouraging others from doing so.

Influence on Healthcare Quality

A Broader Conceptualisation of Harm: Complaints indicate a wider understanding of harm beyond immediate errors, encompassing aspects like patient satisfaction and emotional well-being. They can thus be instrumental in improving healthcare quality.
Impact on Future Healthcare Choices: The experience of complaining can influence a patient’s future healthcare choices, either fostering trust and confidence when handled well or leading to distrust and avoidance when managed poorly.

Treatment Provider’s Perception and Response

Defensive Institutional Responses: Often, responses to complaints fail to fully acknowledge the human relational failures in healthcare, instead focusing on institutional, defensive responses. This misalignment can exacerbate patient dissatisfaction and prevent genuine learning or improvement from the complaint process.
Opportunities for Learning and Improvement: Properly addressed complaints provide opportunities for healthcare entities to learn and improve. However, inconsistent practices and lack of effective training for complaint handlers can hinder this process.

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Importance of a Robust Complaint Handling System for Maintaining Trust and Safety in NHS Mental Health Services

A robust complaint handling system is critical in NHS mental health services for several reasons, including maintaining patient trust and ensuring safety.

NHS Complaint Standards and Their Impact

The NHS Complaint Standards, launched in 2021, have shown positive effects in handling complaints. NHS staff taking part in the pilot scheme reported that these standards provided clarity and consistency, enhancing their capacity and skill in managing complaints. This initiative was found to be successful in facilitating early resolution and had not negatively impacted the staff’s time. The emphasis on early resolution helped in speeding up the complaint handling process.
Pilot sites testing these standards have seen benefits in self-assessment guidance, which is now part of their annual appraisals. The conclusion was that this helps embed a culture within the NHS that welcomes complaints and learns from them, treating them as valuable feedback to improve services.
The plan was that standards would also be referred to in casework to identify good practices and how local complaints handling can be improved.

Research Insights on Complaint Handling

Research by the NIHR Imperial Patient Safety Translational Research Centre suggests that more can be learned from complaints to make improvements in NHS trusts, even if a complaint itself is not upheld. This approach can help in better understanding patients’ needs and perspectives on organisational safety.
The complex nature of the NHS complaints system is often cited as an obstacle to effective complaint handling. A detailed examination revealed that national rules, regulations, and infrastructure play a significant role in influencing complaint handling, investigation, and monitoring within hospitals.
Confusion about the routes for raising concerns was identified, highlighting a need for better awareness among patients and staff about the formal complaints process and the role of the Patient Advice and Liaison Service (PALS).

Recommendations for Improvement

Involving patients and families in complaint investigations as standard practice is recommended to foster dialogue between staff and affected patients. This involvement can help address systemic issues and not just problems unique to one Trust.
A transparent culture and meaningful data analysis strategies are essential to ensure that concerns raised in complaints are translated into quality improvement initiatives. This approach will help in addressing recurring patient safety issues.

Section 2: The Complaints Investigation Process

Detailed Explanation of the NHS Complaints Procedure

Right to Complain

Entitlement to Complaint: Patients have the right to make a complaint about any aspect of NHS care, treatment, or service, as stated in the NHS Constitution.

Initial Steps

Early Discussion: Initially, people who raise concerns are encouraged to discuss these with the service provider, which may resolve the issue quickly. If this is uncomfortable, patients can speak to someone not directly involved in their care.
Patient Advice and Liaison Service (PALS): PALS offers a confidential service to help resolve issues informally before a formal complaint is needed, especially in urgent situations.

Seeking Assistance

NHS Complaints Advocate: Patients considering making a complaint can get help from an NHS complaints advocate to write a complaint letter and attend meetings, though they cannot make the complaint or provide legal advice.

The Formal Complaint Process

Complaint Recipients: Complaints can be made directly to the NHS service provider or to the commissioner of the services. In cases involving multiple organisations, they must cooperate to ensure a coordinated response.
Commissioner Contact: For primary and secondary care services, including mental health, complaints can be directed to the local integrated care board (ICB). NHS England handles complaints about healthcare in prisons, military health services, and specialized services.
Mental Health Act Complaints: Complaints specifically about the use of the Mental Health Act should be directed to the Care Quality Commission (CQC).

Making a Complaint

Timeframe: Complaints should be made within 12 months of the incident or its discovery, with possible extensions if there’s a good reason for delay and a fair investigation is still feasible.
Method of Complaint: Complaints can be made verbally, in writing, or by email. Verbal complaints are recorded, and a written copy is provided. If complaining in writing on behalf of someone else and they are able to give consent, that person’s written consent should be included.

During the Complaint Process

Acknowledgement and Discussion: Within three working days of receiving the complaint, an acknowledgement and a discussion offer are expected. The anticipated timeframe for a response to the complaint, which varies based on the complaint’s nature, should be advised.
Investigation and Response: After investigation, a written response is provided detailing the findings, apologies if appropriate, actions taken as a result of the complaint, and information on how the complaint was handled.

Escalation

Ombudsman Involvement: If dissatisfied with the local handling or the final decision, patients can bring their complaint to the Parliamentary and Health Service Ombudsman, an independent organization making final decisions on unresolved NHS complaints in England.

Roles of Different Stakeholders in the NHS Complaint Investigation

The NHS complaint investigation process involves various stakeholders, each playing a crucial role to ensure the system’s effectiveness and fairness. Here’s an overview of the roles of patients, mental health professionals, and NHS Trusts in the investigation process.

1. Patient’s Role

Initiating the Complaint: Patients or their representatives initiate the complaint process, which can be made to the service provider or to the commissioning body, but not both.
Providing Detailed Information: Patients are responsible for providing detailed information about their grievance, including what happened and their desired outcome.
Participation in Meetings: Patients may be invited to meetings as part of the investigation and can bring a friend or someone from an advisory/advocacy service.

2. Mental Health Professional’s Role

Contributing to Investigations: Mental health professionals contribute information and context to the investigation. For example, nurses involved in an incident may not write the response but will provide accounts of events to the complaints manager.
General Practitioners (GPs): GPs have contractual responsibilities to ensure effective management of complaints and might act as complaints managers at their practice.
Adhering to Principles: Professionals should adhere to principles like investigating thoroughly, being flexible, and providing a prompt and complete response. They should acknowledge mistakes and apologise where appropriate.

3. NHS Trust’s Role

Managing the Complaints Procedure: NHS Trusts are responsible for managing the complaints procedure. They must have a publicly accessible complaints manager and a ‘responsible person’ to ensure compliance with the complaints procedure.
Record-Keeping: Trusts are required to keep records of complaints, actions taken, and lessons learned. This information should be kept separate from patients’ records.
Annual Reporting: Trusts should provide an annual report on complaints, which should be available on request. This report should also be sent to the commissioning body in the case of primary care providers.
Cooperation in Multi-organisational Complaints: If a complaint involves more than one responsible body, they must work together to provide a coordinated response.

Timeline and Stages of the NHS Complaint Investigation Process

The NHS complaint investigation process is structured to ensure thorough and fair handling of grievances. Here’s an overview of the timeline and stages involved:

Stage One: Local Resolution

Initiation: The first stage involves resolving complaints locally, typically at the GP practice, community team base, or hospital level. The emphasis is on resolving complaints as quickly as possible, with speed, sympathy, and a willingness to listen being key elements.
Acknowledgment of Complaints: All complaints must be acknowledged within three working days. If oral complaints can be resolved to the complainant’s satisfaction within one working day, they don’t fall within the formal regulations.

Investigation and Response

Thorough Investigation: All complaints should be investigated thoroughly by speaking to all staff involved or obtaining their written accounts for more complex complaints.
Clear Investigation Plan: An investigation plan should be established for each complaint, including timescales for investigation and response. It should also clarify the nature of the complaint and the complainant’s desired outcome.
Prompt Written Response: A prompt and complete written response is essential. Any delays beyond six months must be communicated to the complainant, explaining the reasons for the delay.
Review and Learning from Complaints: The system should include a process for reviewing and learning from complaints, informing the complainant about actions taken to prevent recurrence.

Meetings and Further Discussions

Organising Meetings: Meetings with the complainant can be part of the investigation process. It’s important to agree on the discussion areas and attendees in advance. Neutral venues may be considered in some cases.
Follow-up Meetings: If the complainant is not satisfied after the response, a further meeting can be offered to address remaining concerns. A conciliator may be present in such meetings.

Final Stages

Outcome Communication: The final outcome of the complaint investigation, including any remedial action planned or already taken, should be communicated to the complainant.
Right to Escalate: Complainants have the right to take the matter to the Ombudsman within 12 months if they are dissatisfied with the response.

Section 3: Rights and Responsibilities

Patient Rights in NHS Mental Health Services: Confidentiality, Fair Treatment, and the Right to Complain

Confidentiality

Confidentiality is a cornerstone of patient care, ensuring that personal information about a patient’s diagnosis, condition, and treatment is kept private. Health professionals in NHS mental health services are obliged to maintain confidentiality except in certain circumstances, such as with the patient’s consent, in emergency situations, or under a court order.

Fair Treatment and Human Rights

The NHS has a responsibility to treat all patients fairly and with respect for their human rights. This includes the right to private and family life, which may be affected in various situations such as being placed in a residential unit far from family, excessive force used for restraint, or refusing family visits while in hospital. However, some human rights are not absolute and can be lawfully restricted for legitimate reasons, such as the need to protect the patient or others.

Patients are also protected under the Equality Act 2010 from unlawful discrimination on grounds such as disability, ethnicity, and sexuality. This act ensures that patients receive equal access to treatment and care, free from discrimination.

The Right to Complain

Patients have the right to complain about any NHS service if they are unhappy with the care they receive. The NHS must acknowledge and investigate complaints properly.

In cases where the NHS breaches legal rights, patients might have the option to take legal action. This can include actions for clinical negligence, where harm has occurred due to a poor standard of healthcare, or judicial review, where the lawfulness of a public body’s decision is contested. Legal aid may be available for such cases, and patients are advised to seek legal advice.

Staff Rights in NHS Complaints and Investigation Process: Fair Investigation, Support, and Representation

Fair Investigation

The NHS ensures fair investigation processes for its staff. The policies followed by NHS Trusts are designed to handle concerns about staff conduct or performance in a manner that is consistent and just. These investigations might arise from various policies, such as Dignity at Work, Grievance, or Freedom to Speak Up. The procedures include identifying circumstances that warrant an investigation, the steps to be taken during the investigation, and the rights of staff throughout the process.

Support for Staff

Support for staff during and after investigations is crucial, not only for the wellbeing of the staff but also for maintaining a learning and supportive environment within the NHS. The psychological impact on staff involved in patient safety incidents can be significant, leading to issues like anxiety, depression, or concerns about job performance. To mitigate these effects, the NHS employs tools like REACTMH and Trauma Risk Management (TRiM) peer support. Key aspects of staff support include normalising the need for staff to seek support, ensuring equal access to support services, and providing different types of support depending on individual needs. However, it’s noted that not all organisations provide consistent support, and there are variations in how different staff groups engage with available support services.

Representation and Participation in Investigations

NHS policies mandate the active participation of employees in the investigation process. This includes being open and honest with the investigation team to establish facts and considering the positions of complainants and witnesses. Employees are expected to cooperate to avoid delays in the process. Managers play a pivotal role in ensuring that employees are informed about the investigation’s progress and understand the reasons behind it. The investigation process takes into account the evidence provided by the employee under investigation, any witnesses, and physical evidence. Findings from the investigation can lead to various outcomes, including the allegation not being upheld, the need for learning outcomes under the Capability Policy, or referral to a formal panel under relevant Workforce Policies. Managers are responsible for meeting with the employee post-investigation to confirm findings and discuss any further actions.

NHS Trust Responsibilities: Impartiality, Transparency, and Resolution in the Complaints Process

Impartiality

The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 govern the local resolution of NHS complaints. All NHS bodies and organisations must comply with these regulations, ensuring impartiality in the handling of complaints. To maintain impartiality, a publicly accessible complaints manager and a responsible person are designated within each NHS body to oversee compliance with the complaints procedure. These individuals or their authorised representatives are required to sign off on all responses to complaints, thereby ensuring an unbiased approach.

Transparency

Transparency in the NHS complaints process is crucial. NHS Trusts are expected to investigate all complaints thoroughly and respond effectively once all facts are established. This includes obtaining written accounts from all staff involved in more complex complaints. NHS Trusts must also be flexible in handling complaints, taking into account the seriousness of concerns raised, lessons learned, and ensuring that responses are balanced and proportionate. A clear investigation plan is essential for each complaint, including an estimate of the timescales needed to investigate and respond. The complainant must be kept updated on the progress and reasons for any delays, especially if the response time exceeds six months. Transparency also entails being open and honest in acknowledging mistakes and apologising where appropriate.

Resolution

NHS Trusts are committed to achieving satisfactory resolution of complaints. NHS Resolution, an NHS organisation, emphasises the importance of learning from complaints to improve services. It adheres to the NHS Complaints Regulations and the Parliamentary and Health Service Ombudsman’s Principles of Good Complaints Handling. NHS Trusts are required to have systems for reviewing and learning from complaints, informing complainants of actions taken to prevent recurrence of issues, and explaining how complaints were investigated and what conclusions were reached. This approach is designed to resolve complaints effectively, addressing any necessary remedial actions and confirming details of complaint handling with the complainant.

Duty to Cooperate

When a complaint involves more than one responsible body, the regulations stipulate a ‘duty to cooperate.’ This means that the concerned bodies must work together to provide a single, coordinated response to the complainant, ensuring a unified approach to addressing the complaint and its resolution.

Legal Considerations in NHS Complaints

Regulatory Framework: The NHS complaints procedure is legally structured under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. This framework applies to NHS bodies, healthcare providers, and independent providers offering healthcare services under NHS arrangements.
Complaints Investigation Process: Complaints can be made to the care provider (e.g., hospital or GP surgery) or the commissioning body. The procedure includes a local resolution stage and may escalate to the Parliamentary and Health Service Ombudsman (PHSO) if the complainant remains dissatisfied.
Responsibility for Complaint Handling: If a complaint involves multiple responsible bodies, there’s a duty to cooperate.
Exclusions from the Procedure: Certain types of complaints are excluded, such as those made by NHS employees related to their work or complaints resolved to the complainant’s satisfaction within one working day.
Time Limits and Ethical Duty: Complaints must generally be made within 12 months of the incident. However, responsible bodies are advised to consider complaints made outside this limit, aligning with the ethical responsibility to address complaints.
Timeliness and Appropriateness of Response: The regulations emphasize the need for timely responses to complaints, with a guideline of six months for providing a full response unless an extended timeline is agreed upon with the complainant.
Apologies and Duty of Candour: Healthcare organisations are encouraged to apologise when appropriate. Since April 2015, the statutory duty of candour mandates transparency and honesty in healthcare services, reinforcing that apologies are not admissions of liability.
Separation from Disciplinary and Criminal Procedures: The complaints procedure is distinct from disciplinary actions against healthcare professionals. These processes are confidential and separate, ensuring fairness and objectivity.
Clinical Negligence Claims: Patients may pursue both a complaint and a clinical negligence claim concurrently. The response to a complaint can be critical in determining the presence of negligence.

Ethical Considerations in NHS Complaints

Empathy and Understanding: Complaint narratives often contain detailed, emotional accounts. Complaint handlers should acknowledge the effort and distress involved in formulating a complaint. Understanding and empathising with the complainant’s perspective is essential.
Subjectivity and Factual Assessment: There is a tendency to treat complainants’ accounts as subjective. Ethically, it’s vital to consider various perspectives and corroborate information from different sources, including the complainant’s, to ensure fairness.
Mitigating Sub-Standard Care: Responses often state that any transgressions by staff were unintentional. Ethically, acknowledging potential shortcomings and taking responsibility is important for maintaining trust.
Incongruences in Responses: Complaints often lead to practice changes, even when they are rebutted. This highlights the ethical importance of learning from complaints and making necessary improvements, regardless of the formal outcome of the complaint.
Negligence and Opposing Perspectives: The approach to complaints involving allegations of negligence often reflects contrasting views between complainants (focusing on care) and responders (focusing on clinical treatment). An ethical response involves reconciling these perspectives and addressing concerns transparently.
Apologies and Trust Repair: Effective apologies, acknowledging responsibility, expressing regret, and offering explanations, can significantly impact the reconciliation process. This aligns with the ethical principle of repairing trust and maintaining relationships with patients.
Potential Litigation Concerns: When complaints are framed in terms of duty of care or negligence, a defensive or quasi-judicial response can exacerbate the situation. Ethically, a more explanatory and less adversarial approach is advisable.
Culture of Defensiveness and Blame: There is a systemic issue of defensiveness and a blame culture within the NHS, which impedes effective complaint handling. Promoting a learning and improvement culture, focusing on “Just Culture”, and overcoming defensiveness are ethical imperatives for improving complaint handling.
Resource and Time Allocation: Complaints often suffer from delays and poor handling due to inadequate resourcing and prioritisation. Ethically, it is crucial to allocate sufficient resources and time to ensure thorough and fair complaint handling.
Fair and Accountable Decisions: The NHS is advised to provide fair and accountable decisions, including meaningful apologies and demonstrating learning from complaints. This is in line with the ethical principle of accountability in healthcare service delivery.

In summary, the legal framework provides a structured approach to handling complaints in NHS mental health services, emphasising timeliness, transparency, and the duty of candour. Ethically, the focus should be on empathy, fairness, learning from complaints, and maintaining trust and accountability in healthcare relationships.

Section 4: Responding to a Complaint as a Mental Health Professional

Responding to a complaint as a mental health professional in the NHS involves a series of initial steps that are crucial for effective resolution and maintaining professional standards. The guidance focuses on understanding the complaint and managing one’s emotional response, ensuring a fair and constructive approach.

Understanding the Complaint

Complaint Nature: Complaints can arise from various reasons, including anger, frustration, communication breakdowns, or a lack of understanding of the healthcare system. Recognising the underlying causes of the complaint is the first step in addressing it effectively.
Common Causes: The most frequent complaints to the GMC involve issues with investigations and treatment, communication problems, and perceived lack of respect for the patient. Addressing these common issues proactively can reduce the likelihood of complaints.
Communication Challenges: Communication barriers, including language differences, can lead to misunderstandings.
Acknowledgment and Response: NHS Complaints Regulations require complaints to be acknowledged within three working days and responded to within agreed timescales. Engaging in this process with a non-defensive, rational approach is critical.

Emotional Self-Management

Empathetic Engagement: Recognising the patient’s right to express concerns is vital. Professionals should approach complaints with empathy, understanding that patients may be looking for reassurance that their concerns are acknowledged and that similar mistakes won’t be repeated.
Avoiding Defensiveness: It’s essential to avoid a defensive reaction to complaints. Understanding why the complaint was made, what went wrong, and how it could have been prevented fosters a more productive and less confrontational resolution process.
Learning from Complaints: The NHS Complaint Standards emphasise the importance of learning from complaints. This involves senior staff regularly reviewing complaints and using the insights gained to improve services. This reflective practice can help in managing emotional responses by focusing on improvement rather than defence.
Training Opportunities: Healthcare professionals should take advantage of complaints awareness training offered by certain health and social care trusts. This training can provide valuable skills in handling complaints effectively and empathetically.

Seeking support: Legal, union, professional bodies.

When a mental health professional working in the NHS faces a complaint, seeking support is a crucial step. This support can be legal, from unions, or from professional bodies. Each type of support offers different resources and guidance to help navigate the complexities of the complaint process.

Legal Support

Medical Defence Organisations: If professionals who are a member of a medical defence organisation, are subject to investigation, they should immediately contact them for advice and legal support. These organisations can provide guidance on how to proceed and what legal actions may be necessary. These organisations usually support Doctors, however other professionals, such as Nurse Practitioners can also arrange individual membership.
Legal Advice and Indemnity Cover: If you are a nurse employed by the NHS, you are automatically covered by their indemnity arrangement. This insures you for any work you do on behalf of the NHS and provides coverage in the event of a claim being made against you. It’s advisable for professionals, especially those not working exclusively for the NHS, to ensure they have adequate insurance and medical indemnity cover consistent with GMC Good Medical Practice. In cases where an individual is not a member of a defence organisation, they may need to seek their own legal advice, often at their own expense. Legal aid is not typically available for doctors under investigation by the GMC.
NHS Resolution: This body provides indemnity to NHS employees for clinical negligence claims that arise from contracted NHS duties. However, it’s important to note that this indemnity does not cover disciplinary issues or referrals to the General Medical Council.

Union Support

Trade Unions: Unions like Unite, the RCN, or Unison offer support to their members in the health sector. These unions work to protect and advance the interests of their members, including offering support in situations involving complaints or disputes within the NHS.

Support from Professional Bodies

Guidance and Advice: Professional bodies, such as medical defence organisations and local medical and dental committees, can provide support and advice during the complaints process. This support is particularly valuable in understanding the intricacies of the process and what steps should be taken to address the complaint effectively.
Separation of Complaints and Disciplinary Action: The NHS complaints process requires a clear separation of complaints from disciplinary action. If a disciplinary investigation begins, any action under the complaints procedure related to that investigation must cease. This separation ensures fairness and objectivity in handling the complaint and any subsequent disciplinary action.

Engaging with the investigation: Documentation, honesty, and cooperation.

In responding to a complaint within the NHS, mental health professionals should approach the process with a focus on documentation, honesty, and cooperation. Here’s a breakdown of these elements:

Documentation: Maintaining thorough and accurate records is crucial. When a complaint is made, the professional involved should meticulously document all relevant interactions and decisions related to the case. This includes notes from patient consultations, decision-making rationales, and any actions taken. Precise documentation not only aids in the investigation process but also serves as a reflective tool for the practitioner.
Honesty: The GMC and NMC emphasise the importance of responding to complaints with honesty, considering the patient’s views, and addressing their concerns. This requirement underlines the ethical duty of professionals to provide a truthful account of events. When errors occur, it’s vital to acknowledge them openly. Being honest in the face of a complaint can help in resolving the issue more effectively and maintain the trust of the patient.
Cooperation: Engaging with the investigation process is a professional responsibility. This involves not only providing necessary information and documentation but also working collaboratively with all parties involved. If a complaint is related to other NHS services or involves multiple care providers, there is an obligation to cooperate across departments or practices.
Confidentiality and Legal Considerations: Investigating a complaint does not negate the need to respect patient confidentiality. It is imperative to ensure that the patient has consented to the complaint process, especially when the complaint is lodged by someone other than the patient. This is particularly relevant in cases where the patient lacks the capacity to make decisions, and a representative is acting on their behalf.
Learning and Improvement: Complaints should be seen as an opportunity for learning and professional development. Reflecting on the complaint to understand what went wrong and how similar situations can be prevented in the future is an important part of professional growth. This reflective practice not only benefits the professional but also improves the quality of patient care.

Learning from complaints: Reflective practice, professional development.

Learning from complaints through reflective practice is a crucial aspect of professional development for mental health nurses. Reflective practice, as described by Linda Finlay, is “learning through and from experience towards gaining new insights of self and practice.” This process is not just retrospective but also predictive, aiding in planning future learning based on past experiences and anticipations. There are different types of reflection:

Reflection-before-action: This involves thinking ahead of time, considering potential challenges and preparations needed for future situations.
Reflection-in-action: This occurs in real-time, evaluating events as they happen and considering immediate reactions or changes required.
Reflection-on-action: This is reflecting after an event, considering what could be done differently in the future.
Reflection-for-action: This involves planning future actions with the intention to improve or change practice.

Reflective practice enhances self-awareness, allowing mental health professionals to understand their values and attitudes better and to evaluate situations more objectively. This not only supports better patient care but also helps in supporting teams and other agencies. By evaluating and developing practice through reflection, professionals prevent stagnation and continue growing in their roles.

Reflective practice is an important skill for mental health nurses, often used in client-centred clinical practice. However, its role in the clinician’s own development is less well appreciated. A study, (please see References below) highlighted how elements of a reflective learning process used by clinically based nurses could enhance their support of students’ learning. It explored the dynamic relationship between experience and reflection, emphasising the importance of individualised, patient-focused care based on effective communication and relationship-building.

Another study identified a conceptual framework of nursing practice based on a relationship-building process. It presented a structure and process of reflection for nursing practice, which helped nurses better understand their work with patients, emphasising the importance of communication and relationship-building in patient care.

Reflective practice is a vital tool for mental health nurses, as well as other clinicians, especially in the context of learning from complaints. It fosters professional growth, self-awareness, and improved patient care. By engaging in reflective practice, mental health professionals can turn complaints into opportunities for learning and development, ultimately enhancing their ability to provide high-quality, patient-centred care.

Section 5: Practical Steps and Best Practices

Immediate actions following a complaint.

The following steps should be undertaken immediately upon receiving a complaint:

Acknowledgment of the Complaint: According to NHS guidelines, a complaint should be acknowledged, and the offer of a discussion about its handling should be made within three working days of receiving it. This discussion should cover the timeline for when a response to the complaint is likely to be sent. The response time varies depending on the nature of the complaint, and if any delay occurs, the complainant should be kept informed.
Confidentiality and Representation: It’s crucial to respect patient confidentiality during the investigation of a complaint. If the complaint is made by someone other than the patient, ensure that they have the authority to do so, and that the patient has consented to this process. For patients who lack the capacity to make decisions, their representative must be deemed appropriate to act on their behalf, and this needs to be verified by the responsible body.
Timeliness and Appropriateness in Response: Responses to complaints must be timely and appropriate. While the NHS regulations don’t set specific timescales for the entire procedure, if a response is not provided within six months (or a later agreed date), the complaints manager must explain the delay to the complainant. It is important to keep the complainant updated on any changes to the proposed timescale.
Saying Sorry When Appropriate: The NHS guidelines emphasise the importance of apologising when appropriate. Patients often seek a thorough investigation, assurance against recurrence, and a sincere expression of regret. Since April 2015, healthcare organizations in England are subject to a statutory duty of candour, which compels them to act in an open and transparent way in dealing with complaints. Apologising is not the same as admitting liability, and there are no legal concerns about issuing an apology.
Separation from Disciplinary Actions: The complaints procedure is designed to address patient complaints and should not be confused with disciplinary actions against healthcare professionals. These two processes should be entirely separate, and disciplinary proceedings are confidential. Complainants are not entitled to know the details or outcomes of any disciplinary actions that may arise from their complaint.

Communication strategies with patients and families.

Effective communication strategies with patients and families during the complaints process in NHS mental health services are essential. These strategies not only address the immediate concerns raised in the complaint but also help in maintaining a therapeutic relationship and trust. The key aspects of these strategies include:

Understanding the Patient as an Individual: Recognising the individuality of each patient is crucial. This involves understanding how their condition affects them and how their circumstances and experiences impact their condition and treatment. It’s important to consider factors like disabilities, language barriers, and social situations. Listening to and respecting the patient’s health beliefs, concerns, and preferences is also vital for effective communication.
Respect for the Patient: All staff involved in NHS services should treat patients with respect, kindness, dignity, compassion, understanding, courtesy, and honesty. Respecting the patient’s right to confidentiality and ensuring their involvement in any discussions about their care is crucial.
Discussing Sensitive Issues: Healthcare professionals should be prepared to discuss sensitive issues in a non-judgemental and sensitive manner. This includes being open to discussing fears or concerns the patient might have and being sensitive to mental health conditions.
Involvement of Family and Carers: Clarify with the patient whether and how they want their family members or carers to be involved in decisions about their care. Ensure that family members and carers are appropriately informed, while being mindful of confidentiality issues.
Encouraging Patient Feedback: Encourage patients to give feedback about their care and respond to any feedback given. Providing information about the complaints procedures and assisting patients in accessing these procedures is also part of effective communication.
Creating a Conducive Environment for Communication: Ensure that the environment is conducive to discussion and respects the patient’s privacy. This includes such things as maintaining appropriate eye contact and addressing the patient as they wish to be addressed. It’s also important to establish the most effective way of communicating with each patient, which might involve using visual aids, different languages, or communication aids.
Avoiding Jargon and Confirming Understanding: Avoid using medical jargon and use words that the patient will understand. Confirming understanding by asking questions is essential to ensure that the patient has grasped the information provided.

Record-Keeping and Documentation Best Practices in NHS Mental Health Services

Record-keeping and documentation are critical components in mental health services, serving as a foundation for quality patient care, communication among healthcare professionals, and legal documentation.

1. Importance and Purpose of Proper Record-Keeping

a. Legal and Communication Tool: Documentation in medical records is a vital legal document detailing a patient’s care. It’s crucial for communicating patient care and serving in legal or regulatory matters.

2. Best Practices in Documentation

a. Complete and Clear Records: Good practice involves maintaining complete and clear records. This includes recording all key decisions or assessments, ensuring legibility and clear identification, and noting patient consent for information sharing.

b. Readiness and Standardisation: Professionals should stay updated with legal requirements and proficient in record-keeping. Standardisation across professions and organisations is essential for efficient patient care.

c. Addressing Gaps: A review identified the need for better confidentiality and disclosure practices, straightforward and accurate communication, and development of personal and professional skills in record-keeping.

3. Structuring and Maintaining Records

a. Structure and Content: Ideally, records should be structured under headings like reason for contact, findings, conclusion, actions to be taken, and parties informed. This structure aids in clarity and comprehensiveness.

b. Legibility and Accountability: Entries should be legible, dated, timed, and signed. The local organisation is responsible for ensuring the quality of training and development for professionals in record-keeping.

4. Practical Tips for Effective Record-Keeping

a. Signing and Identifying Entries: Typed letters and entries should be personally signed, and handwritten entries should have the name written in block capitals for clarity.

b. Timing and Thoroughness: Date and time all entries. Records should be thorough yet concise, reflecting the quality of care provided.

c. Periodic Summaries: It is often helpful to include summaries in long-term patient records, offering an overview of the patient’s progress and treatment over time.

5. The Role of Continuous Improvement

a. Quality Development: Record-keeping and communication should be continually developed under clinical governance. This involves regular reviews and updates to practices as needed.

6. Addressing Challenges and Improving Standards

a. Recognising Importance: Historically, record-keeping has been given low priority, leading to deficiencies. Improving this requires acknowledging its significance in patient care and communication.

b. Integrating Systems: When I started working, there were often separate paper notes and computer records. This has improved in most environments, although does still take place. The lack of coordination between paper and electronic systems highlights the need for integrated solutions that ensure confidentiality and accessibility of patient information.

In conclusion, effective record-keeping in NHS mental health services is not just a regulatory requirement but a cornerstone of quality patient care. It necessitates a comprehensive approach that includes accurate and timely documentation, standardised practices, continuous improvement, and an understanding of the integral role records play in healthcare.

Collaborating with Colleagues and Managers During an Investigation in Mental Health Services

Collaboration among mental health professionals, including nurses, psychiatrists, psychologists, support workers, occupational therapists etc, as well as other healthcare departments and services, is essential in the context of investigations within mental health services. Effective collaboration can lead to better outcomes for service users, improved service delivery, and a more comprehensive understanding of complex cases. The following outlines best practices for collaboration, based on research and practical experiences.

1. Principles of Collaboration

Shared Goals: Collaboration starts with the understanding that all parties are working towards the common goal of the best possible outcome for the service user. This involves a shared commitment to understanding and addressing the service user’s needs and concerns.
Mutual Respect: Effective collaboration requires mutual respect among professionals, valuing each other’s expertise, and acknowledging different perspectives. This is crucial in ensuring that all viewpoints are considered in the investigative process.
Communication: Open and effective communication is the cornerstone of successful collaboration. This includes regular, clear, and honest discussions about the case, challenges, and progress.

2. Collaboration in Practice

Role of Relationships: Building and maintaining strong professional relationships is key. These relationships should be based on trust, flexibility, and a willingness to work together closely and consistently.
Navigating Systems and Bureaucracies: Practitioners often need to manoeuvre through complex systems and bureaucracies. This requires a clear understanding of the roles and responsibilities of different professionals and services, as well as how to navigate these effectively for the benefit of the service user.
Balancing System and Service User Needs: There can be a tension between adhering to system requirements and focusing on the service user’s needs. Practitioners should strive to balance these aspects, prioritising the service user’s needs while also navigating the system effectively.
Flexible and Adaptive Approaches: Given the dynamic nature of mental health investigations, practitioners should adopt flexible and adaptive approaches. This involves being open to changing strategies and plans as new information comes to light or as situations evolve.

3. Collaboration in Case Discussions / Multidisciplinary Meetings / Care Programme Approach Meetings, and Treatment Planning

Case Discussions/MDT/CPA: These opportunities to meet with a range of professionals are used for collaboration, where assessments, reviews, treatment planning, safety and risk issues, and family dynamics are discussed. Efficient use of time is critical, with clinicians typically having only a brief period for discussion.
Key Components:

Tell the Story: Provide a succinct, contextual introduction to the clinical case, covering engagement in services, home and social dynamics, relevant history, mental state examination, and recent events.
Identify Concerns: Clearly articulate present concerns, using direct and incisive statements. This should include specific observations and targeted questions.
Tie Services Together: Conclude discussions by summarising critical feedback, clarifying any loose ends, itemising specific recommendations, and assigning actionable follow-up.

4. Overall Benefits of Collaboration

Enhanced Treatment: A collaborative approach enhances evaluative and ongoing therapeutic feedback, increases adherence to the treatment plan, and helps reduce the risk and frequency of crises. This is especially critical for individuals with severe and persistent mental illnesses.
Holistic Perspective: Collaboration allows for a more holistic perspective on patient care. Different professionals bring unique expertise, and by working together, they can provide a more comprehensive and effective treatment approach.

Section 6: Prevention and Future Strategies

Strategies to Reduce the Likelihood of Complaints in NHS Mental Health Services

1. Promoting Informed Decision-Making and Self-Determination

Empowering Patients: Individuals living with mental health conditions must have the right to make informed decisions about their treatment. This includes understanding all benefits and potential areas of difficulty when creating their personalised care plan.
Comprehensive Information: Ensuring that patients have access to all relevant information is essential for making informed decisions about their mental health.

2. Providing Comprehensive Supports and Services

Beyond Traditional Treatment: Offering a variety of supports and services beyond traditional treatments, such as talking therapies and medications, is critical. This includes peer support services, housing, education, and employment services. This will sometimes require mental health professionals to refer on to other services, or to support patients to access them.
Addressing Specific Needs: Tailoring services to individual needs, such as integrating substance use disorder treatment for those with co-occurring disorders, is key to effective support.

3. Improving Communication and Respect

Effective Communication: Poor communication and lack of empathy are major causes of patient dissatisfaction and complaints. Healthcare professionals must prioritise effective communication not only with patients but also among each other.
Cultural and Language Considerations: Addressing language barriers and cultural differences is crucial in enhancing communication and understanding between healthcare services and patients, especially in a diverse country like the UK.

4. Learning from Complaints

Constructive Approach: Complaints should be viewed as opportunities to learn, reflect, and improve. Understanding the reasons behind complaints can lead to necessary changes and improvements in practice.
Acknowledgment and Apology: Sometimes, all a patient seeks is acknowledgment of failings and assurance that mistakes won’t be repeated. Apologising and managing patients’ expectations can prevent the escalation of issues.

5. System-Wide Changes and Transparency

Transforming Complaint Systems: Implementing a transparent and responsive complaint system can lead to significant improvements. This includes creating peer review panels, training independent advocates, and measuring complainant satisfaction.
Addressing Root Causes: Identifying and addressing the root causes of complaints, such as communication issues or poor clinical responses, can lead to systemic improvements.

6. Challenges in Implementation

Consistent Engagement and Support: Transforming complaint handling and reducing complaints is a broad task that requires consistent engagement and support from a large number of staff across different areas.

Training and Education for NHS Staff on Handling Difficult Situations

The NHS has developed training programs and resources to support staff in this area.

“Handling Difficult Situations with Compassion” Training Program:

Overview: This program, offered by NHS England, is designed for frontline, patient-facing colleagues. It focuses on teaching skills and techniques to handle difficult situations with compassion. This includes using appropriate communication techniques, active listening skills, and keeping oneself well if affected by a challenging situation.
- Content: The training provides education on models of self-awareness, self-compassion, and emotional intelligence. These are vital for maintaining personal and patient wellbeing. It covers various scenarios, such as dealing with challenging or distressed patients, instances of uncivil behaviour, and discussions on difficult topics.
- Benefits: Attendees gain an understanding of compassion, foundation-level communication skills, and practice these skills in a supportive environment. It also offers the opportunity to engage with other NHS colleagues and learn from shared experiences.
- Feedback: Since its inception in 2021, the program has received positive feedback, with a 95% satisfaction rate and a reported 25% increase in confidence in handling difficult situations with compassion among attendees.

E-Learning Module:

Alongside the virtual training program, NHS England has also published an e-learning module. This module is accessible through the Health Education e-Learning for Healthcare website and allows staff to complete the training at their own pace.

Institutional Changes for Better Complaint Management in NHS Mental Health Services

Introduction of New Complaint Standards by the Parliamentary and Health Service Ombudsman (PHSO):

Background: In March 2021, the PHSO published new Complaint Standards for the NHS, a culmination of several years of collaborative work across the NHS and other organisations.
- Objectives: These standards aim to foster an environment where:

Complaints are welcomed and handled well, promoting a just and learning culture.
- Staff are equipped with the necessary skills and experience for effective complaint handling.
- Patients and service users are confident that their concerns are taken seriously and addressed appropriately.
- Staff implicated in complaints are supported throughout the process.

Public Consultation and Development of Guidance Modules:

Process: The PHSO conducted a public consultation, gathering input from NHS complaint handlers, patient advocacy groups, and others. This consultation influenced the development of the Complaint Standards.
- My Expectations: The Complaint Standards are based on ‘My Expectations’, which sets out what patients want to happen when they make a complaint about health or social care services.
- Outcome: As a result, the PHSO developed detailed guidance modules for complaints handlers, simplifying the standards and ensuring ongoing development in collaboration with stakeholders.

Promotion of a Learning Culture and Professional Recognition of Complaint Handling:

Culture Change: The Complaint Standards emphasise treating people fairly, resolving problems promptly, and using complaints as a tool for learning and development.
- Professional Skill Recognition: These standards also mark the first step towards recognising complaint handling as a professional skill, providing clear guidelines for best practices.

Pilot Scheme and Broad Rollout of the Standards:

Pilot Scheme: Later in 2021, the PHSO launched a pilot scheme with various NHS organisations to test the effectiveness of the new standards. This scheme aimed to refine the standards based on real-world experiences.
- Nationwide Implementation: These standards have been implemented across all NHS services, ensuring a consistent and effective approach to complaint handling throughout the health service.

These changes represent a fundamental shift in the NHS’s approach to complaints, moving away from a defensive posture to one that values feedback as a vital component of continuous improvement. By embedding these principles into its institutional fabric, the NHS aims to enhance patient care, increase transparency, and build trust among service users and healthcare professionals.

The Role of Feedback and Continuous Improvement in NHS Mental Health Services

Engagement and Co-Design in Service Improvement:

NHS England’s approach to continuous improvement is heavily reliant on engagement with a wide range of stakeholders, including patients, health and care leaders, and frontline staff. This approach ensures that service improvement is reflective of real-world experiences and needs.
- The delivery and continuous improvement (DCI) review, conducted through integrated care systems (ICSs), emphasises a long-term commitment to quality improvement and employs various assets such as data, evidence, and digital transformation for consistent, high-quality care.

Three Key Actions for Improvement:

NHS England’s Board consolidated the DCI review recommendations into three pivotal actions:

A single, shared NHS improvement approach to enhance productivity and health outcomes.
1. A co-designed leadership for improvement programme, promoting a whole-system focus on healthcare outcomes.
1. Establishment of a national improvement board to focus on shared national priorities and support high-quality, consistent service delivery.

Improvement-Led Delivery:

This concept focuses on a whole-system approach, utilising evidence-based quality improvement methods. It relies on data and measurement to increase productivity and deliver better health outcomes.

Benefits of Improvement-Led Delivery:

In organisations where this approach is embedded, there is increased engagement from both patients and staff in improvement projects, contributing to reduced health inequalities and improved feedback. It keeps the needs of people and communities at the centre.
- For the professional working within services, this approach has led to empowerment, purpose, direction, and improved morale. Staff are equipped with tools and autonomy to drive improvements and are aligned with the organisation’s strategy.

Conclusion: Embracing a Progressive Approach in NHS Mental Health Services

In conclusion, the journey through the landscape of complaints management in NHS mental health services reveals several key takeaways:

Understanding the Landscape: Complaints in mental health services are not just challenges but opportunities for reflection and growth. Recognising common reasons for complaints and their impact on service quality is the first step toward improvement.
Complaints Investigation and Rights: A thorough understanding of the complaints investigation process, alongside the rights and responsibilities of patients and staff, is crucial. It ensures fairness and transparency in handling complaints.
Professional Response to Complaints: Responding to complaints as a mental health professional involves emotional self-management, seeking appropriate support, and engaging actively and honestly in the investigation process. This not only addresses the immediate issue but also aids in professional development.
Practical Steps and Best Practices: Immediate actions, effective communication strategies, and best practices in record-keeping are fundamental. These practices help in managing complaints efficiently and mitigating future occurrences.
Prevention and Future Strategies: Proactive strategies such as staff training, institutional changes, and feedback mechanisms are essential for reducing the likelihood of complaints. They also contribute to continuous service improvement.
The Role of Feedback and Continuous Improvement: Feedback is a powerful tool in shaping services that are responsive to the needs of patients and communities. A commitment to continuous learning and improvement is vital in adapting to changing healthcare landscapes and enhancing the quality of care.

In navigating complaints, a positive approach is essential. It involves viewing complaints not as criticisms but as valuable feedback for growth and improvement. Encouraging a culture of continuous learning and adaptation among NHS mental health professionals will not only improve patient care but also enhance the work environment for staff. By embracing this progressive approach, NHS mental health services can evolve to meet the ever-changing needs of their patients and communities, ultimately leading to a more effective and compassionate NHS.