You Said, We Did
When we receive feedback from patients we seek to improve our services and learn from events. This feedback is received in a variety of ways, such as patient responses to surveys, enquiries with our Patient Advice and Liaison Service, formal complaints received or online feedback from Patient Opinion and NHS Choices.
We have given some examples of the feedback we have received and how it has been used to make a change.
You Said, We Did
- Patient unhappy with 3 cancellations of their appointment.
Outcome: Apology offered. Appointment cancelled due to staff sickness. There are only a limited number of nurses able to administer this specialist treatment. Steps are being taken to train additional staff.
- Transgender patient questions why it is necessary to refer to this on a blood request form.
Outcome: The way in which blood request forms are being printed is being reviewed. The Consultant has written a personal apology to the patient.
- Family raise concerns about poor nutrition; lost dentures; lack of pain relief; poor communication regarding discharge; and, lack of specialist review.
Outcome: Discharge process for palliative care reviewed and revised – additional dietitians have been funded so that team can attend daily MDT meetings for patients who are at a high risk of malnutrition.
- Patient questions why appointments in the clinic have been delayed for many months over the last 2 years.
Outcome: Appointments have been delayed by demand for the service. Dedicated bookings team also being set up to improve communication with patients in future.
- Patient unhappy with Consultants “people skills” and was left feeling insulted and unclean. Also unhappy about being referred to another clinic without knowing which clinic it was.
Outcome: team are going to develop a patient information leaflet to pre-warn patients about the sensitive questions that it will be necessary to ask in a clinic of this type.
- Patient upset that the only lift at Cromer Hospital had been broken for 5 days without being fixed, causing appointment to be delayed by an hour as patient could not access department on the first floor.
Outcome: Lift has now been repaired and apologies provided for the inconvenience. Logistical problems with third party supplier led to the delay. NORSE are looking at the cost of keeping a Critical Spares list and stair lift on site.
- Patient has experienced ongoing pain and discomfort following an ultrasound doppler scan of their legs. Also asks why lower limb included area above the knee.
Outcome: Explanation provided about how why it is necessary to apply pressure and squeeze the leg. Appointment letter is being reworded to ensure that patients are clear that lower limb means the entire leg and not just below knee.
- A Blind patient has requested correspondence by email but is not receiving this and believes the Trust is in breach of the Accessible Information Standards.
Outcome: An Oversight Group has been established to undertake a gap analysis and to identify what action needs to be taken in order to be meet the Accessible Information Standards.
- Patient’s cancer appointment was delayed by one week as results were not available in time.
Outcome: Consultant confirms that departmental practice has now changed so that the MDT date is included in the referral, enabling radiology to factor that into their schedule when assigning scan dates in future.
- Patient asks how a mouth guard burnt their mouth.
Outcome: Quality control measures have been introduced into the Laboratory when cleaning mouth guard’s (splints) with disinfectant prior to packaging to avoid this happening again.
- Patient’s usual method of obtaining a repeat prescription broke down, causing confusion and delay.
Outcome: Consultant apologises for the delay prescribing medication. The system has been changed so that specialist nurses can now prescribe this medication in order to avoid delays in future.
- Visitor highlights inappropriate comments and poor communication.
Outcome: The whole team are attending workshops on communication to focus on effective and empathetic everyday communication skills to improve the patient experience for future patients.
- Patient queries how staff failed to diagnose a retinal detachment.
Outcome: Apology offered that relaying of observations to Eye Doctor did not flag up possible retinal detachment. A new pathway is to be discussed at Clinical Governance meetings and then piloted.
- Patient’s Next of Kin is unhappy that infertility information in the chemotherapy leaflet was not clear and this resulted in an unexpected pregnancy.
Outcome: Apologies provided for breakdown in communication. Patient information leaflet has been revised to make this clearer for the benefit of future patients.
- Patient highlights difficulty in leaving messages with department when trying to rearrange their appointment.
Outcome: Offered sincere apologies for the frustration caused when trying to speak with someone in the department. The team are going to arrange for an answerphone facility to be put on the telephone number given on patient clinic letters.
- Due to an administrative error, patient was never registered with EEAST, which is necessary because of their underlying medical condition.
Outcome: Complaint investigation has highlighted problems with the registration system which have been changed. A more robust system is also being developed after liaising with EEAST.
- Patient was sent another patient’s discharge letter in error.
Outcome: Trust’s IT department have discovered two letters were printed “back to back” on one sheet of paper. Printers have been corrected so that letters will be automatically printed separately in future.
- Patient describes a high standard of care but was unhappy with communication regarding appointments as they were unable to ‘get through’ on the contact number provided.
Outcome: As per the patient’s suggestion, the department is creating a dedicated e-mail address for patients to use to make contact if the telephone lines are busy.
- NOK unhappy that a confused patient was able to leave the ward.
Outcome: Ward has established a seven point action plan to raise awareness of existing policies and improve the way the team deal with such patients in future. Security doors to ward have also been checked.
- Patient attended for clinic appointment, but this could not proceed because the appropriate person was not available.
Outcome: Patient needed a particular intervention which is performed by private company, but did not make staff aware of this, therefore no appointment was arranged. The team are reviewing the wording of the template clinic letters so that patients know who to ask to ensure appointments are booked correctly in future.
- Patient unhappy with information provided re: formula milk and perceived delay in diagnosis of RLF.
Outcome: Information leaflet on why babies are not checked for RLF at birth to be uploaded to Trust’s webpage ‘Feeding and caring for your baby’.
- Patient and NOK unhappy with the wait for a dermatology appointment. They want to know why request for urgent appointment was rejected.
Outcome: The team are currently reviewing the referral process and drafting new guidelines for Consultants and GPs.
- Patient queries why MRI scan was not obtained in the Urgent Care Centre (UCC) which would have led to an earlier diagnosis of fractured vertebrae.
Outcome: The pathway and process for doctors in the UCC to order MRI scans has been revised.
- Patient unhappy at being referred back to GP after two appointment dates offered and declined. Also upset that they could not discuss this with department directly as telephone calls not answered.
Outcome: The team are installing a voicemail system in the Clinic to improve communications with patients when lines are engaged.
- Patient unhappy that they were given conflicting advice by specialist nurses as to whether they had melanoma.
Outcome: Apology provided for the breakdown in communication. Nursing staff will change the way handovers between shifts are conducted, so that they are not in front of patient, to avoid potential confusion and anxiety in future.
- Visitor raises concerns about access to hospital for wheelchair users, which is being restricted by the bicycle racks.
Outcome: Site inspection has indicated that bicycle racks are impeding access at both East and West Atrium. Remedial works to be carried out forthwith.
- Patient concerned that antenatal blood tests were not accessible to a midwife in the Community and patient had to chase these up personally.
Outcome: Over £1M investment in enhanced IT has been identified and agreed. This will result in a significant increase in IT capacity for Community Midwives to ensure they can access blood results and other computer systems.
- Confusion over booking requirements to arrange appointment.
Outcome: Department have changed practice and have extended time period for patient to get in touch to arrange appointments. Team also looking at extending the time the telephone booking line is open.
- Care home queries the discharge and care provided to patient with learning disabilities (LD).
Outcome: LD team are working with department to create a bespoke pathway for the care and treatment of future LD patients. The LD team are also providing additional training to department regarding increased awareness and support required for this patient group.
- Complainant feels consent process left them unprepared for the amount of pain experienced, and no instructions were given about follow up.
Outcome: Department is to introduce a patient information leaflet about the cholecystectomy procedure. The radiologists are also looking at whether they can see patients on the ward prior to the procedure to take consent.
- Patient unhappy with the lack of information about procedure after being diagnosed with ovarian cancer.
Outcome: Standard pre-operative leaflets are now being produced in large print.
- The complaint has raised an Information Governance issue regarding patients being able to hear through the defunct adjoining door between the two clinic rooms during consultation.
Outcome: The Governance Lead is looking into ways to sound proof the door.
- Patient was unhappy with catering – no meal ordered and tea is not hot.
Outcome: Apology offered. The hot water boiler on the ward will be checked to ensure it is set at the correct temperature.
- NOK asks for more information to be provided about the nature of AMU.
Outcome: AMU is producing a leaflet for patients/relatives explaining the nature of the Unit.
- Amongst parents concerns about care was that there was a delay in providing patient with pain relief initially and when a PCA was set up, patient was incorrectly given too much morphine.
Outcome: Re lack of pain relief: changes have been made to ward training and induction to improve learning across the team. Re the morphine overdose: the procedure for setting up PCAs has been changed to avoid the specialist nurses being distracted and to prevent errors occurring again.
- Patient dissatisfied at lack of food options available for coeliac patients.
Outcome: Explained that Serco are currently producing new menus, which include a gluten free menu.
- Patient admitted for pre-hydration prior to CT scan and was unhappy with delay in being given a bed.
Outcome: Apology offered for delay. The decision to admit patients for hydration has been reviewed independent to complaint. Patients are now no longer admitted but encouraged to drink orally at home because it is clear that patients feel better prepared when they are in their own environment for longer.
- Next of kin unhappy about attitude of member of staff when telephoning to pass on information about patient’s condition.
Outcome: Administration Manager is drafting a code of conduct for reception team to use in similar situations in future.
- Patient concerned about poor technique when taking blood.
Outcome: HCA has been spoken to and it has been confirmed they know the appropriate technique. However, further retraining provided, together with a period of observation by a nurse to make sure HCA is competent at taking blood correctly.
- Patient unhappy with the level of detail provided by a member of staff when they left a telephone message, asking patient to call back.
Outcome: Apology provided for unnecessary anxiety caused. Staff in the department have been given clear instructions about the level of information to provide when leaving a message in future.
- Carers unhappy that no side room was available as promised.
Outcome: Apologies provided for breakdown in communication. Managers have met and put in place a new process so that nursing staff are informed of patient’s with special requirements in future.
- Patient does not feel that all the risks of the elective procedure were adequately explained to them, particularly the adverse outcome which has left them in considerable pain.
Outcome: Apology and explanation provided. Patient suffered a very rare complication. Department are reviewing the process of obtaining consent and updating the guidance for patients.
- Patient believes communication is poor between departments resulting in patient missing a scan whilst an inpatient.
Outcome: Error occurred because PAS does not distinguish between intended discharge and actual discharge. Department is looking into whether PAS can be amended to show real time status to avoid situation occurring again.
- Parents unhappy that letter sent direct to patient, even though they are a minor.
Outcome: Apologies provided for the distress caused – the electronic system currently does not have the facility to insert “parent or guardian of” and relies on staff to hand write this. The team are currently in discussions with the provider to get the system changed.
- Patient asks why card payment facility on machines was not working.
Outcome: Steps are being taken with the manufacturer to activate card payment facility in machines.
- Patient concerned that a large number of respiratory medicine outpatient appointments have been rescheduled making planned review 9 months late.
Outcome: An amended booking process is being introduced to avoid this happening in future.
- Carer unhappy that certain car park machines are unable to issue receipts, which is necessary to reclaim expenses.
Outcome: Manufacturer has been contacted and the ticket machine software updated to ensure receipts are provided.
- Patient concerned about the system for delivery and installation of home oxygen, which did not arrive as promised.
Outcome: An action plan is being devised for situations when home oxygen therapy is being requested out of hours.
- Patient was subject to a medication error which, they believe, resulted in them having to undergo a further procedure.
Outcome: Error was due to a number of reasons but involved the clinician selecting the wrong dosage on the electronic prescription (EPMA) ‘drop down’ menu. Drop down menu on EPMA has now been changed to show the most common prophylactic doses first, before the larger therapeutic doses.
- Patient concerned that their confidentiality was breached when they were given a diagnosis in front of their daughter.
Outcome: Locum doctor has been made aware of incident and how to deliver similar news in future. Consultant has arranged for teaching sessions in department to raise awareness of how best to “break” bad news.
- Patient unhappy with the facilities available in clinic leading to an embarrassing incident.
Outcome: Signs have been placed in all clinic rooms highlighting availability of bed pans to enable immediate location, so as to avoid situation arising again.
- Complainant raised concerns about their labour in 2014, including inadequate pain relief.
Outcome: Additional training provided to team confirming that epidural top ups can continue throughout labour. Wider learning also shared with the team regarding the appropriate use of the lithotomy position.
- Patient given double the dose of a chemotherapy drug.
Outcome: Processes for prescribing and administering medication changed, as well as revised labelling of medication.
- Patient dissatisfied with care after an IRU procedure. Patient felt they were in hospital longer than required and the arrangements for a friend to collect patient were confusing.
Outcome: Improved information is provided by IRU to patients and wards to aid communication and to speed up discharge arrangements.
- Patient had an undiagnosed breech delivery as manual palpation failed and the handheld scanner ‘safety-net’ was incorrectly used.
Outcome: Training in scanner use has been revised to prevent error in future.
- Complainant raised concerns about confidentiality i.e. that the department they were planning on attending was visible through the window on the envelope of their appointment letter.
Outcome: Apologies provided, together with assurances that department is changing the template of letters to minimise the risk of this happening again.
- Patient queries why they were being charged for two prescription costs.
Outcome: Better signage will be displayed within the department, raising awareness about the Government’s fixed cost prescription charges, so that patients are better informed about the costs to be incurred.
- Patient concerned they have been prescribed and given excessive dosage of steroids.
Outcome: A new clinical ‘pathway’ is being created between departments to ensure there is better communication about changes in a patient’s steroid medication for patients with giant cell arteritis.
- Incorrect echocardiogram filed within patient’s notes (both patients had the same name). As a result, patient underwent unnecessary examination.
Outcome: A revised checklist has been created to prevent this happening in future.
- Patient asked for a patient information leaflet before consenting to Botox injections used to treat migraines.
Outcome: A chronic migraine patient information leaflet is being developed to improve communication with patients.