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 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.
- 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.
- Parents concerned about 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 setting up procedure for PCAs has been changed to avoid the specialist nurses being distracted and to prevent errors occurring again.
- 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.
- 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 appointment. Team also looking at extending the time the telephone booking line is open.
- 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 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.
- 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 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 UCC is staffed by GPs and would not usually see cases of vertebral fracture. The pathway and process for doctors in the UCC to order MRI scans is currently being revised.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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 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 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 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.
- 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.