You said, we did

Mental Health Services

You said: “The staff at the hospital I was transferred to said they did not have access to my medical history.” 
We did: The patient’s medical history had been transferred between hospitals; however, the service recognised it would be useful to have a checklist of information to share when a patient is transferred.  (AMH)

You said: “My daughter was discharged without her parents being consulted.”
We did: The ward round template has been updated to ensure families or carers are invited to ward rounds where they can contribute to the discussion of patient care. (AMH)

You said: “I did not feel the assessing clinicians had considered my son’s needs, including his Autistic traits.”
We did: The team have undertaken SEN (Special Educational Needs) training and they have been supported by a neurodevelopmental specialist on cases involving ASD and mental health. (SSD)

You said: “I emailed the service with an enquiry but received no contact about whether my request had been handled or not.”
We did: The team will acknowledge receipt of enquiries so that people are aware their matter is being progressed.  (SSD)

 

Forensic Services

You said: “There was a lack of activities available on the ward.”
We did: The ward manager agreed to provide a daily planned activity timetable with a coordinator to oversee it. There will also be community projects, such as Christmas decorations, for patients to be involved in. (High Secure)

You said: “I raised concerns directly with the service, but these were not addressed.”
We did: The local procedure for resolving concerns has been reviewed to ensure concerns raised by patients are addressed. (Offender Health)

You said: “There was a delay in my long term segregation plan being approved.”
We did: The team will ensure that all members of the MDT are contacted promptly to reduce delays in the approval process. (High Secure)

You said: “My son was given a triple dose of his medication which made him unwell.”
We did: The investigation noted that prescription checks had failed when issuing medication. This was addressed by the Matron in supervision meetings. (Offender Healthcare)

Mental Health Services

You said: “Staff were not completing observations at night as they were asleep.”
We did: While there was no evidence of this occurring a new process has been introduced where random checks will ensure observations are being completed appropriately.  (AMH)

You said: “There was a missed opportunity for two CAMHS teams to discuss my daughter’s complex formulation when her care was transferred between teams.”
We did: There is a newly established role of CAMHS Complex Case Manager to support the transition of complex young people between teams and with external agencies. (CAMHS)

You said: “There were delays between first and second appointments, and with surgical recommendations, due to pressure on clinicians in the service.”
We did: The service have recruited more clinicians and have changed job plans so that patients see multiple clinicians who are trained to support them at different points in the treatment pathway. (SSD)

You said: “My discharge summary was sent to a previous GP that was still on my records.”
We did: GP information will be checked with patients on admission. This has been added to the admission checklist to ensure that it is completed.  (SSD)

 

Forensic Services

You said: “My welfare checks were not completed while I was in segregation.”
We did: The team have revised their duties to ensure all welfare checks are completed for patients in segregation. This includes checking the appointment ledgers at the end of each day to ensure all appointments were completed. (Offender Health)

You said: “I was not able to eat or drink due to pain in my jaw, but this was not addressed by staff.”
We did: While Healthcare had provided medication in the future they will also liaise with Kitchens about providing a modified diet, such as softer food, to meet patient needs. (Offender Health)

You said: “I had to raise safety concerns as staff were conducting corridor checks alone which could have ended badly.”
We did: Observations will be completed in pairs whenever possible. When not possible staff will request their colleagues monitor them on CCTV during corridor checks, to ensure patient and staff safety. (High Secure)

You said: “I was not allowed a spork due to my risk and there were no spoons available meaning I would have had to eat with my hands.”
We did: There is now an adequate stock of paper spoons for safe use when eating. (High Secure)

Mental Health Services

You said: “My child was inappropriately referred to two specialist services which delayed their access to treatment.”
We did: The LMHT was made aware of the referral criteria for the specialist services so that they are aware of which patients will be accepted by these services.  (AMH)

You said : “The support for my daughter was confused as there were several agencies involved in her care.”
We did: The service manager is liaising with the ICB about having a complex case manager who will co-ordinate the actions of different agencies when there are multiple agencies involved in a patient’s care. (CAMHS)

You said: “An admin error delayed me receiving a letter declining my referral.”
We did: The admin team have streamlined the letter process, including the use of letter templates, to better manage the volume of letters that need to be produced and sent out. (SSD)

You said : “My post-assessment letter was not an accurate reflection of what was documented during the assessment.”
We did: The practice development lead and admin lead have developed a new process for producing letters that are sent to GPs following assessments.  (MHSOP)

 

Forensic Services

You said: “I was erroneously referred to the wrong hospital department due to an admin error.”
We did: Paper referrals have stopped being used and electronic referrals are now in place. Staff have received training on the process to ensure errors are avoided. (Offender Health)

You said: “There were no prescribers available in mornings to sign off prescriptions.”
We did: Healthcare has recruited two new part-time GPs and a substance misuse team prescriber which should improve availability of prescribers. (Offender Health)

You said: “I was not reviewed by Healthcare when I returned to the site from an external hospital.”
We did: Healthcare will have a ledger to monitor patients who are going to hospital and will only remove them from the ledger once the review has been completed. (Offender Health)

You said: “I was allowed to assault a peer because my care plan was not properly followed.”
We did: Where possible regular ward staff will be allocated to patients who present with the most challenging behaviours. (High Secure)

 

Community Health Services

You said : “My child was upset by a visit to the site and refused to return for future care.”
We did: The service arranged a friendly visit to the site so that the patient could experience it without upset and recover from the previous encounter. (CF&SSD)

You said : “There was a significant delay in my child’s appointment due to a lack of available staff.”
We did: The service is recruiting additional speech and language therapists to help with an increased demand. (CF&SSD)

You said: “There was no documentation of my referral that had been rejected by the service.”
We did: The clinical leads have now been given responsibility for documenting outcomes of referrals. (Planned and Proactive Care)

You said: “The ward team did not monitor the changing needs of my mother.”
We did: Lings Bar hospital is undertaking a rapid improvement program with various aspects of care being reviewed and additional training being provided. (Urgent Care)

Mental Health Services

You said: “My son with Autism was not being managed appropriately on the ward.”
We did: A lead psychologist is reviewing the ward environment and a lead practitioner for neurodiversity will be developing a training package on supporting adults with Autism. (AMH)

You said: “When I called the team, I could hear people in the background joking and laughing while my child was in distress.”
We did: New headphones are being used which reduces the amount of background noise that callers can hear. Clinicians will also be moved to a different office space so there is more privacy when handling calls. (SSD)

You said: “I found the way staff spoke to a young person in crisis to be patronising and unsupportive.”
We did: The team are undergoing training on how to manage crisis calls with young people and they are seeking feedback from young people and carers in order to improve the service. (SSD)

You said: “The service did not make reasonable adjustments for my Autism when arranging appointments.”
We did: The service has introduced changes to support patients with Autism, including ensuring appointments are face to face and having a support worker present if needed. (AMH)

 

Forensic Services

You said: “My needs were not being met during night-time confinement.”
We did: The team are installing a co-wall in the patient’s bedroom to support her communication needs and ease her levels of distress. (High Secure)

You said: “The hot water comes out of the tap at boiling temperature.”
We did: The Estates team reduced the temperature of the tap water. (High Secure)

You said: “Information from my CPA was given to another patient for signing.”
We did: All reports are now sent separately after being checked by the ward manager and PA. (High Secure)

You said: “I was discouraged from talking to my peer in a dialect that staff could not understand.”
We did: The relevant Equality Diversity and Inclusion policy is under review as the staff members actions were found to be inappropriate. (High Secure)

Mental Health Services

You said: “My family were not greeted in a friendly or helpful manner by staff on the ward.”
We did: Training has been arranged for staff about body language and verbal communication. More fluid working with relatives and carers is also being promoted. (AMH)

You said : “I did not understand the role of the Crisis team when calling on behalf of my brother so I didn’t realise they would be able to help.”
We did: Staff have been reminded that it is essential to inform carers and service users of the function of the team so that they can make informed decisions. (AMH)

You said: “I have struggled to get through to the service on the telephone when I have queries about my care.”
We did: The service is trialling a new phone triage system to ensure that service users with complex queries can be responded to while people with simple enquiries are directed to the website to free up the line. (SSD)

You said : “I did not have a clear view or understanding of the therapy model offered to me.”
We did: The Step 4 information leaflet has been amended so there is clear written information about the assessment process and the nature of the therapeutic interventions. (AMH)

 

Forensic Services

You said: “The incorrect medication was administered by an agency nurse, but this was not addressed at the time.”
We did: Staff have been made fully aware of the process in place following an error to ensure that Duty of Candour is followed. (Offender Healthcare)

You said: “The pharmacy incorrectly recorded that I had been handed too much medication which meant they would not give me the medication I needed.”
We did: The staff members involved have been spoken to about this issue and are under supervision for medication management compliance. (Offender Healthcare)

You said: “A staff member was bullying me and claimed it was banter.”
We did: The investigation found that the staff member had been targeted by the patient but there was limited documentation to support this. The ward manager raised the case on a relational security day for the teams learning. (High Secure)

You said: “When visiting a patient, the staff member I spoke to had a very cocky attitude.”
We did: The ward manager spoke with all staff about this case and the importance of being aware of their presentation when supervising visits. (High Secure)

Mental Health Services

You said: “Staff claimed they attended my house for an appointment, but I did not hear anyone knock on my door.”
We did: The team will leave patients a note to demonstrate that they have attempted a home visit if the door is not answered. (AMH)

You said: “Inadequate communication between my GP and mental health services led to my declining health.”
We did: There are now mental health workers based in GP surgeries who will support GPs awareness of what to do when a patient is having a mental health crisis.  (AMH)

You said: “I was distressed by the dismissive and uncaring attitude of staff at the inquest following my husband’s suicide.”
We did: A culture review has been undertaken within the team and the findings were discussed so that they can reflect on their attitude and behaviour. (AMH)

You said: “My partner and I struggled to communicate with clinical staff as they were delayed in responding to emails or would not respond at all.”
We did: The team have introduced a new process for admin staff to centrally monitor all email contact and ensure it receives a timely response from the relevant member of the team. (SSD)

 

Forensic Services

You said: “I was not given an opportunity to share my perspective following a restraint.”
We did: The Head of Business Operations confirmed that patients will receive a post-incident review where they can express their views and concerns following a restraint. (High Secure)

You said: “I was asked for my medical information in the waiting area which meant confidential details were overheard by other patients.”
We did: Notices have been placed in the waiting area so patients are aware they can ask to speak in private if they wish. Staff have also undertaken data protection and customer service training. (High Secure)

You said: “I found my restraint to be abusive but there was no available CCTV footage.”
We did: The Security team are working on a project to introduce body worn cameras for staff. (High Secure)

You said: “I had concerns about the staff being unprofessional and not listening to me at times.”
We did: The service have introduced a patient feedback process so that they can monitor the patient experience of their service. (High Secure)

Mental Health Services

You said: “I was not receiving community support from my LMHT or social care.”
We did: The patient was allocated a community support worker for short term support before being referred to social care. (AMH)

You said: “I was not aware of the plans for my care while my regular clinician was off sick.”
We did: Another clinician contacted the patient to inform them they were on the waiting list for SCM and a medication review.  (AMH)

You said: “I felt dismissed and unsupported by staff while I was in crisis.”
We did: Training has been arranged for all Crisis staff about risk and trauma informed care, this will support their contact with distressed patients. (AMH)

You said: “My child’s clinician was not trained in working with patients’ with ASD, so my child struggled to engage with the sessions.”
We did: All staff within the team have completed training to provide them with the skills to engage and work with young people with ASD. (CAMHS)

 

Community Health Services

You said: “There was a delay in my care because the trust website said I could make a self-referral, but this was not the case.”
We did: The website was updated to be clearer about who can self-refer into the service. (Notts North)

You said: “My family did not receive much support from the team following the death of our relative.”
We did: Going forwards all families will get bereavement letters and will be signposted to bereavement services following the death of a patient. (Notts North)

You said: “I did not have clear information on how to have my prescription renewed.”
We did: The patient information leaflet has been updated with better advice on accessing prescriptions. (South Notts)

You said: “I was not made aware that my family member’s referral for a Macmillan Nurse had been declined.”
We did: The triage process has changed so the Macmillan Nurses will contact the family directly when triaging cases to determine if their input is needed.  (Notts South)

 

Forensic Services

You said: “I was not informed that my appointment had been cancelled.”
We did: Healthcare staff will always send appointment cancellation slips, even if the appointment time has already passed. (Offender Health)

You said: “A staff member was discussing my private medical details in front of others.”
We did: The Head of Healthcare reminded the staff member of the standards of conduct required from staff. (Offender Health)

You said: “A staff member stated that they refused to deal with me, which was discrimination.”
We did: Staff have been asked to undertake customer care refresher training to improve their communication in the future. (Offender Health)

You said: "I was confused whether my observations were being completed safely because there was a privacy curtain covering the en-suite bathroom.”
We did: The privacy curtain was removed from the seclusion room en-suite and the observation policy was printed on the door to ensure staff are aware of the appropriate policy. (High Secure)

Mental Health Services

You said: “Information about my care was shared with my family without my consent.”
We did: The peer support worker on the ward meets patients on a weekly basis to confirm who their information can be shared with. (AMH)

You said: “There were no activities to do while on the ward.”
We did: There is a monthly activity schedule displayed on the noticeboard. Patients also have personalised activity plans which they are given a copy of. (AMH)

You said: “My care was not picked up by my LMHT after I was discharged from an NHS bed in a private hospital.”
We did: Continuity of care principles have been introduced to support work between LMHT's and sub-contracted inpatient care. LMHT staff will be invited to MDT meetings and remain updated about a patient’s care. (AMH)

You said: “I thought my mother’s prescription was incorrect as I was not made aware of a change in medication when she was on the ward.”
We did: A new system has been introduced where patients and their families are offered an appointment at each MDT to discuss the patient’s care, including any medication changes.  (MHSOP)

 

Forensic Services

You said: “Having non-regular staff on the ward creates problems as they don’t know the patients or the ward routines.”
We did: Ward staff have created an easy to read guide for non-regular staff to help them understand the ward routines. (High Secure)

You said: “We have not been able to have daily shaves due to staff shortages.”
We did: The Operational Manager will undertake a review of ward routines to ensure that basic needs are being met. (High Secure)

You said: “I was given another patient’s medication by mistake as it was similar to my own prescription.”
We did: Staff will place labels on the outside of medicine boxes as well as the internal pot to prevent future errors occurring. (Offender Health)

You said: “I was not able to attend a meeting to discuss my father’s care because the staff forgot to send me an invitation.”
We did: Medical Secretaries will ensure no family invites are missed and will keep track of who has responded to any invites. (Low Secure)

Mental Health Services

You said : “ The care plan decided by the multi-disciplinary team was not shared with me or my family”.
We did: A medical secretary is now included in each MDT meeting to ensure the agreed actions are taken and that the meeting outcomes are shared with patients and their family. (AMH)

You said : “I did not have a clear understanding of my diagnosis.”
We did: The patient received autism psychoeducation sessions to support their understanding of their diagnosis. (Specialist Services)

You said : “The Crisis team said they would ask the LMHT to contact me, but they never did.”
We did: The Crisis team have agreed to email the LMHT about any out of hours contact straight after speaking with patients.  (AMH)

You said: “The team classed a brief appointment as a medication review just to meet requirements on how often a medication review should occur.”
We did: The investigation found the parent was not aware of what a medication review entailed. A welcome pack has been developed to provide parents with information about different appointments and what to expect from the service. (CAMHS)

 

Community Health Services

You said: “A staff member made a racist comment about my cultural needs being met because my named nurse had the same skin colour as me.”
We did: The staff member was found to have limited racial sensitivity. They have received training around cultural awareness from the Equality Diversity and Inclusivity lead. (High Secure)

You said: “There is a bad culture on the ward and staff have a bad attitude.”
We did : The ward manager completed a Culture Review which was used to update Operational Policy and improve the ward culture. (High Secure)

You said: “My daughter was gaining weight while in hospital which was impacting her mental health.”
We did: The patient was added to the Healthy Lifestyles programme where she is attending swimming lessons and has received information about her diet. (High Secure)

You said: “Staff did not listen to my concerns about my physical health which delayed me receiving treatment.”
We did: The Medical Director is reviewing policy so that a risk assessment will consider the risk of patients in seclusion developing blood clots due to their reduced mobility. (High Secure)

Mental Health Services

You said: “After I reported a theft by a member of staff I was not fully informed of the outcome of the investigation.”
We did: The clinical safeguarding lead is reviewing the PiPOT policy concerning how feedback is provided to patients following an allegation against a member of staff. (AMH)

You said: “I was left without a catheter as the correct size catheter was not available on the ward.”
We did: The ward will ensure that catheter stock is checked weekly so that there is always a supply of catheters available on the ward. (AMH)

You said: “Incorrect wait times were listed on the service’s website”
We did: The service have produced a new public facing website that makes information clearer and easier to update. (Specialist Services)

You said: “I struggled to contact the service through email or over the phone.”
We did: New admin staff will be starting in the service which will improve their ability to communicate with patients and their families. (CAMHS)

 

Community Health Services

You said: “I did not receive written details of a rearranged appointment which meant I missed the appointment.”
We did: All appointments that are verbally arranged will be followed up with an email or text message. (CYPSSD)

You said: “The clinician treating me seemed unsure of what to do as they were a new member of staff.”
We did: The clinician involved was assigned a mentor to support their preceptorship programme. (CYPSSD)

You said: “I was unable to attend the GP to have my dressings changed.”
We did: The district nurses demonstrated how to change dressings to the patient and his wife so they were able to manage this themselves. (Notts South)

You said: “I was provided with the wrong sized continence pads.”
We did: The clinicians undertaking initial assessments have been reminded to trial samples to ensure that patients can tolerate the products chosen. (Notts North)

 

Forensic Services

You said: I was restrained by staff but was unhappy in the way I was managed.
We did: Although the complaint was not upheld, there is a plan in place for this patient to ensure that restrictive practices will only be utilised as a last resort. (Low Secure)

You said: “Excessive force was used during a rub down search.”
We did: The Quality Matron will audit the ward regularly to ensure the quality of rub down searches will improve. (High Secure)

You said: “There was a gap in my medication prescription after my prescriber did not discuss it in the MDT meeting.”
We did: All prescribers have been reminded that medication should continue to be prescribed until the patient’s case can be discussed in MDT.  (Offender Health)

You said: “I was given the wrong medication by a member of staff.”
We did: The staff member concerned has undergone medication error protocol and a managerial supervision focusing on the dispensing of medication.  (High Secure)

Mental Health Services

You said : “I was unlawfully detained on the ward because my Mental Health Act Section was not renewed in time.”
We did: The ward team and MHA office have improved their processes to ensure all necessary paperwork is completed to extend a Section before it expires. (AMH)

You said : “A staff member made an insensitive comment to me while I was in Crisis.”
We did: The service is developing a new training package for staff on how to manage and respond to telephone calls.  (AMH)

You said : “I did not receive updates about my son’s care as he did not consent to this being shared.”
We did: The clinical psychologist is working with the patient and his parents on improving their relationship so that in the future more information about his care can be shared with the parents. (AMH)

You said: “I was left without a CCO due to staff sickness, despite having a CCO being part of my Community Treatment Order”
We did: The service will ensure that all patients on a CTO will receive a new CCO if their assigned staff member is on a long term sickness absence. (AMH)

 

Forensic Services

You said: “I was confused around the use of restraint diversions.”
We did: The Positive and Safe Violence Reduction team leader spoke with the patient about the reason for the use of diversionary techniques, to aid their understanding. (High Secure)

You said: “My T3 was out of date so I could have been issued medication illegally.”
We did: The process was updated to ensure T3’s are updated when a medication change is made.  (High Secure)

You said: “My family felt they were stared at like they were in a zoo when they came to visit me.”
We did: Social workers will make contact with families prior to their visits so that they are aware of the procedures in place to maintain safety during a visit. (Medium Secure)

You said: “I missed a meal because I did not feel able to attend the dining room.”
We did: The patient worked with their named nurse to devise a care plan which supported him to eat in his room.  (High Secure)

Mental Health Services

You said: “I did not receive the outcome from my assessment with the team.”
We did: The team discussed the importance of ensuring patients know the outcome of their assessment and are aware of treatment options. (AMH)

You said : “There was not enough information available when my child was admitted to hospital.”
We did: The team have produced a new admission pack for young people and their families which is more user friendly. (CAMHS)

You said : “I did not know who to approach with concerns while on the ward.”
We did: All wards now have up to date contact details for the matron and service manager for that area. (AMH)

You said: “There was a significant delay in my GP and I receiving a letter following an assessment”
We did: A new electronic system has been introduced that will make producing letters a more automatic process, improving the production speed of these letters. (Specialist Services)

Forensic Services

You said: “I did not receive results of a blood test because an error was made when labelling the blood samples.”
We did: The process was changed so that blood samples go through a three step checking process to ensure accuracy. (Medium Secure)

You said: “An incident report was submitted against me after staff misheard a conversation and thought I was being racist.”
We did: Staff have been informed they should address any concerns with patients directly to ensure the situation is clarified and patients feel comfortable discussing issues. (High Secure)

You said: “Some of my property went missing when I transferred between wards.”
We did: The ward manager ensured the property lists were updated and safely stored, with a copy being provided to the patient. (High Secure)

You said: “I raised multiple concerns and enquiries about the ward and how to access different services.”
We did: The ward manager met with the patient and agreed to raise a number of ongoing issues and concerns in the ward community meeting to get the views of all patients. (High Secure)

Mental Health Services

You said: “I gave my clothes to laundry services at the hospital, but the clothes shrunk after being washed at too high a temperature.”

We did: Infection Control Policy was updated so that patients’ clothes will only be washed at the highest temperature they can manage without being damaged. (AMH)

 

You said: “I was concerned about my husband’s needs following his discharge from the community team.”

We did: The patient was offered an additional outpatient appointment for a review of his needs.  (AMH)

 

You said: “My consultant failed to sign a form for the DVLA allowing me to drive again.”

We did: The form was completed, and the consultant was reminded of the importance of completing administrative tasks in a reasonable timeframe. (AMH)

 

You said: “I was not given the correct medication by the team”

We did: A medic appointment was booked so that the patient’s medication could be reviewed. (AMH)

 

Forensic Services

You said: “The kitchen was told I was diabetic when I did not want this information sharing with them.”

We did: The process was changed so that healthcare only provides information to the kitchen when a patient consents to this being shared. (Offender Healthcare)

 

You said: “A letter from my solicitor was withheld from me and I did not know why.”

We did: Policy was updated to reflect what information could be shared with a patient when their mail is withheld. (High Secure)

 

You said: “I sent multiple appointment requests to see a doctor, but I received no responses.”

We did: A letter was sent to all patients apologising for the delay in responding to appointment requests, due to pressure on staffing. More staff were recruited to improve staffing levels.  (Offender Healthcare)

 

You said: “My urine test was being handled in the medication room which I thought was unhygienic.”

We did: The process was updated so that these tests are carried out in toilet rooms where liquids can be disposed of immediately.  (Medium Secure)

 

Community Health Services

You said: “There was a delay in my child’s referral being completed because the staff member said only the school could complete the form.”

We did: An updated referral form is now in use which makes it clear who can submit the referral. This can be any professional with the best knowledge of the child. (CYPSSD)

 

You said: “There was a delay in me receiving the necessary equipment from the community nurses.”

We did: District Nursing teams have been made aware they need to review outstanding actions when cases are handed over to ensure all recommendations are completed. (Notts South)

 

You said: “I felt patronised by having to ask for medication in hospital when I can manage this by myself at home.”

We did: The hospital have initiated a project to allow patients to self-administer medication where patients have capacity. (Notts South)

 

You said: “A staff member told me to make a sudden change to my baby’s feeding which caused him distress.”

We did: The team were reminded of following a phased approach when suggesting changes to a feeding schedule. (CYPSSD)

Mental Health Services

You said: “I did not receive a telephone appointment and cannot attend the site due to my disability needs.”

We did: The team leader arranged a home assessment for the patient, to account for his needs. (AMH)

 

You said: “I did not receive the outcome following an assessment because a staff member was of work.”

We did: The team introduced more opportunities to discuss assessments with the wider team so that outcomes could be reached and communicated to the patent in good time. (AMH)

 

You said: “A staff member made insensitive comments about my eating disorder.”

We did: Training regarding eating disorders was provided to the team. (AMH)

 

You said: “I was left without support after the LMHT discharged me from the service”

We did: A psychiatrist appointment was booked in to review the patient’s diagnosis and medication to determine if the LMHT can continue to offer support. (AMH)

 

Forensic Services

You said: “Prison Officers opened my medical information and read it aloud in front of others.”

We did: In the future Healthcare will mark patient summaries for hospital use only and place them in a sealed envelope marked with a ‘medical in confidence sticker’. (Offender Healthcare)

 

You said: “I was assured a game I ordered would be added to the approved games list, but it was not.”

We did: A new process is in place to review and monitor the approved games list at regular meetings. (High Secure)

 

You said: “I was unable to arrange a visit with my father because I could not manage to contact him.”

We did: The Social Work manager made contact with the patient’s family on her behalf. (High Secure)

 

You said: “Healthcare were not taking my health concerns seriously.”

We did: The service manager arranged for the patient to have a further review by the GP. (Offender Healthcare)

Mental Health Services

You said: “I needed support with housing and employment, but the LMHT could not provide this service.”
We did: The LMHT made a referral for a Carers Assessment with Social Care to enable the whole family to access the appropriate support. (AMH)

 

You said : “I had a distressing experience with the Crisis team when seeking support for my daughter.”
We did: The Crisis team had emergency 1:1 supervision meetings to urgently improve their standards of care.  (CAMHS)

 

You said: “My CPN did not have the knowledge to help me and did not seek support from senior staff”
We did: The case was shared in the team forum to encourage staff to seek guidance and support when needed. (AMH)

 

You said : “I was restricted to my ward and had no opportunity to practice my faith.”
We did: This feedback was shared with Chaplaincy and ward staff so they can better support patients’ spiritual needs. (AMH)

 

Forensic Services

You said: “I was worried that the ward was unsafe due to low staffing levels.”
We did: An easy read guidance leaflet was produced to reassure patients around staffing, safety and contingency plans in place on the ward. (Low Secure)

 

You said: “Staff cut power to my room which broke my stereo.”
We did: The ward agreed to pay for the stereo to be repaired for the patient. (High Secure)

 

You said: “I was not given lunch because staff said I was late.”

We did: The staff member was spoken to and reminded that patients should not be denied meals.  (High Secure)

 

You said: “I was not informed of IR1s raised against me so I could not contest these or provide my own account of events.”
We did: Staff have been reminded of the correct procedure when logging an IR1, including informing patients.  (High Secure)

Mental Health Services

You said: “The team did not consider my trauma when delivering my care.”
We did: The team received training for Trauma Informed Care to increase their awareness and improve their clinical practise. (AMH)

 

You said: “My consultant did not discuss my suicidal thoughts or provide me with a clear diagnosis.”
We did: The lead consultant has discussed this with the consultant concerned so that they learn to communicate in a clearer and less abstract manner.  (AMH)

 

You said: “My daughters’ needs where not met following the initial assessment conducted by the team”
We did: The service offered Family Therapy to allow the family to work on their family relationships within a safe space. (CAMHS)

 

You said: “My medication was repeatedly delivered late by the team.”
We did: Medication was changed to a monthly prescription and transferred to the GP for dispensing. (AMH)

 

Forensic Services

You said: “I was given another patient’s medication after the pharmacy made a mistake.”
We did: All medication administered to patients now follows a written process involving a three-point check to confirm the correct patient identity. (Offender Health)

 

You said: “Purple visits were not being facilitated for my family overseas.”
We did: Policy was reviewed to improve staff’s ability to resolve any issues with Purple Visits within a reasonable timeframe. (High Secure)

 

You said: “I was nearly given multiple doses of my medication in the same day due to an error in the pharmacy’s prescribing system.”
We did: Formalised guidance has been developed to improve the working practices of pharmacies across our sites. (Offender Health)

 

You said: “Two members of staff had a bad attitude towards me which made me feel uncomfortable.”
We did: Staff attended a mediation session with the patient to help resolve their concerns. (High Secure)

 

Community Health Services

You said: “The staff member conducting my appointment had a very bad attitude.”
We did: The team developed a Team Behaviours Charter to address attitude and behaviours within the team.

 

You said: “It was difficult to contact the service with any concerns I had, and each visit was with different staff members which provided no consistency in care.”
We did: The service produced updated service delivery advice which addressed multiple gaps that had been identified within the service.

 

You said: “After my mother had a fall on the ward the staff moved her without conducting a risk assessment to determine her condition.”
We did: The falls bundle developed a post falls tab that must be completed as part of the work following a fall. This will ensure risk assessments are completed appropriately.

Forensic Services

You said: “My family did not receive booking confirmation for a visit and so the visit did not go ahead.”
We did: The visit booking process has been reviewed. Visits will be confirmed when the booking is made, with further contact only occurring if the visit can no longer go ahead. (Medium Secure)

You said: “I was uncomfortable at seeing another patient in the same building as me when I thought we were on a no mix list.”
We did: The Operational Group have updated the Operational Procedures with guidance on how to manage patients who are not supposed to mix.  (High Secure)

You said: “Staff were observing me while I was naked, and this is against my religious beliefs.”
We did: Policy and procedure has been updated to allow patients greater privacy, subject to individual and dynamic risk assessments. (High Secure)

You said: “The TV in the communal area is damaged which causes other patients to be frustrated and potentially break the TV completely.”
We did: The damaged TVs will be replaced by IT. Spare TVs will also be ordered to ensure replacements are always in stock in case of any further damage.  (High Secure)

 

Mental Health Services

You said: “I did not receive an important letter informing me a referral had been made for my child.”
We did: Team Lead and Admin Lead will monitor administrative processes so they can report on block in flow as well as raising concerns in Quality and Risk meetings. (CAMHS)

You said: “I was in significant distress as staff restrained me in an unsafe manner.”
We did: The staff involved and the nurse in charge of the shift have learnt and reflected from this experience to ensure they follow the principles of safe restraint in the future. (AMH)

You said: “No support or compassion was shown to my wife as my main carer.”
We did: All staff within the team have completed the Carer Awareness and Triangle of Care training in order to improve their understanding of carer needs.  (MHSOP)

You said: “I had booked a visit to see my child on the ward with the reception, but the ward staff were not aware of this visit”
We did: A system is now in place where the administration team communicate all booked visits with the ward, and these are added to the ward diary. (CAMHS)

Forensic Services

You said: “Despite my requests for help staff did not complete a triage assessment to fully assess my mental health.”
We did: The service manager has informed staff that a triage assessment is always needed unless a patient specifically declines one. (Forensic Community)

You said: “I have multiple mental and physical health conditions which are not given equal consideration by my responsible clinician.”
We did: The patient was informed who was responsible for each of his health conditions so that he had a better understanding of how his care was being managed. (Low Secure)

You said: “A staff member made inappropriate and upsetting comments about my family members.”
We did: The ward manager has introduced reflective practises to ensure staff, and patients, consider how they are coming across in the moment. (High Secure)

You said: “Another patient overheard a message left for me by my sister and this patient told me about it rather than a staff member passing on the message.”
We did: This issue has been highlighted in the Divisional Patient Experience and Improvement action log for senior management to review and improve how telephone messages are passed to patients. (High Secure)

 

Mental Health Services

You said: “I was not made aware of the names or job roles of the staff treating me on the ward.”
We did: The staff board on the ward has been updated with photos, names and designations. Staff have also been reminded to introduce themselves to patients and wear ID badges when on the ward. (AMH)

You said: “Following an appointment the clinician did not submit a referral for me as they said they would.”
We did: A process has been introduced whereby clinicians will have to tick off each action as completed for a patient following an appointment before the case is signed off. (AMH)

You said: “A safeguarding referral was made that was distressing and affected my relationship with my daughter.”
We did: The operational lead arranged a training session for the whole team on when to make a MASH referral and when it would be more appropriate to make a referral to the Early Help Unit. (CAMHS)

You said: “I experienced an excessive wait time to be seen by the service”
We did: More staff have been recruited and waiting times were targeted with the result that wait times are now down to two weeks. (Specialist Services)

Forensic Services

You said: “Healthcare staff just handed me an unprofessional and unhelpful note rather than communicating with me.”
We did: The modern matron has reminded staff that there are proper procedures and formats in which communication and information is relayed between healthcare staff and patients. (Offender Healthcare)

You said: “There was no care plan in place for my epilepsy.”
We did: The clinical matron developed a care plan for epilepsy and referred the patient into the multi pathway for weekly monitoring and communication between all pathways. (Offender Healthcare)

You said: “The therapeutic relationship broke down between me and staff following an incident.”
We did: A mediation meeting was arranged in order to resolve the issues between staff and the patient. (High Secure)

You said: “I was worried about my safety and the risk of self-harm during the night.”
We did: The modern matron introduced a nurse call button in the patient’s room so that he can seek assistance when needed. (High Secure)

 

Mental Health Services

You said: “My daughter was discharged alone from A&E while still unstable following a Crisis incident”.
We did: This incident was discussed at the Clinical Leads Group Supervision to ensure discharge arrangements are discussed with medical staff. (AMH)

You said: “Crisis staff did not modify their communication approach to manage my ASD needs.”
We did: Training has been undertaken to increase the CRHT staff ability to communicate with patients and to ensure they can modify their approach based on a patient’s needs. (AMH)

You said: “The service where not providing me with information regarding my son’s care.”
We did: A response letter was sent to the parent which provided a full summary and disclosure of services as well as outlining the care provided to the patient so far. (CAMHS)

You said: “I felt a possible diagnosis of EUPD had been ignored by the consultant psychiatrist I saw”
We did: The lead consultant arranged for an appointment with another consultant psychiatrist in order to have a diagnosis of EUPD explored. (AMH)

 

Community Health Services

You said: “My child was given a flu vaccine at school that I had not consented to.”
We did: The service have liaised with the developers of the online consent system to make changes that will make it clearer to staff which vaccine has been consented to and should be administered to children.

You said: “The team did not contact me to provide an update or request a medical history after my mother had a fall in her care home.”
We did: The standard operating procedure was updated to ensure the team speak to family members even if the patient lives in a care home.

You said: “My relative did not have a nephrostomy flushing because the team where not able to provide this service”
We did: A Task and Finish group was established to standardise care of nephrostomies. New guidance was developed for the care of a nephrostomy tube for patients in the community.

Forensic Services

You said: “I did not receive reimbursement for property that was damaged five months ago.”
We did: The modern matron looked into this reimbursement request and ensured that it was action appropriately. (High Secure)

You said: “The ward do not recognise what aspects of my presentation are due to being deaf.”
We did: Deaf awareness training was arranged for staff and the ward manager will liaise with deaf services to ensure ongoing support is provided when working with deaf patients. (High Secure)

You said: “I felt that other patients and staff were targeting me and behaving in a threatening way after I transferred to the ward.”
We did: Staff were asked to support the patient as they settled into the new ward. There was also a staff meeting to discuss the best ways to make the patient feel safe and comfortable. (Medium Secure)

You said: “When I was transferred between wards my property went missing and staff did nothing about it.”
We did: Staff were reminded of the importance of following ward procedure as it is set out in the policy documents. (High Secure)

 

Mental Health Services

You said: “I was not updated when my daughter suffered cardiac arrest on your ward and was admitted to A&E”.
We did: Carer Peer Support Workers have now been employed on wards to improve communication between staff and the family/carers of patients. (AMH)

You said : “I did not receive numerous letters and documents from the service, including appointment letters and a crisis plan.”
We did: The team have now ensured that all the required paperwork has been sent to the patient to ensure they have full access to this information. (AMH)

You said: “I was not satisfied with the consultant who had been assessing me and wanted a second opinion”
We did: The lead consultant arranged for an appointment with another consultant psychiatrist in order to have a second opinion formulated. (AMH)

You said : “My family feels left without support while we have an 18 month wait for Small Steps.”
We did: A home visit assessment was arranged with two clinicians to determine what support could be provided while the patient and their family is on the waiting list.  (CAMHS)

Forensic Services

You said: “I did not receive a dose of my medication because it was not delivered to me.”
We did: The patient will now be issued with medication for 28 days at a time and the pharmacy have set up an automated reminder to ensure he does not miss future medication. (Offender Health)

You said: “I felt that being given a small sip of water was not enough to swallow medications.”
We did : All Healthcare staff agreed that in the future patients should be allowed to drink a full cup of water before oral medication is checked. (Offender Health)

You said: “There was a mix up when serving Halal gravy on my meal.”
We did: Food items will be clearly labelled in the future to avoid further incident with Halal meals. (Medium Secure)

You said: “I was given the incorrect medication by accident and feel there should be two qualified nurses checking medication.”
We did: The ward manager and team leaders are embedding all qualified staff members on the ward with the correct process for administering medication. (High Secure)

 

Mental Health Services

You said: “My structured named nurse sessions were not happening regularly on the ward”.
We did: Senior staff were re-deployed on the ward to help manage staff shortages and improve the quality of care. Named nurse sessions continue to be audited to ensure they are occurring regularly. (AMH)

You said : “I was not receiving any treatment from the service.”
We did: The patient was added to the waiting list for trauma focused work. (AMH)

You said: “My child’s ASD needs were not being met and we needed additional support to cope with their ASD.”
We did: The service appointed an ASD nurse specialist to provide support in these cases and in addition other staff have undertaken ASD training. (CAMHS)

You said : “My prescription was late in being sent to the pharmacy.”
We did: There is now a process in place to ensure prescriptions are sent out early to account for any delays in postage.  (Specialist Services)

 

Forensic Services

You said: “My mail was opened by staff and sent to another department for storage.”
We did: A procedure was introduced stating patient letters should not be opened under any circumstances. If there are security concerns about the contents, then post will be opened by patients in front of staff. (Medium Secure)

You said: “Some of my items were not returned after being sent to the laundry”.
We did: Staff were informed of how to properly document and record clothing items when they are sent to the laundry to ensure all items are returned to the correct owner. (High Secure)

You said: “I was not notified that a visit from my son had been booked which meant I didn’t have any preparation time.”
We did: The Head of Social Care implemented a new system for notifying patients about onsite visits. (High Secure)

You said: “The doctor incorrectly re-wrote my medication.”
We did : It was agreed that qualified nursing staff would be responsible for checking medication charts are correct. Deputy Matrons will hold regular audits to ensure this is being completed. (High Secure)

 

Mental Health Services

You said: “Staff let me leave the ward without completing a risk assessment and did not realise when I was absent without leave”.
We did: The staff member monitoring patient leave is now responsible for ensuring a risk assessment is completed and that a planned time of return is recorded before a patient leaves the ward. (AMH)

You said : “I was not allocated a new care coordinator after staff sickness.”
We did: More staff have been recruited and agency staff have also been used to cover any gaps in staffing.  (CAMHS)

You said: “I had not been paid a compensation claim for missing items more than one year after raising the issue”
We did: The service manager discussed the issue with the complainant and provided compensation in full for the missing items. (MHSOP)

You said : “My father’s CPN went on leave without notifying anyone so we did not know to check up on him.”
We did: The team have been reminded of the importance of informing patients and carers of any absence and the care provision that will be in place. The team will also improve planning support internally to ensure staff absence is covered. (AMH)

Forensic Services

You said: “Due to staff shortages I have not been able to get out of segregation on a regular basis.”
We did: An email was sent to all staff advising them that an IR1 must be completed when segregation cannot be relaxed due to staffing shortages. The ward is also putting a traffic light system in place, to keep patients informed. (High Secure)

You said: “I am concerned with how the hospital communicate with families”.
We did: A paper was submitted to Rampton Operational Group and Security Committee looking at how to improve communication with families about patients' unplanned admissions to hospital. The family volunteer and support manager is also working with carers about issues such as communication between the wards and carers. (High Secure)

You said: “Staff member was using their phone whilst I was being escorted.”
We did: It was agreed that staff should not use personal mobile phones when escorting patients. The local leave procedure (FW/W/10) was amended. (Medium Secure)

You said: “Therapeutic involvement workers have been included in ward staff numbers, which means activities are interrupted when they are called off to do other duties.”
We did: Deputy Matron shared concerns about the impact on activities with the ward manager, for this to be discussed in the next community meeting. (High Secure)

 

Mental Health Services

You said: “The service did not action my referral causing a delay in an assessment”.
We did: Service manager apologised for the systems and processes not being effective. It was confirmed that these have been reviewed and amended to ensure this does not happen again. (MHSOP)

You said: “I was not involved in discussing my medication on discharge.”
We did: It was communicated in a meeting that staff should ensure patients have a clear understanding of the medication they are discharged with and reason for it.  (Adult Mental Health)

You said: “My Care plan was not being reviewed every 7 days as name nurse sessions were not occurring.”
We did: Various actions are in place to monitor and improve the reviewing of care plans, through audits, management supervision and team discussions. Staff are also accessing training. For learning this will also to be discussed in the Quality Forum, and will be included in the care plan training delivered by the MHSOP Training for Quality Practitioner (MHSOP)

You said: “The crisis plan was not followed when I was distressed and my CPN was not informed the following day”
We did: An email was sent to all county south CRHT clinicians reminding them that all out-of-hours contact forms should be scanned and emailed to the relevant care team the next working day. (Adult Mental Health Services)

Forensic Services

You said: “Staff ignored my request to get my property back.”
We did: The team were reminded to input sufficiently detailed descriptions of patients’ property into the database, so that property disputes can be investigated. (High Secure)

You said: “I was given an outdated box of medication”.
We did: The procedure OH-P-002 was promoted and discussed with staff. (Offender Health)

You said: “I was not seen by healthcare staff on return from A&E.”
We did: Officers have been advised that patients need to be seen by healthcare on their return from hospital to ensure follow up treatments and appointments are not missed. (Offender Health)

You said: “I experienced a delay in receiving my medication.”
We did: The head of healthcare said that staff would endeavour to update patients if there was going to be a delay. (Offender Health)

 

Mental Health Services

You said: “There were difficulties obtaining an assessment and suitable worker so that my daughter's care and support could move forward”.
We did: The service now has a new process in place so all young people are contacted if their allocated clinician is off long-term to enable safety and risk planning. (CAMHS)

You said: “My letter was opened and read by someone it wasn't addressed to and has since been lost.”
We did: Admin staff were asked to take more care when reading envelopes. (Corporate service)

You said: “I feel discriminated against because of my disability - autistic spectrum disorder. “
We did: The autism awareness training has recently been updated and we hope it will be possible to make the new version available to staff. At that point, the training will be promoted throughout the trust and all health professionals will be encouraged to complete it. (Adult Mental Health Services)

You said: “The crisis team did not answer the phone during a crisis.”
We did: Staff were asked in a team meeting to help the shift lead take calls if they could, and to explain to patients the reason for any delays when calling them back. (Adult Mental Health Services)

Forensic Services

You said: “No one responded to my emergency call bell.”
We did: The alarm/nurse call system was checked and configured correctly. (High Secure)

You said: “My applications for treatment were ignored”.
We did: All appointment requests are now triaged by an advanced nurse practitioner to make sure patients get to see the appropriate clinician. (Offender Health)

You said: “A staff member’s comment was inconsiderate and unprofessional.”
We did: Staff were reminded that although comments might be intended as light-hearted and without malice, they might not always be taken that way by a patient. (Offender Health)

You said: “I am not receiving my mail.”
We did: It was agreed that the Security Department would update patients if there were any problems with their mail. (Medium Secure)

 

Mental Health Services

You said: “My husband was discharged without all his property.”
We did: Staff were reminded to complete updated property sheets both on admission and discharge. (Mental Health Services for Older People)

You said: “I attempted to access the crisis house but was not admitted, despite my care plan allowing me stay in the crisis house four times a year.”
We did: Staff were not aware of inclusion and exclusion criteria and were not following the correct referral pathway.  These details were shared with staff prior to a discussion in a team meeting. (Local Mental Health Team)

You said: “I didn't receive my appointment summary until 2 months after my appointment.”
We did: The process for passing information from consultants to secretaries was addressed. Additionally, staff have now been recruited.  This means that such delays will be much less likely in the future. (Local Mental Health Team)

You said: “My letter was sent to an old address.”
We did: Staff were encouraged to regularly check and update family, carer and nearest relative details to prevent it happening again. (Adult Mental Health Services)

You said: “I was given another patient's medications.”
We did: The team reviewed processes to prevent this kind of error happening in future.” (Offender Health)

You said: “There was a lack of communication from the ward about our son’s progress and discharge planning.”
We did: The matron reissued the ‘carers and confidentiality’ leaflet to staff and discussed the issue in team meetings. (In-patient Adult Mental Health)

You said: “I was refused paracetamol for an injury”
We did: Staff were advised to be more lenient about supplying paracetamol and ibuprofen, given the restrictions on purchases in the prison canteen, and where a patient has suffered an injury, to give them pain relief until a prescription can be obtained. (Offender Health)

You said: “There was a lack of communication, openness and willingness to help in relation to our father's stay on the ward.”
We did: This was acknowledged. With patients’ consent, consultants are now using MS Teams in multidisciplinary team meetings to liaise with families. (Mental Health Services for Older People.