The Francis Inquiry recommended that NHS Trusts should publish information about upheld complaints on their websites. We are committed to sharing information to improve learning and will publish upheld complaints every quarter on our website.
▶ Upheld Complaints - January, February, and March 2026
| A patient reported a prolonged wait for medication in a same-day emergency care setting following a previously requested prescription. Concerns were also raised regarding inaccurate discharge information and incorrect medication formulation. |
| Staff have been instructed on the importance of ensuring discharge documentation is accurate, complete, and reflective of the patient’s clinical needs. The case is being used as a learning example to highlight how documentation errors can impact patient safety and cause distress. The team has also reflected on the importance of assessing individual medication requirements at the point of discharge and ensuring that patients receive appropriate formulations based on their needs. |
| A patient reported concerns regarding delayed treatment for thyroid eye disease, with symptoms including visual disturbance, swelling, pain, and systemic effects. |
| Additional clinical capacity is being provided through recruitment of more medical staff to support service demand and improve patient access to care. |
| A patient and their accompanying person reported that a clinician behaved in a rude manner during an episode of care. |
| Senior nursing and medical leadership met with the patient and their partner to provide an apology. The concerns were also discussed with the clinician involved for reflection and learning. |
| A patient experienced pain during a procedure, followed by an adverse reaction to medication and distressing symptoms. |
| Staff have been instructed to ensure that discussions about treatment options and pain management should take place in a private setting wherever possible. They have also been asked to use clear, compassionate communication and to continuously assess pain levels before and during procedures, responding promptly if a patient reports discomfort. |
| A patient reported delays in accessing specialist review for a musculoskeletal condition, which resulted in private treatment being sought. |
| A digital triage and referral tracking system has been introduced to improve visibility of referrals and reduce delays in future care pathways. |
| A patient reported that a hospital appointment was cancelled at short notice after a prolonged wait. The patient also described significant caring responsibilities that made rescheduling particularly difficult. |
| An alert has been added to the patient record to identify their role as a carer so that future appointments and communications can take this into account. |
| Concerns were raised regarding the manner in which a clinician communicated with a distressed child and family during sedation-related discussions. |
| Clinicians involved in sedation pathways have been instructed to provide clear, realistic explanations to patients and families, and to ensure that all discussions are fully documented. Compliance will be monitored through audit over a defined period. |
| A patient reported a complication following an ear procedure and requested further review and follow-up. |
| A reflective discussion has taken place for the member of staff involved. Specialist review has been requested, and services are working to expedite the provision of follow up. |
| A patient reported significant pain during a minor procedure, feeling that their concerns were not adequately addressed, and that communication was dismissive. |
| Staff have been directed to pause procedures when a patient expresses distress, to regularly check comfort levels, and to ensure clear explanations are provided throughout care. Patients must be supported with appropriate reassurance and offered immediate apology if distress occurs. |
| A patient experienced delays in treatment for an infection and reported that both emergency and urgent care settings did not initiate timely treatment. |
| The case has been shared across emergency and urgent care teams as a learning opportunity to improve documentation, escalation, and timely initiation of treatment. |
| A patient reported a prolonged delay in follow-up for a serious condition, with deterioration identified at a later appointment. |
| A backlog recovery programme has been implemented, including prioritisation based on clinical urgency and increased clinic capacity. Administrative processes and patient contact systems are also under review to improve access and responsiveness. |
| A patient reported being incorrectly removed from a cancer pathway despite ongoing clinical risk indicators. |
| A consultant reviewed the case, provided an apology, and ensured the patient was reinstated onto the correct clinical pathway. |
| A patient with a severe infection experienced delays in emergency assessment and imaging, followed by further deterioration requiring surgery and subsequent readmission after a serious medical event at home. Concerns were raised regarding potential risks associated with prolonged waiting. |
| The case and feedback have been shared with emergency care teams for reflection and learning. Emphasis has been placed on early escalation to specialist services for time-critical conditions and on reducing delays in assessment and treatment. The case will also be reviewed at a departmental learning forum to support service improvement. |
| A patient received correspondence addressed incorrectly. |
| An apology was issued, and the matter was investigated as a data governance incident. Patient contact details were confirmed and corrected where required. |
| Concerns were raised regarding communication with family members following a patient’s death and issues relating to clarity of information provided. |
| The ward team reviewed communication practices to ensure roles and responsibilities are clearly explained to families. Improvements are being considered to ensure that messaging consistently reflects ongoing care and support for all patients. |
| A patient reported delayed communication of imaging findings, which were later identified as malignant, resulting in delayed treatment and significant emotional and physical impact. |
| The case was reviewed by senior clinical leadership. Processes for communication of significant imaging findings have been reinforced to ensure timely escalation and notification to both patients and referring clinicians. |
| A family reported receiving incorrect information regarding a patient’s condition, along with concerns about information sharing without appropriate consent. |
| The clinician involved reflected on the error with senior supervision. Learning has been identified regarding accurate identification of patients and appropriate communication protocols with families. |
| A patient with additional needs experienced repeated cancellations and reported inappropriate staff behaviour during an appointment disruption. |
| Reasonable adjustments have been formally documented within the patient’s record to ensure future appointments take their needs into account. |
| Concerns were raised regarding lack of timely assessment, communication and emotional support following pregnancy loss. |
| Services are working to expand early pregnancy assessment capacity, including out-of-hours provision. Governance processes have been updated, and learning has been shared across relevant clinical teams. Improvements are being made to ensure more compassionate, timely, and co-ordinated care. |
| A patient reported repeated cancellations and poor communication regarding clinic scheduling, including having to attend without being seen due to capacity issues. |
| The issue was escalated to senior management, and the appointment was rescheduled. The pattern of cancellations is under review to improve scheduling reliability and communication with patients. |
| A patient reported incorrect information displayed on an online patient portal. |
| An apology was provided, and assurance was given that medical records have been reviewed and corrected where necessary. |
| A patient requested reimbursement for travel-related costs incurred during preparation for a procedure. | |
| An apology was provided for the inconvenience experienced. |
▶ Upheld Complaints - October, November, and December 2025
| A patient raised concerns about delayed diagnosis and treatment of sudden hearing loss, believing this resulted in reduced recovery and permanent hearing impairment. |
| The patient received apologies for the impact the delays experienced, and the clinicians involved reviewed the case with senior supervisors to support reflective learning. Key areas for improvement have been identified and addressed across the Emergency Department and clinical teams are strengthening the early recognition of acute hearing loss, including ensuring comprehensive neurological examinations are undertaken and that a broad range of potential diagnoses is considered. There is an increased focus on timely escalation for urgent specialist input and with clearer expectations in place to ensure prompt referral. Clear communication with patients regarding diagnosis, treatment and medication was reinforced. The case for discussed at a departmental learning forum. |
| A patient reported delayed treatment during a medical emergency and felt that staff communication and attitudes were dismissive. Concerns were also raised regarding lack of seating in the waiting area. |
| Escalation processes within the Emergency Department have been strengthened to support more timely assessment of patients. A review of waiting area arrangements, including seating availability, is underway with a view to increasing seating. Staff have been reminded to prioritise patient comfort during busy periods. Patient flow is reviewed daily through safety meetings and monitored through ongoing service improvement work. |
| Concerns were raised regarding delays in follow-up communication and difficulties coordinating care with family members due to cognitive impairment. Difficulties were also reported in obtaining prescribed medication. |
| The concerns were reviewed with the relevant clinical team to support learning. The patient’s records were updated to ensure that a nominated contact is included for future communication to support safe and appropriate involvement of family members. |
| Concerns were raised about delays in treatment, communication gaps and delays in discharge documentation. |
| A formal review process for discharge documentation has been introduced to improve accuracy and timeliness before finalisation. |
| A patient with communication difficulties reported that their needs were not adequately recognised during care. |
| Staff were reminded to review all available communication support documentation and care plans. An electronic flagging system is being developed to highlight patients with additional communication needs. Compliance is being monitored through regular clinical oversight. The case was shared for departmental learning, and staff were instructed on the expected communication standards. |
| A patient attended at the incorrect time due to inaccurate information provided. |
| Staff have been instructed to verify appointment details directly from scheduling systems before providing information to patients. |
| Concerns were raised regarding delays and confusion around diagnostic imaging requirements and associated care planning. |
| Staff have been instructed to ensure appropriate signposting to specialist teams. Communication systems have been reviewed to improve clarity for callers. Imaging requests are now reviewed collaboratively between relevant specialties to ensure safe planning. Processes have been strengthened to ensure timely notification of cancellations. |
| A patient received correspondence containing personal details relating to another individual. |
| Staff reviewed the correct patient identification procedures to consolidate their knowledge and learning. Processes for verifying patient details have been reinforced to reduce the risk of manual errors and improve data accuracy. |
| Concerns were raised regarding aspects of inpatient care for a patient with significant mobility limitations, including skin integrity and therapy support. |
| Training on prevention and management of pressure damage has been revisited with staff. Therapy services have introduced improvement initiatives for patients with reduced mobility. Leadership and oversight within therapy services have been strengthened, and staff training programmes have been expanded to support consistent standards of care. |
| A patient reported concerns regarding staff attitude, communication and wound assessment. |
| Staff have been reminded to provide regular updates regarding waiting times and patient care progression. Documentation audits have been introduced to ensure appropriate clinical recording. Patient flow and operational performance are monitored through daily governance processes. |
| A patient missed an outpatient appointment due to traffic issues on the hospital site. |
| An apology was provided and the appointment was rearranged. |
| A patient reported distress due to the way serious medical information was communicated. |
| An apology was provided. Staff were instructed to ensure patients are supported during difficult conversations and offered the option of involving a family member or supporter. |
| Concerns were raised regarding staff attitude and concerns that appropriate consent was not clearly obtained. |
| Feedback was provided to the clinician through senior clinical leadership to support reflective practice and improvement. |
| A patient experienced delays following referral to a specialist service. |
| Service improvements have been introduced to reduce waiting times and improve follow-up pathways, including patient-led follow-up options. |
| Concerns were raised regarding delays in the handling of complaint and safety investigations. |
| Apologies were issued and improvements have been made to internal processes to ensure more timely handling of complaints and safety reviews. |
| Concerns were raised about long waits, hydration and nutrition provision, communication, and dignity during care. |
| Staff have been reminded of expectations regarding dignity, empathy and trauma-informed care. Regular patient checks and communication updates have been reinforced. Hydration and nutrition provision processes have been strengthened. Standards relating to patient placement and care environment have been enhanced and are subject to ongoing monitoring. |
| A patient raised concerns regarding surgical outcomes and subsequent care. |
| An apology was provided and the experience was acknowledged, including recognition that further treatment led to improvement. |
| A patient experienced cancellation of a planned procedure due to unavailable equipment. |
| Booking systems have been updated to ensure equipment requirements are checked in advance of scheduling procedures. |
| Concerns were raised that a significant finding may not have been identified on a previous scan. |
| A process has been introduced for secondary review of selected imaging studies to support quality assurance and reduce the risk of missed findings. |
| Concerns were raised about delays in receiving test results and inaccuracies in medical records. |
| Processes have been strengthened to improve timely communication of results. Staff have been directed to verify clinical histories carefully to ensure accuracy in documentation. |
| Concerns were raised regarding communication standards at reception. |
| Clear expectations have been set for staff to provide clear, compassionate and patient-centred communication. Behaviour is being monitored through feedback and observational review. |
| Concerns were raised regarding patient handling, communication and consent during clinical procedures. |
| Staff have received refresher training on safe handling, communication, and documentation standards. Pain assessment practices have been reinforced, and Clinical oversight has been enhanced to through audit and supervision. Reflective practice has been initiated for involved staff. |
| Concerns were raised regarding anaesthetic care during a surgical procedure. |
| A supervised learning plan has been implemented for the clinician involved, with focus on communication, technical skills, and safe practice. |
| A patient experienced a delayed diagnosis which subsequently required emergency surgical intervention. |
| The case has been reviewed for learning and shared within clinical teaching sessions. Diagnostic pathways have been reviewed to strengthen safety-netting and decision-making processes. |
| A patient raised concerns regarding clinical processes and requested clarification on follow-up testing and documentation. |
| Staff received additional training on consent documentation. Audits have been introduced to monitor compliance. Communication processes have been strengthened to ensure patients are appropriately informed about involvement of other healthcare providers. |
| Concerns were raised regarding delays in receiving diagnostic results and communication within women’s health services. |
| Senior teams reviewed communication pathways between relevant specialties. Coordination processes have been strengthened to improve clarity of management plans and reduce delays. Additional checks have been introduced to improve oversight of result reporting and patient communication. |
▶ Upheld Complaints - July, August, and September 2025
| A patient raised concern that a nurse was allocated to them during a procedure despite a formal agreement that they would not be involved in their care. |
| The Trust sincerely apologised for this oversight, acknowledged the distress it caused, and ensured the patient’s preferences were shared with the whole team. Reassurance was given that alternative arrangements will be made for any future procedures. |
| A patient reported that they received inconsistent support during consultations and follow up appointments. |
| The Trust apologised for the experience and reassured the patient that consistent support will be provided, with another nurse or support worker available to assist during future clinics. |
| A patient expressed concern about repeated delays in appointments and diagnosis, alongside distress caused by rude comments from a member of staff. |
| The clinical team has carefully reflected on this feedback and recognises the impact on the patient. Staff have been reminded of the importance of checking documentation and appointments thoroughly. Timely recording, prescribing, pain assessment and compassionate communication with families have been reinforced. Bespoke training on pain management has been delivered, and the team is actively working to foster a more respectful and supportive environment. |
| A relative raised concern about treatment on a ward involving the use of sedatives, delayed care and risks to patients. |
| Refresher training has been delivered to support staff in providing timely prescribing and regular observations, with escalation protocols reinforced to ensure patients are cared for safely and promptly. |
| A patient was distressed following an incident in a changing area impacting their dignity. |
| A heartfelt apology has been given and refresher training has been introduced to help prevent similar incidents. Staff have been instructed to knock, wait for verbal confirmation and confirm identity. Patient information will be clarified to support dignity and reassurance. |
| A patient reported severe delays in receiving an eye clinic appointment. |
| A questionnaire system has been introduced to review patients on the waiting list and identify anyone needing more urgent appointments. Additional consultants have helped to increase capacity, and a prioritisation tool has been introduced, supported by a Clinical Optometrist managing lower risk cases. |
| A patient raised concern that their shoulder dislocation was missed in the Emergency Department, leading to significant delay in treatment. |
| Clinicians now complete a secondary assessment for all trauma patients, and imaging will be personally reviewed to reduce the risk of similar experiences. Clear and timely updates will be provided to patients, with learning incorporated into departmental training. Discharge planning and communication have been strengthened to better support patients. |
| A patient experienced booking errors, which led to delays and unnecessary travel. |
| Booking systems and correspondence have been improved collaboratively to reduce future inconvenience. A process for prompt acknowledgement of complaints has been introduced, and progress will be monitored through audits and patient feedback. |
| A relative reported poor communication and delays during a patient’s discharge. |
| The Trust apologised for the experience and reassured the patient’s family that medication reviews will be completed promptly, referrals and mobility needs will be clearly documented, and weekly spot checks carried out to ensure care plans are accurate. Significant changes in a patient’s condition will be promptly shared with families in a timely and supportive manner. |
| A patient reported unprofessional behaviour during a consultation. |
| The feedback has been shared with the member of staff to support reflection and improvement. |
| A patient complained about waiting over an hour without assistance at their appointment. |
| The Trust offered a sincere apology and arranged a meeting between the patient, senior staff, and the consultant to listen to the patient's concerns and improve the service. |
| A patient reported complications following an inguinal hernia repair. |
| The Trust apologised for the distress caused and arranged further corrective surgery to support the patient’s recovery. |
| A patient raised concern about long waits, poor nursing care and inadequate pain relief. |
| Staff have been instructed to actively check whether pain medication is effective. Additional skills training has been delivered with follow up assessment and falls prevention training has taken place to enhance patient safety and comfort. |
| A family representing a patient with dementia expressed concern about hygiene, infection control and lack of meaningful activity. |
| Environmental checks have taken place, and cleaning responsibilities have been clarified for all staff. Infection control updates have been shared, and escalation posters have been displayed. Activity tools have been introduced, delirium training has been delivered, and risk assessments have been reviewed, alongside improved communication with families. |
| A patient reported that blood results were not transferred between sites and documentation was delayed. |
| Procedures have been improved to support continuity of care, daily communication with families has been introduced, and further staff training on timely and accurate documentation has been delivered. |
| A patient raised concern about delays, poor attitude and insufficient pain relief. |
| Feedback has been shared with the nursing team in a supportive manner. Pain management options and escalation routes have been reinforced to ensure patients feel heard and are comfortable. |
| A patient experienced a delayed operation which extended recovery and caused financial impact. |
| Strengthened clinic cancellation procedures are now in place, and appointment booking is monitored more closely. Call bell responses have been established, and a welcome pack is being developed to help patients feel informed and supported. |
| A patient experienced missing information in clinic letters and delays in MRI results. |
| Feedback has been shared for learning, an apology provided, and a consultant appointment arranged. Processes for communication and reporting incidental findings have been improved, and nurses now monitor attendance and waiting times to better support patients. |
| A relative reported inappropriate access to patient records and an incorrect record for another patient. |
| Staff training has been revisited to protect confidentiality, verification procedures have been strengthened, and monitoring has been put in place. Senior leaders have carried out a full investigation in line with policy to ensure trust and safety are upheld. |
| A relative expressed concern about poor end of life care for a patient who subsequently died. |
| A meeting has taken place with the family, a sincere apology has been offered, and learning from the incident has been shared to support compassionate improvements in care. |
| A patient reported that a fracture was initially missed and information was not communicated clearly. |
| Written information is now provided to all fracture clinic patients, and staff have been reminded to explain procedures clearly and allow time for questions and reassurance. |
| A relative raised concern that delirium was not managed well. |
| Training on patient passports and delirium has been delivered to support better recognition and care. Pain assessments are now recorded consistently, families will be directed to helpful information, and documentation training has been reinforced. |
| A parent reported a lack of compassion towards an unwell baby and mother. |
| Staff have been instructed on the importance of gaining informed consent before giving medication, and parents will be fully involved in care planning and kept informed throughout their child’s care. |
| A patient reported a delay in receiving a postnatal Anti D injection beyond the recommended period. |
| The cross-checking system has been carefully reviewed with the screening team to ensure that learning is applied and recurrence is prevented. An enhanced process is now in place and regularly monitored. |
▶ Upheld Complaints - April, May, and June 2025
| A relative raised concerns about end-of-life care provided to a patient, including lack of monitoring, the decision to transfer the patient between wards late at night. They also said it took too long to recognise that their mother had an infection and to start antibiotics. |
| As a result of this complaint the Trust has apologised that the nursing team from the discharging ward did not inform relatives at the time of the transfer or early the following morning. The matron has discussed this matter with the ward team and will do further work on internal communication that transferring a patient late at night is never taken lightly. The matron also recognised there was poor documentation, which meant no details from the handover were written in the records, and will address this with the team. |
| A relative raised concerns about the attitude and competence of radiology staff during a cannula insertion, stating that the patient experienced severe pain following several failed attempts and that the member of staff did not seek help. |
| As a result of this complaint the Trust asked the radiographer to provide a formal reflection on how they can improve their practice, including better communication and seeking help earlier, which will be reviewed by their line manager. Concerns were also discussed with the superintendent radiographer for CT scans. |
| A relative told us that an elderly patient with full mental capacity and continence was told to pass urine in a continence pad when she asked for help to use the toilet. Patient remained in a wet pad overnight causing skin irritation. The patient also said a nurse on the ward was abrupt, refused to let her use her coat when she was cold, but that she received kind and compassionate care during her Emergency Department admission. |
| As a result of this complaint the Trust reminded staff of the importance of ensuring call bells are within reach at all times and this is documented in the notes. This practice will be discussed at the Divisional Chief Nurse meeting to ensure all ward managers embed and monitor good practice in the use of pads. Feedback about temperature and compassion has been shared with nursing staff to encourage reflection and improvement. The Trust has also arranged for posters to be displayed in the area highlighting contact details for matrons so that patients and relatives can raise concerns directly. |
| A patient told us that their ectopic pregnancy and fallopian tube rupture was not identified at their first Emergency Department visit and they were discharged, only for the ectopic pregnancy to be identified when they returned later. |
| As a result of this complaint the Trust has reminded triage nurses of the importance of reassessing patient pain, particularly during long waits. Biweekly audits of nursing documentation will be introduced to ensure pain assessments are consistently recorded and acted upon. The Trust will also review its Patient Group Directives to ensure nurses can supply or administer appropriate pain relief in a timely manner. Feedback will be shared with the ward team to support learning and improve communication. |
| A patient told us that they were questioned on the ward in a manner that lacked sensitivity and privacy, staff lacked empathy and understanding when concerns were raised, they felt staff treated them differently, and they were told they would be discharged in the morning but did not leave until the afternoon. |
| As a result of this complaint the Trust has advised nursing teams to ensure patients are informed that discharge will only take place once all necessary administration is completed. Patients will now be informed of likely discharge times in correlation with completion of the discharge checklist. The anaesthetist involved has reflected on their practice and will change their approach in the future. |
| A relative raised concerns about the ReSPECT status recorded on a discharge summary, believing there was a misunderstanding as the patient wanted resuscitation rather than a do-not-resuscitate decision. |
| As a result of this complaint the Director of Medical Education and the Divisional Chief Nurse discussed the case with the doctor involved to raise awareness and support learning. |
| A relative raised concerns about a patient’s diabetes management, saying the patient was given unsuitable food such as cakes and biscuits, did not believe the patient was medically fit for discharge, and raised concerns about insulin being included in discharge medicines despite needing a District Nurse to administer it. |
| As a result of this complaint the therapy manager spoke directly with the patient’s relative, apologised, and explained that during acute admissions the focus is on recovery and that factors such as infection and medications can affect blood sugar. Insulin management is prioritised to avoid restricting diet. The therapy manager suggested early input from the diabetes team during future admissions and highlighted the availability of ‘heart healthy’ menu options to support better choices. |
| A patient told us they had concerns about their birth experience, including prolonged rupture of membranes, lack of access to records for informed decision-making, dismissive staff attitude, delays in treatment, poor communication, substandard care, and lack of transparency and support. |
| As a result of this complaint the Trust will share learning with the wider team, particularly the need to recognise the urgency of starting oxytocin after rupture of membranes, and the importance of clear communication at all times. |
| A patient told us they had a poor experience with a consultant. |
| As a result of this complaint the Trust has reviewed the number of patients attending clinic to ensure workloads are manageable and reduce pressure on clinicians. The consultant involved has been asked to be mindful of comments made about colleagues. |
| A patient told us they found a clinician rude and condescending during an outpatient clinic appointment. |
| As a result of this complaint the consultant has committed to incorporating the learning from the patient’s feedback into their practice to avoid a recurrence. |
| A relative was unhappy with the ReSPECT plan, feeling that required communication was not achieved. |
| As a result of this complaint the Trust has provided feedback to the doctors involved and included the ReSPECT process on the departmental governance agenda. A palliative care consultant will give a talk to juniors and consultants to reiterate vital points. |
| A patient told us they were concerned about the assessment of foot issues in the Urgent Treatment Centre in June 2024. Four days later they attended the Emergency Department, were admitted, and transferred to another hospital for emergency surgery. |
| As a result of this complaint the General and Specialist Medicine, Vascular and Trauma & Orthopaedics teams, with Trust support, have developed a new diabetic foot pathway to improve diagnosis, management and follow-up. |
| A patient told us they experienced long delays in receiving blood test results. |
| As a result of this complaint the Cardiology administration team has introduced a new system with consultants’ personal assistants to monitor and chase outstanding test reports. |
| A patient told us that a patient’s elective hysterectomy was cancelled at short notice due to funding issues. |
| As a result of this complaint the Women’s Health team will discuss the case at its multidisciplinary learning meeting to remind clinicians to clarify funding as early as possible inpatient pathways. |
| A patient told us they were distressed by policies in place at Ashford Day Surgery Unit, such as no partners being allowed, and by the attitude of a doctor during surgical management of miscarriage. |
| As a result of this complaint the Trust has provided personal feedback to the registrar and consultant involved. The locum consultant has left the Trust and the registrar will also be leaving. A feedback and learning session has been arranged for staff to reflect on the patient’s experience. |
| A patient told us they received an incorrect diagnosis which later resulted in major surgery, and felt they were pushed to discharge despite feeling very unwell. |
| As a result of this complaint the Emergency Department team have reiterated the importance of proper, accurate and concise discharge summaries with clear instructions to GPs. Updated discharge summaries will be sent to the GP. Staff have been reminded not to copy and paste notes, to record all red flag symptoms and safety-netting advice, and to provide accurate notes. A digital solution with QR codes for discharge information is being developed. An addendum has been added to the notes to reflect the patient’s concerns and an amended discharge summary sent to the GP. The Trust has reminded clinicians of the significance of rising lactate levels in abdominal pain and updated guidelines accordingly. The case has been shared at the ED Quality and Safety Huddle and teaching sessions, and the Acute Abdomen pathway is under review. |
| A relative told us that their relative was rushed to A&E due to high pressure in their eyes. Despite the urgency of the condition, they were not seen by a specialist with fears that patient was at risk of becoming blind. |
| As a result of this complaint the Trust has introduced Red, Amber, Green ratings for follow-up patients to prioritise urgent cases. Safety-netting letters are now sent to overdue patients, with a new statement added advising patients to contact the hospital if their condition changes. All patients who call about overdue appointments or changes in condition are clinically reviewed by the Consultant of the Day, and the review is documented. |
| A patient told us that when his relative called the Orthopaedic department reception to check on the progress of a clinic letter, the administration staff member she spoke to was very rude and aggressive. |
| As a result of this complaint the Service Manager listened to the call recording, was disappointed by the staff member’s behaviour, and has addressed it with the staff member who has apologised. The matter is being managed through Human Resources procedures, and team meetings will reinforce the importance of professional telephone etiquette. |
| A patient told us that they wanted a full review of their case, including scan results and lack of follow-up since August 2024. They also asked for clarification on why their case was not escalated despite worsening symptoms, and whether their place on the gynaecology waitlist could be reconsidered. |
| As a result of this complaint the Trust confirmed no referral to Gynaecology had been received until the Emergency Department attendance. The Trust apologised for the misunderstanding and explained that the doctor in ED assumed the patient was already under care. Following a records review, a consultant gynaecologist confirmed the patient will now be offered an appointment without requiring a GP referral. |
▶ Upheld Complaints - January, February, and March 2025
| A complainant called the dermatology department multiple times but never received a call back from a doctor to answer their questions despite being told they would. |
| The Trust apologised for the complainant’s experience and the misunderstanding that led to a breakdown in communication. The patient went on to have a follow-up appointment. |
| A complaint was received from a patient stating that their appointment was in person even though they had called to change it to a telephone appointment. The patient called again to correct this, and the staff member had no record of their call. |
| The Trust apologised for the patient’s experience and the miscommunication and confusion it caused. A member of the administration team mistakenly did not read the ‘slot comment’ added to the appointment on the patient’s record to state that the appointment had been changed to telephone from face-to-face. The Service Manager provided training for the administration team to avoid recurrence of this error. The Trust was pleased to hear that the appointment eventually transpired to be by telephone but was very sorry about the initial confusion. |
| A Patient contacted the Trust concerned about not receiving the results of MRI scan results. |
| The Trust apologised for the delay and the distress this caused and have since appointed a dedicated musculoskeletal radiologist which will improve reporting times and communication of results. |
| An elderly patient had in skin irritation and was concerned they had not been supported adequately to use the toilet facilities. The patient also experienced feeling cold whilst on the ward and poor attitude from a nurse. |
| The Trust apologised for this lapse in care and dignity and took action to ensure matron contact posters are visible for patients/relatives to raise concerns in real time, and shared feedback directly with staff to support reflection and reinforce the importance of call bell access for patients and appropriate toileting care. |
| A patient’s ectopic pregnancy was not identified on their first ED attendance, and they later required emergency care. |
| The Trust deeply regretted the delay in diagnosis and apologised for the distressed caused. The Trust also reviewed its patients group directives to ensure patients had ongoing assessment of pain and access to timely pain relief. |
| A patient did not receive promised call-backs and received incorrect information about an appointment format. |
| The Trust apologised for the confusion and lack of follow-up. Administrative processes were reviewed to strengthen documentation and ensure appointment checks are confirmed accurately. |
| A patient felt that staff showed a lack of sensitivity, privacy, and empathy, and experienced poor discharge communication. |
| The Trust apologised for the distress caused and feedback to anaesthetic and nursing staff to reflect on their practice and reinforce the importance of maintaining privacy in shared bays. The Trust discharge quality improvement continues to focus on strengthening communication of discharge arrangements with our patients. |
| Concerns raised over inappropriate food given to a diabetic patient with dementia. |
| The Trust apologised for the oversight. Staff have been reminded of the patient’s specific dietary needs, and clear signage is now in place at ward level and included in shift handovers. |
| A child’s mother was concerned about a consultant’s communication and behaviour. |
| The consultant offered a sincere apology for their behaviour and its impact. The division is monitoring clinic pressures while reminding consultants to maintain respectful with clear communication. |
| A patient described a receptionist as unpleasant and unhelpful. |
| The staff member received additional training and a reminder of professional standards. Customer service training has also been delivered across the team. |
| A patient experienced long delays receiving blood test results. |
| A new system has been introduced to ensure oversight of outstanding test results and to prevent delays in communication. |
| An elective operation was cancelled at short notice. |
| The Trust apologised for the impact the short notice cancellation had and rebooked the patient’s surgery. The Trust continues to review our scheduling processes to minimise short-notice cancellations. |
| A patient was distressed by policy restrictions (e.g. no partners) and insensitive behaviour. |
| Feedback was shared with the clinical team. The locum consultant has now left the Trust. A staff learning session was held to reflect on and improve patient experience. |
| A patient received an incorrect diagnosis, underwent major surgery, and felt discharged too early. |
| The Trust apologised for the patient’s poor experience. Wide-ranging actions include Revisions to the Acute Abdomen pathway including enhanced escalation protocols, additional teaching sessions for clinical staff. Updates to discharge documentation. Introduction of a new digital QR code system to support discharge information and red flag symptom advice. |
▶ Upheld Complaints - October, November, and December 2024
| A complainant went to the Emergency Department (ED) and felt their concerns were dismissed. They were discharged in the middle of the night while having multiple health conditions and a broken shoulder. |
| The Trust apologised for the dismissal during the discharge process and acknowledged that the experience in the Emergency Department (ED) did not meet expectations. This is not the standard of care the Trust aims to deliver. The Trust takes patient feedback seriously and strives to provide compassionate, thorough care. The Trust acknowledged the lack of an appropriate referral to the Home First team and reinforced with the ED team the importance of ensuring that patients with new fractures feel confident in their ability to manage at home before discharge. The Trust is developing new leaflets to explain different types of fractures, provide advice for caring for these injuries, and offer contact information for further advice. |
| A complaint was received from a patient who was last seen by a physiotherapist in January 2023, and a further appointment was requested but never scheduled. |
| The Trust apologised for this error and has implemented further safety netting in the clinical office to ensure this does not happen again. All follow-up appointments are now scheduled as requested, with an additional process to capture any missed follow-up appointments. |
| A complaint was received from a patient who had an appointment at the end of October 2024 and had yet to receive any correspondence following the appointment when they wrote to the Trust at the end of December 2024. |
| The Trust acknowledged and apologised for the delay, which was due to the organisation moving to a new letter dictating system at the time of the patient’s appointment. The doctor was not familiar with the system, causing the delay in dictating the letter. Further training was provided. |
| A complaint was received from a patient who was seen in the Emergency Department (ED). They asked the nurse several times when they would have their bladder scan and waited to be told there was no available scanner. |
| The Trust apologised for this experience and the impact it had on the patient due to the lack of necessary equipment. The nurse made several attempts to locate another scanner near the ED, but this was not properly communicated to the patient. The Trust is focused on improving the timeliness of both primary and secondary care assessments and is pleased that the patient eventually had the necessary bladder scan. |
| A complaint was received from a patient asking why it takes until midday to complete the ward round. |
| The Trust apologised for the patient’s experience and that it did not meet their expectations. The Trust hoped that once the patient was seen, they felt their time with the team was not rushed or cut short. The Consultant of the Week on duty that day noted that staff shortages slowed down the speed of the ward round. The Trust monitors staffing levels to ensure they are optimised wherever possible and uses contingencies. The Team apologised to the complainant for the delay. |
| A complaint was received from a patient raising concerns about the manner in which a urology nurse communicated with them. |
| The Trust apologised for the complainant’s experience. The complaint was shared with the nurse concerned, who apologised and has reflected on the incident. |
