Policy on Complaints Investigation Policy Page: Page 1 of 12
Author: Assistant Director Legal, Resolution & PALS Version: 1.0
Date of Approval: January 2024 Status: Final
Date of Issue: January 2024 Date of Review January 2026

1. INTRODUCTION
   
   1.1 The North West Ambulance Service Trust (“the Trust”) is committed to providing high standards of care which is centred on its patients and service users. As part of this, the Trust welcomes all
   insights, including complaints and concerns, from its service uses. Complaints and concerns
   provide the Trust with a valuable opportunity to review and reflect on its practices, implement
   changes and continuously improve delivery of care and the experience which our patients, and
   their families, receive.
   
   1.2 It is important that those who raise a complaint or concern to feel that they have been listed to, that we have responded to their concerns and shown empathy and compassion in responding to their complaint.
   
2. PURPOSE
   
   2.1 The Trust aims to resolve complaints and concerns fairly, honestly and in a way which encourages open and meaningful communication. Complaints and concerns will be handled in accordance with the Good Complaint Handling principles from the Parliamentary Health Service Ombudsman.
   
   2.2 The Trust aims to resolve complaints and concerns as quickly and effectively as possible and will
   ensure that routes by which complaints can be raised are easily accessible and well publicised to
   service users irrespective of age, gender, disability, race, sexual orientation, religion/belief.
   
   2.3 This policy sets out the roles and responsibilities of all colleagues in relation to complaints,
   concerns and comments. Implementation of this policy will ensure fair, open, proportionate and
   timely incident and investigation management.
   
   2.4 The Trust will ensure that it complies with current legislation as set out in the Local Authority and
   National Health Service Complaints (England) Regulations 2009 (“the Regulations”) and guidance
   from the NHS Complaints Standards and Health Service Ombudsman (“PHSO”) when dealing with
   complaints.
   
   2.5 Implementation of the policy will ensure: –

• That complaints and concerns will be investigated and responded to in a fair, honest and
  transparent manner identifying contributory factors together with systematic and individual
  learning.
  
• That proportionate and timely investigations are undertaken by colleagues with the necessary
  skills and competence.
  
• Those who raise concerns or complaints are listened to and treated with courtesy, compassion
  and empathy and are not disadvantaged because of having raised a complaint with us.
  
• Complaints are investigated promptly, thoroughly, honestly and openly.
  
• Those who raise complaints are kept informed of progress and the outcome of the investigation
  in a timely manner.
  
• The production of high quality and compassionate complaint responses.
  
• Those colleagues involved in the investigation are supported.
  
• That themes and trends from investigations and outcomes are identified and evaluated.
  
• That learning from complaints informs service development and improvement.
  
• Trust complaint handling complies with the applicable legislation, guidance and best practice.

3. SCOPE

3.1 This policy applies to complaints raised by our patients and service users in relation to the Trust’s
services, all individuals acting on behalf of the Trust including employees, volunteers, contractors,
students, agency staff and those employed on honorary contracts.

3.2 This policy is not designed for staff to raise a complaint against another member of staff except
where a member of staff is making a complaint as, or on behalf of, a patient about services provided
by the Trust.

3.3 This policy is not intended to be used in relation to concerns raised by external organisations, such
as other NHS Trusts. Such concerns are dealt with under the Reporting an Incident to NWAS
process.

3.4 All colleagues are required to follow this policy so that the Trust can ensure compliance, best
practise and legal obligations to demonstrate that:

• Any service user of the Trust, their family, or members of the public are given the opportunity
  to seek advice, raise concerns and/or make a complaint about any of the services it provides.
  
• Any individual who raises a complaint can expect to receive frequent updates and a high quality
  response in a timely manner.
  
• Lessons from complaints are identified and shared throughout the organisation to improve
  standards of care and prevent future harm/poor experience.

3.5 Adherence to the policy will ensure that complaints are investigated and managed in line with: –

• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  
• The Local Authority Social Services and National Health Service Complaints (England)
  Regulations 2009.
  
• The NHS Constitution for England.
  
• The Parliamentary and Health Service NHS Complaint Standards.

Who can make a complaint?

3.6 The Regulations provide that any person can make a complaint to the Trust if they have or are
receiving care and services direct from our organisation. A person may also complain to us if they
are not in direct receipt of our care or service but are affected, or likely to be affected by any action,
in action or decision by our organisation.

3.7 A complaint is defined as an expression of dissatisfaction about care or treatment or Trust services
requiring a considered corporate response in line with the principles of Good Complaints
Management set out by the Parliamentary Health Service Ombudsman. A concern is defined as a
matter where immediate remedial action can be taken for early resolution.

Timescales for making a complaint.

3.8 Under the Regulations, a complaint must be raised no later than 12 months after: –

• The date on which the matter, which is the subject of the complaint, occurred; or
  
• If later the date on which the matter which is the subject of the complaint came to the notice of
  the complainant.

3.9 In the event that a complaint is raised outside of this 12 month period the complaint may still be
accepted and investigated if the Assistant Director Legal, Resolution and PALS (or a nominated
Deputy) is satisfied that:

• There is a good reason for the complaint not having been brought within that time period; and
  
• That it is it is still possible to investigate the complaint effectively and fairly.

Complaints which give rise to Duty of Candor

3.10 This policy ensures that complaints are investigated, managed and responded to in accordance
with the applicable legislation and best practise. Where a complaint identifies that moderate or
severe patient harm has occurred, Duty of Candor will be enacted. This policy should be read in
conjunction with the Duty of Candor procedure for more guidance.

4. ROLES AND RESPONSIBILITIES

Trust Board

4.1 The Trust Board has the overall responsibility to ensure that complaints are taken seriously and
that investigations are conducted to the standards identified in this policy and associated
procedures. It will ensure that complaint handling, particularly the identification of learning is
integrated within governance and risk management processes and systems for improving patient
experience. It monitors and reviews Parliamentary and Health Service Ombudsman investigation,
findings and outcomes.
Chief Executive

4.2 As the Accountable Officer, the Chief Executive is responsible for ensuring compliance with
arrangements made in accordance with The Local Authority Social Services and National Health
Service Complaints (England) Regulations 2009 and in particular, ensuring that action is taken, if
necessary, in light of the outcome of a complaint.

4.3 The Chief Executive Officer, their deputy or a named delegate will review, approve and provide
signatory to all formal complaint responses.

Director of Corporate Affairs

4.4 The Executive Director with the overall responsibility for the Resolution Team and the management
of complaints and concerns raised with the Trust. Through the Assistant Director Legal, Resolution and PALS they will keep the Executive Leadership team and the Trust Board informed of any
significant or high-profile complaints.

Assistant Director Legal, Resolution and PALS

4.5 The senior leader with the overall responsibility for complaints policy development, implementation,
review and for managing the procedures for handling concerns and complaints in accordance with
the Regulations.

4.6 They will ensure that:

A programme of training and education in complaints handling and early resolution is
developed and implemented across the Trust.

Area Directors
4.7 Are responsible for ensuring that complaints within their operational area are investigated. They,
or a nominated representative will be responsible for reviewing and approving investigation
outcome responses.

Resolution and PALS Team
4.8 The Resolution and PALS Team will:

• Ensure that all complaints and concerns are investigated and responded to, in accordance
  with this policy.
• Record all complaint and concern investigations on DCIQ.
• Keep and maintain the DCIQ record in accordance with the current data protection
  legislation and any other information security arrangements applied within the Trust.
• Keep the complainant informed as to the progress of the investigation.
• Provide a high quality response on the outcome of the investigation.
• Where the complaint involves more than one NHS provider, the Resolution and PALS Team
  will liaise with that provider and ensure that, so far as is practicable, a single coordinated
  response is provided to the complainant within an agreed timeframe.
  
  All Trust Managers / Clinical Leads
  4.8 Trust Managers and/or clinical leads, with support from the Resolution Team, are responsible
  for:
• Facilitating the investigation into the complaint.
• Establishing who has been involved and request statements/recollections from those involved
  as required.
• Reviewing patient records to establish facts/review care as required.
• Collate statements and ensure all issues have been responded to.
• Ensure all aspects of the complaint have been addressed.
• Assess the severity of the complaint and whether the circumstances meet the criteria for
• investigation under the Patient Safety Incident Response Framework.
• Ensuring the investigation summary is returned to the Resolution Team within agreed
  timeframes.
• Ensuring all or any detailed actions are completed and that there is evidence of improvement
  as appropriate
• Providing immediate and on-going support to staff involved in a complaint.

All Staff and Volunteers
4.9 All staff, employees, volunteers and third party providers have an obligation to: –

• Cooperate with any request to assist with an investigation.
• Be familiar with the principles of early resolution and what immediate actions can be taken to
  address any concern/complaint raised directly with them.
• Participate in any feedback or review process identified by an investigation into a
  complaint/concern.
• Implement any lessons identified, approved and agreed at the conclusion of an investigation
  into a complaint or concern.

1. IMPLEMENTATION
   This document will be available on the Trust intranet and via the Green Room. It will be available to
   members of the public on request.
2. MONITORING AND REPORTING
   The management of complaints will be monitored via the Quality and Performance Committee.

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