Assurance, Management of Service User Feedback

A key component of the NCGLT is to ensure that the Policy and its management processes are fully complied with throughout the organisation.

Evaluations will be conducted to assess where the Policy is working well and where improvements may need to be made.  This involves examining feedback, statistics, trends and policies and asking staff, former Complainants and other Service Users what they think about the system.

Evaluating the feedback management system involves:

  • Asking people who have used the complaints system what they thought of the process and the outcomes;
  • Asking Service Users what they know about the feedback process and what they expect;
  • Using statistical information to check timelines, the number and types of complaints that have been made and how this has changed over time;
  • Reviewing the outcomes of individual complaints including a review of recommendations made;
  • Using feedback data to determine the learning that has occurred, how this learning has been shared, the changes that have been implemented and how these changes have been monitored; and
  • Comparing service level complaints system against external standards, and where possible, with services of similar size and nature.

The Management of Service User Feedback for Comments Compliments and Complaints Policy

The National Complaints Governance & Learning Team will audit and revise both this Policy and the accompanying Guidance Manual on a three year basis.  The review of these documents will include feedback from key stakeholders, healthcare staff and Service Users.

Learning to Get Better: Recommendations

This investigation by the Office of the Ombudsman in 2015, looked at how the HSE handles complaints across their services.  In particular, it looked at how well the HSE listens to the feedback and whether the HSE is learning from this to improve the services provided.

While recognising a visible commitment to complaints processes throughout the HSE, the Ombudsman noted that the ability to deliver on this commitment continues to remain a challenge in many incidences.  Frameworks for complaint handling are not enough on their own to ensure that there is an appropriate consideration of an outcome to a complaint.  Systems must be designed and implemented to address the needs of both the Complainant and the service at every stage – from making it easy to make a complaint in the first place to implementing any learning that has arisen as a result.  In view of this and arising from his investigation the Ombudsman made the following 36 recommendations, divided into;


  1. Multiple methods of making a complaint should be available and easily understood, both during and after treatment. These should include comment boxes within hospital wards (if not already in place). A fully accessible online version of Your Service Your Say should be developed to allow Complainants to make a complaint online.
  2. The HSE should undertake a review of Your Service Your Say with a view to making sure that Service Users have greater clarity, guidance and information on how the complaints system works.
  3. A standard approach should be adopted by all hospitals in relation to the information available to the public when viewing their website, particularly those hospitals availing of the HSE website – hospital details on this site should all contain the same information and the same links for ease of reference.
  4. Complaints Officers should be provided with appropriate and accessible facilities within each hospital to meet Complainants.
  5. Independent advocacy services should be sufficiently supported and signposted within each hospital so patients and their families know where to get support if they want to raise a concern or issue.
  6. Each hospital should actively develop and encourage volunteer advocates with the hospital who can help support patients who wish to express a concern or make a complaint.
  7. A no “wrong door” policy should be developed so that wherever a complaint is raised, it is the system and not the Complainant that is responsible for routing it to the appropriate place to get it resolved.
  8. Regulators and the Ombudsman should work more closely together to co-ordinate access for patients to the complaints system. In this regard, the online platform should be extended to provide a better publicised point of information and access for Complainants.
  9. Each hospital group should develop a process to allow for the consideration of anonymous complaints.
  10. Each hospital should appoint an Access Officer (as statutorily required under the Disability Act 2005) who should attend all necessary training as provided by the HSE.
  11. A detailed complaints policy statement should be displayed in public areas within all hospitals, on the hospital website, and in, or near, the Complaints Officer’s office. Induction and other training for staff should include a reference to the policy. Staff should also be periodically reminded of the provisions of the policy.
  12. Each hospital that has not yet done so, should include a reference to this Office:
    • In any letter or correspondence notifying the patient/family of the outcome of the complaint to the hospital;
    • On websites, booklets and information leaflets where the hospital refers to their complaints system;
    • Verbally if explaining how to make a complaint to a patient or their family.


  1. The HSE should introduce a standard approach to implementing Your Service Your Say across the public health service. This should include standard forms, standard guidance for patients and staff, standard categorisation of complaints and standard reporting to give certainty to Complainants and to allow for comparison on complaint handling, subjects and outcomes between hospitals and hospital groups.
  2. Addressing concerns at ward level should be a main focus for each hospital. All hospital staff should be provided with the appropriate training to allow them to deal with issues as they arise.
  3. Consideration should be given on a wider front to amending the statutory complaints process (and the remit of the Ombudsman) to allow for the inclusion of clinical judgement as a subject about which a complaint can be made.
  4. Each hospital group should have a Complaints Officer to take overall responsibility for the complaints process and co-ordinate the work of complaints staff in each hospital in the group.
  5. A standardised process and template for recording and documenting complaints at ward level should be embedded via a standardised system across the hospital groups.
  6. A standardised structure and template for collecting and documenting a complaint should be developed across the hospital groups outlining the nature of the complaint, preferred method of communication and desired outcomes.
  7. A standardised information system for the recording of complaints, comments and compliments should be developed across the hospital groups.
  8. Each hospital group should implement mandatory training on complaints handling for all Complaints Officers and other staff involved in the complaints process.
  9. Each hospital group should provide an induction module for all new hospital staff on the hospital complaints process and its underlying statutory framework.
  10. Each hospital group should implement a bi-monthly audit of the complaints dealt with within the group in order to assess the quality of the process, including the response.
  11. Each hospital group should develop a facility to allow for independent (i.e. outside the HSE) investigation of complaints where the complaint received is of sufficient seriousness and where appropriate.
  12. The HSE and the hospital groups should take steps to ensure that all complaints are thoroughly, properly and objectively investigated and comprehensively responded to.
  13. Each hospital group should develop an Open Disclosure training programme in line with the HSE National Guidelines and make it available to all staff.
  14. The Department of Health should undertake a full review of the Health Act 2004 (Complaints) Regulations 2006. This Office looks forward to working with the Department in this regard.


  1. The outcome of any investigation of a complaint together with details of any proposed changes to be made to hospital practices and procedures arising from the investigation should be conveyed in writing to the Complainant with each issue in the complaint responded to.
  2. Each hospital group should develop a standardised policy on redress.


  1. Each hospital group should redevelop standardised reporting on complaints with greater attention paid to the narrative contained within complaints data so that senior management can identify recurring themes / issues and take action where appropriate.
  2. Each hospital group should provide a six monthly report to the HSE on the operation of the complaints system detailing the numbers received, issues giving rise to complaints, the steps taken to resolve them and the outcomes.
  3. The HSE should publish an annual commentary on these six monthly reports alongside detailed statistical data (using the reports published in the United Kingdom by the HSCIC as a model)
  4. Each hospital group should appoint a senior member of staff to assume an active and visible leadership role in the complaints process with key involvement in education, training and reporting arrangements.
  5. Senior managers in each hospital should foster and encourage positive attitudes towards complaints to ensure that each hospital is open to feedback and is responsive to complaints.


  1. Each hospital group should develop a standardised learning implementation plan arising from any recommendations from a complaint which should set out the action required, the person(s) responsible for implementing the action and the timescale required.
  2. Each hospital group should put in place arrangements (both within and across the hospital groups) for sharing good practice on complaint handling. This should include a formal network of Complaints Officers to ensure that learning and best practice is shared throughout the public hospital sector.
  3. Each hospital group should publicise (via the development of a casebook) complaints received and dealt with within that hospital group. This casebook should contain brief summaries of the complaint received and how it was concluded/resolved (including examples of resulting service improvements) and should be made available to all medical, nursing and administrative staff as well as senior management. This could usefully form part of a larger digest incorporating all information on adverse incidents whether arising from complaints, whistle blowing or litigation to ensure that there is a comprehensive approach to learning from mistakes.

The HSE is committed to reporting on a bi-annual basis, the implementation of the above 36 recommendations, not only across the Hospital Groups but also throughout the Community Health Organisations.

It is the responsibility of the Complaint Manager within each Community Health Organisation and Hospital Group to collate the data for this report and forward to NCGLT when requested.  The NCGLT will audit the implementation of the recommendations on a regular basis.

The Ombudsman is also committed to auditing the implementation of these 36 recommendations across the Community Health Organisations and Hospital Groups.