If the complaint cannot be resolved informally through the informal means, the matters are addressed through the formal investigative process.
The Complaints Officer is responsible for carrying out the formal investigation of the complaint at Stage 2 and may draw on appropriate expertise, skills, etc., as required.
The following process must be adhered to:
(i) Acknowledge the Formal Complaint
The acknowledgement letter must be sent to the Complainant within 5 working days of receipt of the complaint.
When acknowledging a formal complaint:
- Acknowledge the receipt of the complaint, acknowledging the date it was written and informing the Complainant of the date it was received.
- There is a No Wrong Door approach for feedback within the HSE. Therefore, the date a formal complaint is received in the HSE marks the commencement of the legislative timeframes, e.g. the complaint must be acknowledged within 5 working days of receipt.
The standard Acknowledgement Template Letter in the Letter Pack must be used and personalised as appropriate.
Letters personally signed by staff are received better than letters electronically signed or signed by support staff on behalf of somebody.
Remember: Include your work contact details
(ii) Investigate the Complaint
- The Complaint Officer will initiate the investigation of the complaint once all steps have been taken to remove or treat any immediate harm caused by the action about which the complaint is being made.
- The investigation will be carried out by the Complaint Officer who will liaise with all relevant parties as required (see timeframes).
- A Complaint Officer may request any documents and communicate with any persons he or she believes can assist with the investigation of the complaint (see timeframes).
- The Complaint Officer may also request further information about the complaint from the Complainant to enable a full and proper investigation of the complaint (see timeframes).
- In addition, a Complainant may make written representations in support of his/her complaint and such representations will be considered by the Complaint Officer.
- For some very complex cases or where deemed appropriate, the Complaints Officer may establish and lead an investigation team, consisting of all relevant persons and staff with expertise and knowledge to carry out the investigation. The size and membership of this investigation team will be dependent on each complaint and will be determined by the Complaints Officer. Each member of the investigation team should support the investigation in an unbiased and unprejudiced manner.
- The investigation team will identify the terms of reference of the team and this will be signed by all persons involved. The terms of reference determine the objectives of the investigation team and the limits of its responsibility and authority.
- All information obtained by the Complaint Officer (and investigation team where appropriate) in the course of investigating a complaint will be deemed to be confidential information and he or she may not discuss, communicate or disclose it except where necessary for the proper investigation of the complaint. (Health Act 2004 (Complaints) Regulations 2006).
- Where the investigation of the complaint highlights that the complaint or part of the complaint indicates an employee related issue then this issue is referred by the Complaint Officer to the Accountable Officer for appropriate action (in conjunction with designated personnel in the Human Resources Department) under the relevant processes detailed in (see Table 3)
Plan, Plan, Plan!
More investigations suffer in terms of quality because of poor investigative planning than for any other single reason
Best Practice governing the investigation process
- The investigation will be conducted thoroughly and objectively with due respect for the rights of the Complainant and the rights of the service/staff members to be treated in accordance with the principles of natural justice.
- The Complaints Officer will have the necessary expertise to conduct an investigation impartially and expeditiously. Where appropriate, the Complaint Officer may request appropriately qualified persons to carry out clinical assessments, validation exercises etc.
- Confidentiality will be maintained throughout the investigation to the greatest extent consistent with the requirements of fair investigation.
- A written record will be kept of all meetings relating to the complaint. These records should be kept in a separate complaints file, treated in the strictest confidence and stored in a secure environment.
- The Complaint Officer may interview any person who they feel can assist with the investigation. Staff are obliged to co-operate fully with the investigation process and will be fully supported throughout the process. (link to Supporting Staff).
- Staff who participate in the investigation process will be required to respect the privacy of the parties involved by refraining from discussing the matter with other work colleagues or persons outside the organisation.
- It will be considered a disciplinary offence to intimidate or exert pressure on any person who may be required to attend as a witness or to attempt to obstruct the investigation process in any way.
Figure 4: The Steps – Investigation (view in word)
All staff have an obligation to participate and support the investigation of any complaint where requested.
(iii) Develop recommendations
The Complaints Officer will decide on any recommendations to be made as a result of the findings of the investigation.
These recommendations to include:
- action to be taken to remove the causes of the complaint or its likelihood for re-occurrence as far as is reasonably possible where deemed necessary by the investigation.
- redress for the Complainant where deemed appropriate by the investigation
A Complaints Officer may not, following the investigation of a complaint, make a recommendation the implementation of which would require or cause:
- the Executive to make a material amendment to its approved service plan, or
- a service provider and the Executive to make a material amendment to an arrangement under section 38 of the Health Act 2004.
A Complaints Officer may not make a finding or insert a comment on his/her report, adverse to a person, without first having afforded the person concerned the opportunity to consider the finding or criticism and to make representations in relation to it.
(iv) Prepare Report
Post investigation of the complaint the Complaints Officer will prepare a signed and dated report (see Complaints Officers Letter Pack)which will include:
- his/her findings,
- any recommendations which he or she considers appropriate,
- the reasons for such findings and recommendations, and
- issue report to Complainant and Accountable Officer (e.g. Head of Service)
All complaint reports must include a Recommendation(s). Where a complaint is not upheld the recommendation of the Complaint Officer is to inform the Complainant that the complaint is not upheld, therefore no further action needed.
In detail, the contents of the report should include: (Insert Complaint Report Content Detail)
- A description of the complaint.
- Reason(s) for actions resulting in the complaint.
- A description of the investigation process to assure the Complainant that their complaint has been fully and fairly investigated.
- The Complaints Officer’s findings and recommendations.
- An apology when the investigation showed that the HSE was at fault, if appropriate.
If the complaint was not substantiated, the report will outline the reasons why this decision was reached.
The report forwarded to the Complainant will also advise that he/she may request a review of the outcome of the investigation of their complaint and will provide the Complainant with the details of how to request the review.
The recipients of the final report will be invited to contact the Complaints Officer to clarify any issues in the report.
Upon conclusion of the investigation report the Complaints Officer will as soon as is practicable forward a signed report to the Complainant and the Head of Service (Accountable Officer) as appropriate.
The Complaints Officer may need to consider anonymising parts of the report to protect the identity of the Complainant or the staff member when deemed appropriate by the Complaints Officer.
Where a staff member against whom a complaint has been made is unhappy with the finding/recommendations against them, they may invoke the Grievance & Disciplinary procedures with their line manager. (see Supporting Staff)
Complaints Officer must use the approved report template (see Letter Pack)
(v) Implementation of Recommendations made by Complaints Officers
- Within 30 working days the relevant Head of Service (Accountable Officer) will write to the Complainant and Complaints Officer detailing their Recommendation Action Plan (see Letter Pack)
- Where a recommendation the implementation of which would require or cause the Executive to make a material amendment to its approved service plan, the relevant Head of Service (Accountable Officer) may amend or reject the recommendation.
- Where the recommendation is being amended or rejected or where alternative measures are being taken, the relevant Head of Service (Accountable Officer) must give the reasons for their decisions.
- The relevant Head of Service (Accountable Officer) must put an action plan in place for the implementation of the recommendations of the investigation. The action plan, persons responsible and timeframes are to be identified and recorded.
- Where a Complainant has requested a review of the outcome of the investigation, the relevant Head of Service (Accountable Officer) will suspend the implementation of a recommendation and will notify the Complainant of this suspension.
- If after a period of time recommendations made are not implemented and the Complainant is dissatisfied, they should be advised to contact the relevant Hospital Group Chief Executive Officer / Community Health Organisation Chief Officer.
- Where no Recommendation Action Plan is forthcoming from the relevant Head of Service (Accountable Officer), the Complaints Officer must follow up (Letter Pack)
(vi) Recording Formal Complaints
At every stage of the process the Complaints Management System (CMS) must be updated, to include:
- Details of Complainant
- Summary of complaint
- Details of acknowledgement
- Delay letters sent
- Terms of Reference (Individual issues)
- Complaint categories
- Final complaint report
- Recommendations
Sensitive personal data such as clinical information must not be uploaded onto this system, due to Data Protection requirements.
All interactions with the Complainant about their complaint should be recorded.
Any complaint addressed by a Complaints Officer regardless of whether it is informally or formally resolved must be recorded on the Complaints Management System (CMS)
Manual files should be kept in a separate complaints file, treated in the strictest confidence and stored in a secure environment (see Training).
All Complaints Officers and designated support staff must attend Complaints Management System training!
