Stage Three, Assessment Phase - HSE Internal Review Process

Each Community Healthcare Organisation, Hospital Group and National Division has a nominated Complaints Manager who is the initial contact for requests for review.

 The Complainant must be advised by the Complaints Officer at Stage 2, of their right to have the outcome of their complaint reviewed through the HSE Internal Review Process or via Independent Review, such as, Ombudsman, Ombudsman for Children, other professional bodies and to whom they should make an application for review.

Link to Complaints Manager Contacts Details

Where a Complainant is dissatisfied with recommendations made by a Complaints Officer (Stage 2), he/she may apply for a review of the recommendations to the relevant Complaints Manager within 30 working days of the date on which the report was signed and dated by the Complaints Officer.

On receipt of a request for review the Complaints Manager will immediately appoint an appropriate Review Officer.

A Review Officer shall determine the appropriateness of a recommendation made having regard to all aspects of the complaint and its investigation and in so doing he or she shall not vary the original recommendation or make another unless he or she deems it appropriate to so do.

The functions of the Review Officer are twofold:

  1. To determine the appropriateness of a recommendation made, having regard to the two elements:
    1. All aspects of the complaint
    2. The investigation of the complaint
  2. Having determined the appropriateness of the recommendation to uphold it, vary it, or make a new recommendation if he/she considers it appropriate to do so.

The Review Officer is independent in his/her function as a Review Officer.

a. Assessment Phase

Where a request for a review is received beyond the period specified above, the Review Officer may extend the time limit for requesting a review if he/she determines that special circumstances make it appropriate to do so.

Where it is decided that the time limit for requesting a review will not be extended, the Review Officer will notify the Complainant in writing of this decision within 5 working days of the decision having been made and recorded.

Before a Review Officer deems the complaint suitable for Stage 3 review, a number of checks must be made.

The Review Officer will carry out an assessment of the complaint where he/she will firstly determine if the complaint is included or excluded under Part 9, Section 48 of the Health Act 2004…Link to table 1…

Following this initial assessment if the Review Officer is now satisfied that the complaint subject matter falls within the provision of Part 9 of the Health Act, the complaint will be managed in accordance with the legislation.

Requesting information from the Complainant

  1. The Review Officer must check that the Complaints Officer has complied with process, and ensure the following steps have been undertaken:
    • Satisfy himself or herself of the identity of the person concerned and where the person making the complaint is not the Complainant, satisfy himself or herself that that person is entitled to do so.
    • If another pathway is appropriate (e.g. Trust in Care, Safety Incident Management, etc.)

      Remember: If the Review Officer identifies that the Complaints Officer has not followed appropriate process (as above) this must be reflected in the final review report to ensure learning and future quality improvemen

Additional Assessment Criteria

As part of the assessment phase, the Review Officer must determine that:

  • the subject matter of the complaint is not trivial,
  • the complaint is not vexatious,
  • the complaint is made in good faith, and
  • the complaint has not already been resolved.

Where the above criteria is not met, either during the assessment or the investigation, the Review Officer may decide not to investigate or further investigate the complaint.

The Complaints Manager must update the Complaints Management System (CMS) accordingly.

Transfer of a review to an alternative Review Officer

When a complaint is received by a Review Officer, it is their duty to carry out an investigation where appropriate. In exceptional circumstances, a Review Officer may feel that s/he is not in a position to investigation a complaint.

Reasons why a transfer may need to happen include:

  • They may have difficulty in remaining impartial and non-biased in the investigation of the complaint
  • Have previous poor interpersonal or working relationships with the parties involved
  • The complaint is one of particular national significance for the organization; involves a large number of HSE locations and services, and/or that may attract considerable media attention
  • For further information, contact your Complaints Manager.

Withdrawal of Reviews

A Complainant may, at any time, withdraw their complaint. The Review Officer must update the Complaints Management System to reflect this status.

However, where the Review Officer has reasonable grounds for believing that public interest would best be served by the continuation of the review, he or she must refer the matter to their relevant Complaints Manager. The Complaints Manager will adjudicate on this matter.

This matter is dealt with in more detail in Training Programme……(scenario FAQ)

Review of the outcome of the Assessment

The Complainant may appeal the decision of the Review Officer not to proceed with a Stage 3 review of their complaint. The Complainant has the right to an external independent review (e.g. Ombudsman). ….link…contacts

Process upon completion of the Assessment

Where the Review Officer determines that the complaint does not meet the criteria, he/she will inform the Complainant in writing, within 5 working days of making the decision/determination, that the complaint will not be investigated and the reasons for it.

Where alternative complaint processes are appropriate for the management of such complaints, the Review Officer will refer the complaint directly to the appropriate health service personnel for management under the relevant policy, procedure or guideline. The Complainant is to be informed (within 5 working days) of where the complaint is being referred to and why.

Remember: Update the Complaints Management System!

Complaints that may be managed using the processes outlined in this Guidance Manual.

(Link to Table 2)

Complaints that do not fall within the remit of this Guidance Manual (and must be referred to the appropriate personnel to be addressed using the appropriate Policy, Procedure, Guidelines or Legislation as detailed in this table) .

Table 3: Complaints that cannot be managed using Part 9 of the Health Act 2004

Matters excluded from right to complain under Part 9 of the Health Act 2004.

A complaint is excluded under Part 9 of the Health Act 2004 if it is in relation to any of the following matters:

  • a matter that is or has been the subject of legal proceedings before a court or tribunal;
  • a matter relating solely to the exercise of clinical judgment by a person acting on behalf of either the Executive or a Service Provider;
  • an action taken by the Executive or a service provider solely on the advice of a person exercising clinical judgment;
  • a matter relating to the recruitment or appointment of an employee by the Executive or a service provider;
  • a matter relating to or affecting the terms or conditions of a contract of employment that the Executive or a service provider proposes to enter into (includes terms or conditions relating to superannuation benefits, disciplinary procedures or grievance procedures);
  • a matter relating to the Social Welfare Act;
  • a matter that could be the subject of an appeal under section 60 of the Civil Registration Act 2004;
  • a matter that could prejudice an investigation being undertaken by the Garda Siochana;
  • a matter that has been brought before any other complaints procedure established under an enactment (e.g. complaints made under Part 2 of Disability Act, 2005 or the Mental Health Act 2001).

There may be times where a complaint contains both a) matters that can be investigated under YSYS and b) ‘non-Part 9’ matters. The issues that fall under YSYS can be investigated accordingly and the ‘non-Part 9’ matters are referred to the appropriate personnel to be addressed using the appropriate Policy, Procedure, Guidelines or Legislation.

Who can request a review?

In accordance with Section 46, Part 9 of the Health Act 2004 the following may make a complaint:

  • Any person who is being or was provided with a health or personal social service by the HSE or service provider,
  • Any person who is seeking or has sought provision of such service.

If a person is entitled to make a complaint review but is unable to do so because of age, illness or disability, the complaint review may be made on that person’s behalf by:

  • a close relative or carer of the person,
  • any person who, by law or by appointment of a court, has the care of the affairs of that person,
  • any legal representative of the person,
  • any other person with the consent of the person, or
  • any other person who is appointed as prescribed in the regulations.

If a person who would otherwise have been entitled to make a complaint review is deceased, a complaint review may be made by a person who, at the time of the action in relation to which the complaint review is made, was a close relative, or carer of that person. A close relative is defined in Section 45 of the Health Act, 2004 as being a parent, guardian, son, daughter, spouse or someone who is cohabiting with the person on whose behalf the complaint review is being made.

Types of review

A review may be made about any action of the HSE or associated Service Provider that:

  • it is claimed, does not accord with fair and sound administrative practice, and
  • adversely affects or affected that person

As defined in the Health Act 2004, an action does not accord with fair and sound administrative practice if it is:

  • taken without proper authority,
  • taken on irrelevant grounds,
  • the result of negligence or carelessness,
  • based on erroneous or incomplete information,
  • improperly discriminatory,
  • based on undesirable administrative practice, or
  • in any other respect contrary to fair or sound administration.

A Stage 3 Internal Complaint Review can be:

  • A complaint that falls within the remit of Part 9, Health Act 2004, which may include multi-site issues.
  • A complaint that partially falls within the remit of Part 9, Health Act 2004, e.g. including clinical judgment aspects.  A Review Officer must advise the Complainant that the clinical judgment issues cannot be reviewed under the Your Service Your Say process.

However, the Review Officer can advise QPS, Clinical Director, etc. that the complainant is dissatisfied with their response to the initial complaint.