Complaints Procedure


To ensure an effective working model for complaints management, including written procedures and guidelines for handling and investigation of complaints, is implemented organisation wide.


To ensure an effective working model for complaints management, including written procedures and guidelines for handling and investigation of complaints, is implemented organisation wide.


The organisation undertakes to investigate all complaints courteously, sympathetically, objectively, expeditiously, and thoroughly, with a view to obtaining information that results in an honest and balanced resolution to the problem and provides a rapid response and appropriate reassurance for the complainant.


The London Welbeck Hospital has a three-stage process for handling complaints.


Stage 1 – Local Resolution

Stage 2 – Complaint Review in the case of failure to resolve (nominated  Board member- Professor Roger Fenner)

Stage 3 - Independent External Adjudication is available through – CRS (Cosmetic Redress Scheme) where the complainant remains dissatisfied, and the issues are unresolved.

All staff will receive training and information on what constitutes a complaint, and the procedures for receiving and managing a complaint in the first instance.



  • The names of the patient or complainant shall remain confidential except to facilitate the investigation of a complaint.

  • The names of all staff members or clinicians shall remain confidential except to facilitate the investigation of a complaint.

  • Complaints by a patient representative shall be addressed ensuring that the complainant is a legitimate representative and in doing so with the patient’s knowledge and consent, but also recognising patient confidentiality. If the patient is not able to consent then the patients lawful representative shall be informed.

Verbal complaints

If a staff member receives a verbal complaint and is empowered to manage the complaint, good practice shall be adopted by staff:

  • put the patient at ease, be supportive and empathetic

  • listen carefully and understand the nature of the complaint

  • ensure privacy and a relaxed atmosphere

  • remain calm and respectful

  • take responsibility for further action and communication


The staff member receiving the complaint should notify the Senior Nurse or the manager to which the complaint relates (if not the same). The senior person must inform the Hospital Manager (HM) who will inform the admitting Consultant.


The senior person (Ward team leader or Theatre lead) will:

  • summarise the complaint to the patient and resolve immediately where possible. If it is not possible to resolve the issues immediately the senior person will

  • explain that the complaint is being investigated, who is carrying out the investigation, and who they should contact in the event of a query. The patient should be informed that an acknowledgement and if possible, a response will be provided within 48 hours.


The investigation should be completed within 1 working day if the patient is in the hospital and within 20 working days if the patient has been discharged. The senior person or investigator should report back immediately any problems in completing the investigation, which should be communicated to the patient in writing by the Hospital Manager. Where there is no reason for delay the complaint should be dealt with within 20 working days. Responses to serious verbal complaints must be in writing.


On completing the investigation the senior person and Hospital Manager (Catherine Moran) should evaluate the investigation and decide the action to be taken.


The outcome is fed back to the patient immediately in all cases where the patient is still in the hospital. If the patient has left the hospital the Hospital Manager (Catherine Moran) will  ensure that a written response to the patient is sent within 48 hours.


The Hospital Manager will then:

  • update and complete the complaints register in liaison with the Head of Administration

  • file all investigation papers and as the nominated Customer Care / Complaints manager ensure that all learning outcomes are shared hospital wide and that any necessary changes to practice occur.

Written Complaints

The member of staff who receives the written complaint will immediately forward the letter to the Hospital Manager (Ms Catherine Moran).

NOTE (a) the complainant is entitled to raise a complaint within six months of the event or of discovering that there is something to complain about.

(b) A complainant has six months to process their complaint between stages 1 and 2 and between stages 2 and 3.


Stage 1 – Local Resolution


  • On receipt of the complaint the Hospital Manager will ensure an acknowledgement letter is sent to the complainant within two working days.

  • If the complaint letter is received from someone other than the patient, then, the patient’s written consent to disclose information about his/her case must be requested courteously.


Process of Investigation


The Hospital Manager will undertake a thorough investigation of the circumstances around the complaint ensuring that all personnel are invited for a statement of their involvement. In addition the patient records and/or any other relevant information will be reviewed in order to assemble the facts and complete a comprehensive report.

Stage 1 should be completed within 20 working days. If for any reason the Stage 1 process does not meet the 20 working days timescale, a holding letter will be sent to the complainant informing them of the reasons for the delay. If following the outcome of stage 1 the complainant remains dissatisfied the case is progressed to Stage 2 of the London Welbeck Hospital complaints procedure.


Stage 2 – Complaint Review Nominated Management Board Member


The LWH Nominated Management Board Member is Professor Roger Fenner. In all cases where the complainant remains dissatisfied with the conclusion and outcome of Stage 1, Professor Fenner will undertake an independent objective review of the complaint, the process of investigation and the conclusions reached. If the complainant remains unhappy with the outcome of Stage 2, the complainant is referred to Stage 3.


Stage 3  Adjudication


Where the patient remains dissatisfied with the outcome of the investigation at Stage 2  the matter is referred for Independent External Adjudication through the Cosmetic Redress Scheme (CRS) who aim to resolve the issues.


The Hospital Manager will ensure that the Cosmetic Redress Scheme (CRS) has access to all documentation relating to the complaint, including correspondence between the hospital and complainant.