Procedure for Complaints

1) Introduction 

The purpose of the policy is to ensure that all patients (or their representatives) who have the cause to complain about their care or treatment can have freely available access to the process and can expect a truthful, full and complete response and an apology where appropriate. Complainants have the right not to be discriminated against as the result of making a complaint and to have the outcome fully explained to them. The process adopted in the practice is fully compliant with the relevant NHS Regulations (2009) and guidance available from defence organisations, doctors` representative bodies and the Care Quality Commission. Everyone in the practice is expected to be aware of the process and to remember that everything they do and say may present a poor impression of the practice and may prompt a complaint or even legal action. 

The general principle of the practice in respect of all complaints will be to regard it first and foremost as a learning process, however in appropriate cases and after full and proper investigation the issue may form the basis of a separate disciplinary action.  In the case of any complaint with implications for professional negligence or legal action, the appropriate defence organisation must be informed immediately. 

2) Procedure 

2.1 Availability of information 

The practice will ensure that there are notices advising on the complaints process conspicuously displayed in all reception/waiting areas. Complaint forms are available at reception and the Practice website.  

2.2  Who can a formal complaint be made to? 

Complaints should be made to the Practice in the first instance.      In the event of anyone not wishing to complain to the practice, they can make their complaint to NHSEngland at:    

By telephone: 03003 11 22 33  
By email:   
By post: NHS England, PO Box 16738, Redditch, B97 9PT 

In those cases where the complaint is made to NHS England, the practice will comply with all appropriate requests for information and co-operate fully in assisting them to investigate and respond to the complaint.  

Healthwatch Lewisham is also the current provider of NHS complaints advocacy.  Contact details are:  

Healthwatch Lewisham
Community House
South Street
Phone: 0208315 1916 

2.3 Who can make a complaint?  

A complaint can be made by or, with consent, on behalf of a patient (i.e. as a representative); a former patient, who is receiving or has received treatment at the Practice; or someone who may be affected by any decision, act or omission of the practice. 

A Representative may also be

  • by either parent or, in the absence of both parents, the guardian or other adult who has care of the child; by a person duly authorised by a local authority to whose care the child has been committed under the provisions of the Children Act 1989;  or by a person duly authorised by a voluntary organisation by which the child is being accommodated
  • someone acting on behalf of a patient/ former patient who lacks capacity under the Mental Capacity Act 2005 (i.e. who has Power of Attorney etc.) or physical capacity to make a complaint and they are acting in the interests of their welfare  •
  • someone acting for the relatives of a deceased patient/former patient 

In all cases where a representative makes a complaint in the absence of patient consent, the practice will consider whether they are acting in the best interests of the patient and, in the case of a child, whether there are reasonable grounds for the child not making the complaint on their own behalf.  In the event a complaint from a representative is not accepted, the grounds upon which this decision was based must be advised to them in writing. 

2.4 Who is responsible at the practice for dealing with complaints?  

The practice’s "Responsible Person" is the Practice Manager, Antonia Makinde. She has responsibility for managing complaints and ensuring adequate investigations are carried out.  She is also responsible for ensuring complaints are handled in accordance with the regulations, that lessons learned are fully implemented, and that no Complainant is discriminated against for making a complaint.  She is supported by Jane Feldman, Practice Coordinator who will deal with the initial complaint.  In the event that the Practice Manager is not available, complaints will be managed by one of the Partners.   

2.5 Time limits for making complaints 

The period for making a complaint is normally:

(a) 12 months from the date on which the event which is the subject of the complaint occurred; or

(b) 12 months from the date on which the event which is the subject of the complaint comes to the complainant's notice. 

The practice has discretion to extend these limits if there is good reason to do so and it is still possible to carry out a proper investigation.  The collection or recollection of evidence, clinical guidelines or other resources relating to the time when the complaint event arose may also be difficult to establish or obtain. These factors may be considered as suitable reasons for declining a time limit extension, however that decision should be able to stand up to scrutiny. 

3) Action upon receipt of a complaint   

3.1 Verbal Complaints:  It is always better to try and deal with the complaint at the earliest opportunity and often it can be concluded at that point. A simple explanation and apology by staff at the time may be all that is required  

A verbal complaint need not be responded to in writing for the purposes of the Regulations if it is dealt with to the satisfaction of the complainant by the end of the next working day, neither does it need to be included in the annual Complaints Return.  

If resolution is not possible, the Complaints Manager will set down the details of the verbal complaint in writing and provide a copy to the complainant within three working days. This ensures that each side is well aware of the issues for resolution. The process followed will be the same as for written complaints.  

3.2 Written Complaints:  On receipt, a written acknowledgement will be sent within three working days prior to a written response within 30 days.  A face to face or telephone discussion prior to the written response provides the opportunity to clarify the complaint.   

In instances where other bodies (e.g. secondary care/ Community Services) are involved, then the complainant’s consent will be required.   

If it is not possible to conclude any investigations within the advised timescale, then the complainant must be updated with progress and revised time scales on a regular basis. In most cases these should be completed within six months unless all parties agree to an extension. 

4) The Investigation 

The practice will ensure that the complaint is investigated in a manner that is appropriate to resolve it speedily and effectively and proportionate to the degree of seriousness that is involved. 

The investigations will be recorded in a complaints file created specifically for each incident and where appropriate should include evidence collected as individual explanations or accounts taken in writing. 

5) Final Response 

This will be provided to the complainant in writing (or email by mutual consent) within 30 working days, and the letter will be signed by the Responsible Person.  The letter will be on headed notepaper and include:   • An apology if appropriate (The Compensation Act 2006, Section 2 expressly allows an apology to be made without any admission of  negligence or breach of a statutory duty) • A clear statement of the issues, details of the investigations and the findings, and clear evidence-based reasons for decisions if appropriate • Where errors have occurred, explain these fully and state what has been or will be done to put this right or prevent repetition. Clinical matters must be explained in plain language • A clear statement that the response is the final one and the practice is satisfied it has done all it can to resolve the matter at local level • A statement of the right, if they are not satisfied with the response, to refer the complaint to the Parliamentary and Health Service Ombudsman,  Millbank Tower, Millbank,  London, SW1P 4QP or visit the 'Making a complaint page'  at (to complain online or download a paper form).  Alternatively the complainant may call the PHSO Customer Helpline on 0345 015 4033 from 8:30am to 5:30pm, Monday to Friday or send a text to their 'call back' service: 07624 813 005 

6) The Next Step

Practice Procedure:

1) All written complaints when received by a member of staff will be passed to the Practice Coordinator immediately

2) The Practice Coordinator will acknowledge the complaint within three working days of receipt  

3) In the event of the Practice Coordinator not available, the complaint will be passed to the Practice Manager

4) The Practice Coordinator will carry out an initial investigation, and draft an appropriate response

5) The Practice Manager will support the Practice coordinator in completing the process

6) The Practice Coordinator will include the complaint in the agenda at the next full practice meeting.  

  • Discussions at meetings will focus on the following:

i. What happened and why did it happen?
ii. Could anything have been done differently?
iii. What lessons have been learnt?
iv. What needs to change and how will this be implemented? 

  • A decision is made and recorded at the meeting on any further action that may be required.
  • Any further action required is actioned.
  • A review is held at the next significant event/complaints meeting to confirm the validity of the actions. 

Reviewed September 2018    September 2019