Do national policies for complaint handling in English hospitals support quality improvement? Lessons from a case study (2024)

Abstract

Objectives

A range of public inquiries in the English National Health Service haveindicated repeating failings in complaint handling, and patients are oftenleft dissatisfied. The complex, bureaucratic nature of complaints systems isoften cited as an obstacle to meaningful investigation and learning, but adetailed examination of how such bureaucratic rules, regulations, andinfrastructure shape complaint handling, and where change is most needed,remains relatively unexplored. We sought to examine how national policiesstructure local practices of complaint handling, how they are understood bythose responsible for enacting them, and if there are any discrepanciesbetween policies-as-intended and their reality in local practice.

Design

Case study involving staff interviews and documentary analysis.

Setting

A large acute and multi-site NHS Trust in England.

Participants

Clinical, managerial, complaints, and patient advocacy staff involved incomplaint handling at the participating NHS Trust(n=20).

Main outcome measures

Not applicable.

Results

Findings illustrate four areas of practice where national policies andregulations can have adverse consequences within local practices, and partlyfunction to undermine an improvement-focused approach to complaints. Theseinclude muddled routes for raising formal complaints, investigativeprocedures structured to scrutinize the ‘validity’ of complaints, futiledata collection systems, and adverse incentives and workarounds resultingfrom bureaucratic performance targets.

Conclusion

This study demonstrates how national policies and regulations for complainthandling can impede, rather than promote, quality improvement in localsettings. Accordingly, we propose a number of necessary reforms, includingpatient involvement in complaints investigations, the establishment ofindependent investigation bodies, and more meaningful data analysisstrategies to uncover and address systemic causes behind recurringcomplaints.

Keywords: patient complaints, National Health Service, England; health policy

Introduction

Patient and family complaints (hereinafter: complaints) are increasingly recognisedas a critical source of insight for quality improvement. Representing complexnarratives of healthcare failures, complaints include social, institutional andclinical problems not always identified by hospital-driven monitoring systems (e.g.,incident reporting systems, case reviews),^{1, 2} and have beenassociated with hospital mortality rates and adverse surgical outcomes.^{3, 4} Critically,most patients and families submit complaints to prevent harm from occurring to others,⁵ but are currently often left dissatisfied.^{6, 7}

In the English National Health Service (NHS), which receives over 200,000 formalcomplaints per year, failures to detect and respond to harm and negligence reportedin complaints have been illustrated across a range of public inquiries (e.g., TheMid-Staffordshire Inquiry, The Shipman Inquiry, Morecambe Bay Investigation).^8–10 In acknowledgement of thesefailures, several reforms were introduced to improve learning from complaints, suchas the regulatory requirements for hospitals to formally investigate and collectdata from complaints. Yet, as the most recent Inquiry at The Shrewsbury and TelfordHospital NHS Trust has unfolded, it appears that system-wide progress has beenlimited (Table 1).

Table 1.

Key inquiries and policy reviews indicating failings in learning fromcomplaints in English NHS hospitals.

Year	Inquiry or review	Purpose	Key findings relating to failings in the complaints process
2013	A review into the quality of care and treatment provided by 14hospital trusts in England	Review into the quality of care and treatment provided by 14English NHS hospital Trusts with persistently high mortalityrates.	‘There was a tendency in some of the hospitals to viewcomplaints as something to be managed, focusing on theproduction of a carefully-worded letter responding to thepatient’s concerns as the main output … [over] using thatinsight to make improvements to services.’ (p.19)¹¹
2013	The Mid Staffordshire NHS Foundation Trust Public Inquiry	Investigation into failings and negligence at theMid-Staffordshire NHS Foundation Trust between 2005 and2009.	‘Although the complaints of individuals were many in number, andprovided graphic proof that something was seriously wrong at theTrust, the complaints were received into a system that failed todraw the necessary alarm signals from them, let alone therelevant lessons.’ (pp. 245–246)⁸
2013	A review of the NHS hospitals complaints system	A review into the handling of complaints in NHS hospital care inEngland following findings from the Francis Inquiry; mainlythrough 2500 comments submitted by the public.	‘Many people who complained felt that nothing had been learnt orachieved as a result of their complaint. They were disappointedabout this because this had been one of their reasons forcomplaining in the first place.’ (p. 23)¹²
2015	The Morecambe Bay Investigation	Inquiry into avoidable deaths of at least 11 babies and a motherat Furness general hospital between 2004 and 2013.	‘Reporting to the Board was minimal, focusing on numbers andcompletion rates within specified days … giving very littleindication of what was being complained about, and nothing aboutactions being taken to rectify issues raised.’ (p. 76)⁹
2017	A review into the quality of NHS complaints investigations	A Parliamentary and Health Service Ombudsman review of 150 NHSinvestigations in which avoidable harm or death had been allegedin complaints from patients and families.	‘NHS Trusts are not always identifying patient safety incidentsand are sometimes failing to recognise serious incidents. Wheninvestigations [of complaints] do happen, the quality isinconsistent, often failing to get to the heart of what has gonewrong and to ensure lessons are learnt.’ (p. 2)¹³
2022	Independent review of maternity services at the Shrewsbury andTelford Hospital NHS Trust	A review into maternity failings at The Shrewsbury and TelfordHospital NHS Trust between 2000 and 2019 which initiallyinvolved 23 cases of alleged failings, but has since grown tothe investigation of 1486 cases.	‘There was a lack of input from senior members of the leadershipteam in the writing, review, approval, quality control and trendanalysis of complaints. … The review team has identifiedfamilies where care was sub-optimal, where different managementwould likely have made a difference to the outcome, however thecomplaint responses justified actions, delays and omissions incare.’ (p. 44)¹⁴

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NHS: National Health Service.

The complex, bureaucratic nature of the NHS complaints system is often cited as anobstacle to effective complaint handling, but a detailed examination of how suchbureaucratic rules, regulations and infrastructure shape complaint handling,investigation and monitoring within institutions has yet to be conducted. This studysought to examine how national policies structure local practices of complainthandling, and how are they understood by those responsible for enacting them withinlocal practice.

Methods

Study setting

This study was conducted at a multi-site acute NHS Trust in London (England)which consists of five acute sites and a range of community services. The trustwas selected based on convenience. The lead researcher was located at the Trust,but had limited pre-existing relationships with the complaints department orfrontline. The most recent 2018 Care Quality Commission inspection report at thetime of study described the Trust as treating complaints seriously and derivinglessons from investigations. The site was therefore considered an‘information-rich case’¹⁵ to explore complaint handling, relative to existing evidence that ismainly generated in poor performing hospitals through public inquiries. Adistinctive feature of this Trust is the presence of a centralised complaintsdepartment with designated non-clinical ‘investigators’, who occupy a certaindegree of distance from frontline practice. The Trust is one of the largest inthe country, with an average of over 1,000 complaints per year between 2015 and2019.

Participants

Staff were recruited using purposive sampling supported by the complaints managerand frontline contacts. This enabled the identification of relevant staff roleswith systematic involvement in complaint handling or with direct experience ofreceiving a complaint (Table 2). Efforts were made to recruit across different levels ofseniority, service types and sites within the Trust. The number of participantsper staff group reflects their relative degree of involvement in complainthandling.

Table 2.

Description of participants by staff group.

Staff group	Description	N
Complaints manager	Oversees complaint handling by screening complaints atinitial receipt, reviewing responses and developing qualitymonitoring reports	1
Complaints administrators	Coordinate complaint handling process by logging details ofcomplaints, supporting investigators and providingpoint-of-contact to complainants	4
Complaints investigators	Responsible for investigating formal complaints throughcollaborating with front-line clinical staff to identifywhat happened, whether the complaint is to be (partly)uphold, and to indicate if there is a need forimprovement	3
Clinical managers	Oversee formal complaint investigations on their ward (e.g.,provision of staff statements on reported incidents)	5
Patient Advice and Liaison Service	Point-of-contact in the hospital setting to provide adviceto patients, resolve informal concerns and receivecompliments	3
Local complaints advocacy	Local advocacy service that provides support to complainantswho experience difficulty in accessing or going through thecomplaints process	2
Patient Experience Directorate	Oversee complaints, PALS and other patient feedbackactivities (e.g., Friends and Family Test, NHS Choices,national surveys)	1
Clinical staff	Front-line staff with experience of having been involved ina complaints case (i.e., no systematic involvement in thecomplaints process)	1
Total		20

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PALS: Patient Advice and Liaison Service.

Procedure

Semi-structured interviews were held at the organisation’s main hospital betweenJune 2018 and June 2019, lasting an average of 43 minutes (range 10–81 minutes).Interviews were shorter when interviewees had limited regular involvement in thecomplaints process (e.g., front-line clinical staff). Questions explored staffunderstandings of how complaints handling routine is enacted. Inconsistencies,workarounds and adverse impacts were explored through follow-up questions, suchas through using alternative representations (‘interesting, staff member X saidY’) and problem prompts (‘what happens if [unexpected problem]?’).¹⁶ The topic guide was developed based on informal observations, documentanalysis and scoping of existing literature on complaint handling. Informalobservations included five hours of shadowing, attending meetings in thecomplaints department, and informal conversations with the complaints managerand advocacy service. Document analysis included a review of national regulationand policy reports, organisational complaints policy and workflow charts, andhospital records.

Data analysis

Interviews were audio-recorded and transcribed verbatim. Data were analysedthematically by the lead researcher (JD, social scientist). Open codes wereinitially developed based on transcripts and documentation, which were thengrouped into higher-order organising themes.¹⁷ A sample of four interviews was also coded by a second researcher (LF,health policy researcher) and discussed to refine codes and interpretations.Interviews were analysed concurrently with the data collection, and alongsidedocumentary analysis, to enable exploration of inconsistencies and to probeemerging themes in subsequent interviews. A process map was developed todescribe the routine for handling a complaint as understood by those responsiblefor enacting it (derived from the interviews with supporting material fromnational regulatory and local policy documentation to guide interpretation).

Results

Triangulation of policy documentation and interview transcripts identified fourcritical areas of practice where the design of national rules and policiesfunctioned to undermine a patient-centric and improvement-focused approach tocomplaints, relating to access, the conduct of investigations, data collectionsystems and performance targets. A detailed map of the organisational routine forhandling a complaint as described by interviewees can be found in Onlinesupplementary file 1.

Access: muddled routes for raising concerns

A frequently mentioned issue across staff groups was the confusing landscape ofroutes for raising concerns. Central to this was the lack of awareness, amongboth patients and frontline staff, regarding the distinct functions of formalcomplaints and the Patient Advice and Liaison Service (PALS), a point-of-contactwithin hospitals created to resolve lower-level concerns and queries directly onthe ward. The visibility of PALS (one of its main attributes) positions theservices as a catch-all destination for patient concerns and queries, and servedto overshadow complaints departments in some cases.

One of the biggest challenges that patients face in contacting us isknowing the difference between informal and formal complaints. Theyautomatically go to PALS because it is there in the hospital, easy tosee, and they think that they can help them to make a formal complaint.So, trying to distinguish the difference is something people are reallystruggling with and they come to us and say ‘I have been to complaints’,but they have not, they have been to PALS. (Patient advocacy worker)

Confusion among clinical staff was evident in the interviews, wheresome participants repeatedly confused ‘PALS’ with ‘complaints’. Others notedthat PALS had become somewhat misused by front-line staff when encounteringdissatisfied patients, as reflected in the organisational mantra ‘if unhappy,send to PALS!’ (Clinical manager) referred to by several participants.

Honestly, everyone automatically goes: ‘PALS, if you want to make acomplaint, you go to PALS’. I used to do it. I used to work in thebooking office. All I knew was, ‘If you want to make a complaint, you goto PALS’. (PALS officer)

The combination of muddled procedures to raise concerns and staffsignposting meant that most concerns were handled via PALS, with patients attimes unaware that they had not, in fact, complained formally. Although this waspositively regarded by hospital staff as providing quick relief to what by somewas characterised as a mere ‘failure in interpersonal communication’, itconcerned patient advocacy workers who noted that in many cases patients desirethe more bureaucratic process because they want their complaint to be formally‘known and recorded’.

Investigation: scrutiny, corroboration and defensive tactics

Formal investigative procedures at the Trust were predominantly structured tojudge the ‘well-foundedness’ of complaints, as stipulated by nationalregulations. The legitimacy of complaints was appraised by investigators throughcross-validating raised issues with corresponding hospital documentation andstaff statements, with internal evidence being regarded as superior.

That is really the key for our investigations, is to make sure there hasbeen some learning. Unless, of course, it is completely unwarranted, thecomplaint, in which case we will be very direct about that and say,‘sorry, there is no root to this complaint, and it is well documentedthat this did not happen.’ (Complaints investigator)

Paradoxically therefore, complaints were only utilised for qualityimprovement in cases where they described the already known and managed. Thisreflects a persistent belief that complaints are subjective and subordinate toclinical perspectives and hospital data. It further positions the provider andpatient perspectives as antagonistic, with any inconsistency leading to thedismissal of one account, rather than seeking to understand and exploredissonance and realising its potential to reveal institutional blind spots orfailures in communication.

If the complainant's recollection is different, mainly different fromwhat you have actually ascertained yourself, then I would say that wasnot upheld, because our opinion is completely different from theirs.Even though they’re stating that harm was done. (Complaintsinvestigator)

This asymmetric weighting of provider and patient evidence ininvestigations was further reflected in the comparatively limited opportunitiesfor patients to provide input. Apart from highly sensitive cases, such as thoseinvolving death, it was not routine practice to involve complainants ininvestigations. This stood in stark contrast with opportunities for the involvedward, for whom the investigative process often was described as a highlyinteractive process between the investigator and the involved ward. One notableexception was a clinical manager of a small ward who had initiated a dialogicalpractice, where every complaint case was discussed with all actors involved. Itwas noted that this was made possible by their low case and complaints load, andwould be harder to realise in large, busy wards that deal with complaintsregularly.

In some cases, the ability for involved staff to shape investigations startedlong before the investigation. Accounts from investigators described a tendencyon the frontline to pre-emptively report detailed accounts of incidents whenexpecting a complaint.

When the staff realise, I think, on the ward, that a family couldpossibly put a complaint in, whether warranted or otherwise, they tendthen to start to document very detailed summaries of the care. It isvery unusual for you to send a complaint through, and the ward not to beexpecting it. From that moment on, really, they make sure thateverything is documented correctly. (Complaints investigator)

Although most time and resources in the complaints process werespent on investigative activities, only a small proportion of complaintsresulted in recommendations for local action, such as a staff re-training,protocol implementation, or policy change (i.e., 4.4% according to hospitalrecords, of which 89.3% were [partly] upheld). Importantly, even in those cases,complaints staff noted it was difficult to close-the-loop and establish whetherchanges had actually been actioned by staff on the ward.

I am chasing seven actions right now that have not been done, or theymight be done in real-life, but they have not been closed on Datix. Ihave chased most of them three times. (Complaints administrator)

Complaints staff attributed this lack of timely action to anavoidant and defensive attitude towards complaints on the frontline,contributing to their sense of being othered within the institution.

If people did not view complaints as such a negative thing, if there wasnot a mindset of ‘us’ versus ‘them’ when it comes to people working withus, it would make things a lot easier. Because people just are notoverly cooperative at times which can be frustrating because we it islike ‘We work for the same Trust. We are on the same team. Why?’ We aretrying to take the negative and make it positive. (Complaintsadministrator)

National data collection systems: creating ‘false information’

Although a national data collection system (named ‘KO41a’) was introduced inresponse to the Mid-Staffordshire Inquiry to ‘improve the patient experience bylistening to public voice’,¹⁸ all four complaints administrators responsible for enacting codingthrough this scheme considered it inappropriate for use. They consistentlyreferred to the issue that categories did not describe the problems thatcomplaints tend to report and were further insufficiently granular foractionable learning. Two complaints administrators provided the example of asingle category to reflect all issues related to clinical care.

You will have a whole load of Clinical Treatment, Clinical Treatment, butyou are thinking ‘it is not the Clinical Treatment’. It is not brokendown correctly at all. For me, I see it as false information. It is notaccurate so, therefore, how can you know how to improve? (Complaintsadministrator)

As this taxonomy represented the main means for reporting on trendsacross complaints at national and organisational levels, this resulted inscepticism regarding the usefulness of these reports for quality monitoring and improvement.

I know that [the complaints manager] will run reports from the hospital’sinformatics system and pull out the trends, so he will see how manycomplaints were logged, for example, under Clinical Treatment. So, yes,he will say, ‘Okay, 80 per cent of my complaints'. I do not know what hedoes with that information because that cannot be useful. (Complaintsadministrator)

These limitations resulted in data entry merely being perceived asa ‘tick box exercise’, despite representing a large portion of time and workinvolved in complaint handling. Within a system already short in time andresources, there was a sense that time spent coding could better be used forinteracting with patients and providing social support.

Unsurprisingly, the data collection system did not adequately support thecomplaints manager in identifying recurring themes across complaints, who wasnecessitated to rely on memory rather than recorded data. Accordingly, thecomplaints manager noted the need for a ‘smarter’ system to record and monitorincoming complaints.

To see trends, see emerging themes, perhaps things that I might not havebeen able to spot. I think that would be really good, because often weare relying on our feel for it, but if there was a way to flag up –‘you’ve had five about this in the last week’ – it would be really good.(Complaints manager)

The importance of logging and identifying recurring problems wasechoed by clinical managers and a complaints investigator, who noted that solereliance on case-by-case investigations provides limited means to understandwhether there are systemic factors behind local issues.

I think we probably should do more following up and trying to gaugewhether there are similarities across areas and whether there is deeperlearning that we can take from the complainants. Because I think weprobably do the learning from an individual complaint in an individualdepartment reasonably well, but does that ripple out further? I am notsure we follow up a lot with: ‘are there similarities between these anddoes that reveal a bigger need?'. (Complaints investigator)

Performance targets, adverse incentives and workarounds

At managerial levels, monitoring relating to complaints was primarily focused onnational performance targets for complaints handling, which in turn are mainlyrelated to timescales for investigating and responding to complainants, andvolumes of complaints received, leaving their relative severity unexplored.

The Trust like numbers because it is easier to get your head around thanoutcome targets. This year we have had something like 50 fewercomplaints than last year, so that is a good thing because it shows weare getting better. But it does not tell you that actually thecomplexity and severity of some of the complaints this year were beyondanything we have ever seen before. (Patient Experience Directorate)

One interviewee expressed concern about the focus on reducingcomplaints volumes as creating adverse incentives, such as impedingaccessibility of the complaints process, as reflected in a statement provided byone of the interviewees ‘we want PALS to go up and complaints to go down’ (PALSofficer), which may partly explain frequent signposting to PALS as discussed intheme 1.

This year we have got number targets which I am in two minds about … ifyou've got a reduction in formal complaints, it could suggest thatactually our care is getting better and people have less reason tocomplain. It could, however, indicate that we don't have a very openculture and we're suppressing complaints, so we could be saying we'lljust pass this one on to someone else or we'll have people in thedivisions discouraging people from raising concerns. (Patient ExperienceDirectorate)

Performance targets for complaint handling predominantly focused onadministrative aspects, with pressure not to exceed response timelines set outby national policy. The influence of these targets on staff sensemaking of theirrole and goals was evident in the interviews. For example, following currentpolicy, the number of days that hospitals have to complete an investigation isdependent on the complaint’s relative level of risk. This contingency betweentime and risk meant that risk ratings had become operationalised as a mechanismto manage the often pressured timelines of investigations (rather than purely anindicator for level of risk).

So let’s say, it’s a joint complaint with different trusts, thatautomatically goes as medium risk because they need their time and weneed our time to get our details straight. (Complaints coordinator)

The normalisation of this workaround was reflected in staffaccounts when asked how they understood ‘risk’.

Medium is 45 [days to investigate], and high is 65. … It’s more abouttime. That’s how I’d see it, now. Obviously, if there is a very seriouscomplaint, of course it’s going to be medium, but it’s just more abouttime. (Complaints administrator)

Discussion

Our study contributes to existing complaint handling research by illuminating hownational policy can shape local practices and can impede an improvement-focusedapproach to complaints.^19–22 The procedural problems identified in ourfindings speak to a recent complaints study in the English NHS which concluded thatfailures in learning are not necessarily ‘a consequence of sinister or malignorganisational actors seeking to impose silence’ (p. 7)²³, and, instead,can be a case of (often) well-intentioned staff confined by an overly formalised andbureaucratic system. Through a detailed examination of the enactment of this systemwithin local practice, we have generated a number of recommendations for reform(Table 3).

Table 3.

Lessons and recommendations for the NHS complaints process based on thisstudy’s findings.

1. Clarify the distinct roles of PALS and formal complaintsprocesses to staff and patients, such as through leaflets andsignposting within hospitals, to avoid PALS from being a barrierto the formal process. (theme 1)

2. Remove the regulatory requirement for hospitals to judgewhether complaints are ‘well-founded’. All complaints areopportunities towards better understanding patients’ needs andtheir unique perspective on organisational safety. Involvepatients and families in complaints investigations as standardpractice and create opportunity for dialogue between involvedstaff and harmed patients. (theme 2)

3. Establish independent complaints bodies for investigating andanalysing complaints in order to fully leverage the potential ofcomplaints to flag problems that risk being ignored, contested,or underappreciated through institutional sensemaking frames (inparticular in settings with poor safety culture or stigma aroundcomplaints). (theme 2)

4. Improve or replace national data collection systems (i.e.,‘KO41a’) which currently represent a bulk of time and effortinvolved in complaint handling, but produce meaningless results.A reporting taxonomy needs to sufficiently discriminative todistinguish patterns of poor care and support the triaging ofdeeper investigation. A taxonomy should also have constructvalidity: i.e., reflect the themes patients describe incomplaints (rather than the categories that policy makers andproviders wish to count and manage). (theme 3)

5. Ensure that administrative and quantitative Key PerformanceIndicators for complaint handling (e.g., time to respond,numbers received) are not prioritised over harder-to-measureoutcomes, such as those regarding learning and improvement.Timely responses are important for complainants, but should notbe at cost of efforts to improve. Similarly, the monitoring ofsimple numbers of complaints as a quality indicator isinappropriate, as it does not provide information about theseverity or complexity of complaints – e.g., a small number ofcomplaints can indicate an inaccessible process and the tip ofan iceberg, rather than high-quality care. (theme 4)

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NHS: National Health Service; PALS: Patient Advice and LiaisonService.

Unlike countries with (semi-)independent complaints bodies (e.g., Finland, Sweden),English settings are required to investigate their received complaints, and reportwhether they are ‘well-founded’²⁴. Although, in theory, local investigations enable hospitals to actionimmediate improvements, our study suggests this may only occur for the smallproportion of complaints that are corroborated by internal points of view, oralready part of existing quality improvement workstreams, and thus reflect thealready known and managed. This serves not only to uphold unequal power dynamicsthrough assuming the superiority of clinical perspectives, but also negates theprecise value of complaints as a means to uncover problems that tend to be missed,discounted or underappreciated by those within institutions. Unsafe or poorpractices in healthcare often reflect issues that are normalised and thus, to someextent, blind to those enacting them.²⁵ Dissonant, outsider perspectives, such as those captured in complaints, areneeded to highlight and challenge these practices.^2,26

Further, asking hospitals to grade their own homework carries particular risks in thecontext of organisations with poor safety culture. The impact of a hospital’s sharednorms, values and beliefs on the effectiveness of safety practices is well known inthe case of incident reporting systems and safety investigations,^{27, 28} and may havesimilar effects on a hospital’s conduct of complaints investigations – meaningcomplaints mechanisms may be least effective in settings where they are mostneeded.

Although national efforts have been made to improve learning through national datacollection systems (e.g. ‘KO41a’¹⁸), this did not generate meaningful quality monitoring outputs at theinvestigated setting. This is in sharp contrast to the growing body of research thathas developed and validated methods to reliably analyse complaints.²⁹ Regardless, it can be argued that narrative and dialogical approaches thatenable the juxtaposition of sensemaking between patients and providers, such aspatient involvement in investigations, listening clinics or public committees, mayoffer greater potential in understanding the needs and experiences of patients, anduncovering the implicit assumptions, beliefs and practices that make organisationsunsafe.

Study strengths and limitations

Although findings resonate with earlier reviews at other English NHS settings,^{8, 12} itmust be noted that this study was conducted at a single multi-site NHSorganisation, meaning that the findings cannot be assumed to begeneralisable across settings or countries. To aid interpretation offindings relative to other settings, a detailed description of the studysetting was included. A strength of the case study design was that itallowed for an in-depth exploration of enactments and adverse impacts ofnational policies in local practice.³⁰

Critically, ‘work-as-imagined’ often varies from ‘work-as-done’.³¹ We aimed to gain insight on the latter by querying the activities ofstaff (‘what do you do?’, ‘what do you do next?’, ‘and then?’),triangulation with policy documentation, problem prompts and alternativerepresentations. However, given that the study predominantly relied oninterviews, the data represent a mix of how staff envision they are requiredto conduct the work and how this can play out in different ways, and weacknowledge that the study would have benefited from directobservations.

Conclusion

This study has contributed to existing evidence by demonstrating how challenges totranslating complaints into quality improvement can originate from nationallydefined policies and regulations for complaint handling. Recommendations for changeinclude patient involvement in complaints investigations, the establishment ofindependent investigation bodies, and more meaningful data analysis strategies touncover and address systemic causes behind recurring complaints at national andorganisational levels.

Supplemental Material

sj-pdf-1-jrs-10.1177_01410768221098247 - Supplemental material for Donational policies for complaint handling in English hospitals supportquality improvement? Lessons from a case study

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Supplemental material, sj-pdf-1-jrs-10.1177_01410768221098247 for Do nationalpolicies for complaint handling in English hospitals support qualityimprovement? Lessons from a case study by J van Dael, TW Reader, AT Gillespie, LFreise, A Darzi and EK Mayer in Journal of the Royal Society of Medicine

Footnotes

Competing Interests None declared.

Funding: This work is supported by the National Institute for Health Research (NIHR)Imperial Patient Safety Translational Research Centre and Imperial CollegeLondon. Infrastructure support was provided by the NIHR Imperial BiomedicalResearch Centre. The research was enabled by the iCARE environment and used theiCARE team and data resources.

Ethics approval: Not applicable (this study was conducted as part of a service evaluation).

Guarantor: EM.

Contributorship: This manuscript was written by JD with comments from AG, TR, and EM. Analysis wasconducted by JD and LF. JD, AG, TR, AD and EM contributed to theconceptualisation of this study. All authors reviewed and approved themanuscript.

Acknowledgements: We thank the reviewers for their insightful comments on an earlier version ofthis manuscript.

Provenance: Not commissioned; peer-reviewed by Peter Ross, Bill Kirkup, Charles Vincent andJulie Morris.

ORCID iDs: J van Dael https://orcid.org/0000-0002-9949-5802

AT Gillespie https://orcid.org/0000-0002-0162-1269

Supplemental material: Supplemental material for this article is available online.

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