Complaints Procedure

If you have concerns about your experience with the Trust, if something has gone wrong or you are dissatisfied and wish to make a complaint, please tell us.

The following information describes our complaints procedure and how to make a complaint. It also tells you about how your complaint will be handled and what you can expect from us.

The Trust complaints procedure is in line with the Northern Ireland Public Services Ombudsman’s (NIPSO) Health and Social Care, Model Complaints Handling Procedure, 1 July 2025.

What is a complaint?

The Trust regards a complaint as:

“Any expression of dissatisfaction by one or more members of the public about our action or lack of action, or about the standard of service provided by us or on our behalf.”

If you need to complain about something, you are encouraged to do so. Your complaint may involve more than one Health and Social Care (HSC) body or service, or relate to both HSC services, or it may be about someone working on the Trust’s behalf.

Complaints about an independent sector provider, contracted to deliver a service on behalf of the Trust, should be raised with the provider directly.

What the Complaints Procedure covers

Complaint issues can include a range of areas such as:

• Failure or refusal to provide a service
• Inadequate quality or standard of care and treatment, or an unreasonable delay in the provision of care
• Failure to properly implement or follow policy, procedures and standards
• Failure to properly apply law, procedure or guidance when delivering services
• Failure to follow the appropriate administrative process
• Poor conduct, behaviour or attitude of a member of staff
• A concern about the actions or service of an organisation who is delivering services on our behalf
• Disagreement with a decision (except where there is a statutory procedure for challenging that decision, or an established appeals process).

NHS Scotland Complaints procedure

What can’t be dealt with through the Complaints Procedure

There are some areas which the Trust are unable to manage through the Complaints Procedure. These include:

• Routine first-time service requests
• Fitness to practice issues referred to a professional regulatory body (however, the issue will require careful examination, as there may be elements which can proceed under the guidance of this policy, with fitness to practice issues being dealt with by the regulator and/or the Trust via its Human Resources (HR) policies)
• Requests for a second opinion in respect of care or treatment
• Serious Adverse Incidents (SAI) involving the Trust (aspects of the complaint which are not being addressed within the scope of the SAI review will proceed to be managed in accordance with this policy)
• Legal claims for negligence seeking compensation
• Coroner’s cases
• Complaints relating to criminal conduct or a criminal investigation (an active complaint may be paused whilst this review continues and should be agreed with the organisation undertaking the criminal investigation and communicated to the service user)
• Requests for information under the Data Protection or Freedom of Information (Northern Ireland) Acts and requests for reviews of decisions under these statutory regimes
• Where there is an established appeals process applicable to the service.

• Staff grievance or a grievance relating to employment or staff recruitment (managed under other Trust procedures)
• Disciplinary investigations
• Whistleblowing
• Children Order representations
• Protection of vulnerable adults
• Independent Inquiry

We also realise that it is not possible to list everything that you cannot complain about. If other procedures can help you resolve your concerns, you will receive information and advice regarding this.

Who can complain?

Anyone who receives, requests or is directly affected by our services, or a service contracted or commissioned by us, can make a complaint. This includes the representative of someone who is dissatisfied with our service (for example, a relative, friend, advocate or adviser). If you are making a complaint on behalf of someone else, this will normally require the person’s verbal or written consent. Please also read the sections on Getting help to make your complaint and consent.

How do I complain?

You can complain in person by speaking with any member of the team where you have received care, treatment or advice, or where the event that you want to complain about happened.

It is easier for us to resolve complaints if you make them quickly and directly to the service concerned. Staff will always try to resolve any problems on the spot if it is possible to do so.

You can also complain by:

• completing the online web form,
• email,
• phone, or
• in writing

When submitting your complaint, please tell us:

• your full name and address
• your phone number, if you are happy to provide it, so you can be contacted to discuss your complaint in more detail
• your email address (if this is your preferred method of contact)
• the full name, address and date of birth of the person affected, if you are complaining on behalf of somebody else
• as much helpful detail as you can about the complaint
• what has gone wrong
• what outcome you are seeking, and
• how you would like us to communicate with you

Providing this information will help us to clearly identify the problem within your complaint and what needs to be done to resolve matters.

Contact details are as follows:

Service User Feedback Team

Southern Health and Social Care Trust

Clinical and Social Care Governance Department

Lurgan Hospital Site

100 Sloan Street

Lurgan

BT66 3NX

Telephone: 028 3756 4600

Email: serviceuserfeedback@southerntrust.hscni.net

How long do I have to make a complaint?

NIPSO MCHP guidance recommends that you make your complaint within six months of:

• the event you want to complain about, or
• finding out that you have a reason to complain

Staff may consider complaints raised outside of this timescale. For example, where issues such as bereavement, poor health, communication difficulties, serious patient safety concerns or limited support have delayed the complaint.  If you feel that the time limit should not apply to your complaint, please explain why. If that the complaint cannot be reviewed, you will be notified in writing explaining the rationale.

Expected Behaviour

The Trust recognises that people may act out of character in times of trouble or distress. Sometimes a health condition or a disability can also affect how a person expresses themselves. The circumstances leading to a complaint may also result in the service user displaying unacceptable behaviours.

Service users who have a history of challenging or inappropriate actions, or have difficulty expressing themselves, may still have a legitimate grievance, and it is important that all complaints are taken seriously. However, the actions of some service users may result in unreasonable demands on time and resources or unacceptable behaviour towards staff.

The Trust will provide prior warning to the service user of their intention to impose any restriction unless doing so would create an unreasonable risk. Any actions taken to restrict an individual’s access to the complaint’s procedure will be proportionate and be proactively reviewed. Service users will be advised if/when any restrictive measures have been removed.

Responsibilities of complainants

As a service user of the Trust, you have the right to expect the best possible services. If this doesn’t happen, you have the right to complain. When you complain, you are requested to follow these guiding principles:

• Provide adequate details of your complaint
• Set out clearly the cause for dissatisfaction
• Provide accurate details and supporting correspondence or other relevant supporting evidence
• If there has been a delay in submitting your complaint explain the cause of that delay
• Explain what you believe to be a satisfactory outcome
• Treat our staff with good manners, politeness and respect at all times
• Accept that the Trust will act fairly and promptly in dealing with your complaint
• Be reasonable, open minded and listen to reasonable explanations; and
• Be realistic as it may not always be possible to achieve the outcome you want.

What happens when I have complained?

You will always be informed of who is dealing with your complaint and/or provide you with contact information should you have further queries.  Our Complaints Procedure has two stages:

Stage One: Frontline Response

The aim is to resolve complaints quickly and close to where the service was provided. Where appropriate, this could mean an on-the-spot apology and explanation if something has clearly gone wrong, with immediate action to resolve the problem.

Sometimes there may have to be enquiries made to obtain information before responding to your complaint. It is our aim to give you a response at Stage One within 5 working days or less, however there may be circumstances where more time is needed to provide you with a full and complete response. If this is the case, a response will be provided within 10 working days.

If the complaint cannot be resolved at this stage, you will be informed of what you can do next.  An explanation regarding a more detailed investigation may be required under Stage Two of the Complaint Procedure.

Should you remain dissatisfied with the Stage 1 response please outline what remains outstanding and what outcome you are looking for. This should be done within 30 days of receiving the response outcome for Stage One of the process. In exceptional circumstances, the Trust may be able to accept a Stage Two complaint after the time limit and if you feel that the time limit should not apply to your complaint, please explain why.

Stage Two: Investigation

Stage Two deals with two types of complaints:

• those that have not been resolved at Stage One, and
• those that are complex and require a detailed investigation that cannot be achieved within Stage One timescale.

At Stage Two the Corporate Service User Feedback team will:

• acknowledge receipt of your complaint within 3 working days
• where appropriate, discuss your complaint with you to understand why you remain dissatisfied and what outcome you are looking for
• try to resolve the complaint where possible through alternative resolution approaches such as mediation or conciliation; and
• explain the timeframe for a Stage Two written response, which should be provided within 20 working days.

If the investigation will take longer than 20 working days, you will be informed, outlining revised timeframes for a response and keep you updated on progress.

NHS Scotland Complaints procedure

What if I’m still dissatisfied?

After you have received the final response, if you are still dissatisfied with either the decision or the way in which the complaint was dealt with, you can ask the Northern Ireland Public Services Ombudsman (NIPSO) to look at it.

NIPSO is a free, independent organisation that investigates complaints and are the final stage for complaints about HSC services in Northern Ireland.  NIPSO is not an advocacy or support service (however there are other organisations who can help you with advocacy or support details are available on request.

NIPSO generally expect complaints to be brought to them within six months of you receiving a response from us informing you that the complaints procedure is complete and of your right to refer your complaint to NIPSO.

NIPSO will generally ask you to provide details of your complaint and a copy of our final response to your complaint.

You may wish to get independent support or advocacy to help you progress your complaint with NIPSO.

NIPSO’s contact details are:

The Northern Ireland Public Services Ombudsman
33 Wellington Place
Belfast
BT1 6HN

If you are writing to NIPSO, simply write on the envelope: FREEPOST NIPSO and it will be delivered free of charge.

Freephone: 0800 34 34 24
Email: nipso@nipso.org.uk
Web: NIPSO (link opens in new window)

If you would like to visit the NIPSO office in person, you must make an appointment.

If NIPSO cannot investigate your complaint and your complaint requires an alternative route for independent review, NIPSO will tell you and provide you with the relevant contact details.

Getting help to make your complaint

We understand that you may be unable, or reluctant, to make a complaint yourself. The Trust accepts complaints from a representative (friend, relative, or an advocate) as long as you have given permission for us to deal with that person.

The Patient Client Council (PCC) (link opens in new window) is an organisation that provides free and confidential advice and support to patients and other members of the public in relation to HSC services. The service promotes an awareness and understanding of the rights and responsibilities of patients, advising and supporting people who wish to make a complaint about a HSC organisation. Further information and contact details can be found on the PCC web site https://pcc-ni.net or email: info@pcc-ni.net or by telephoning on 0800 917 0222.

The Trust is committed to making our services easy to use for all members of the community. In line with our statutory equality duties, reasonable adjustments can be made to help you to access and use our services. If you have trouble putting your complaint in writing, or want this information in another language or format, such as:  tell a member of staff, contact us through an interpreter (if required) on 028 3756 4600 or email us at serviceuserfeedback@southerntrust.hscni.net

Consent

When a complaint is reviewed, a service user’s health or social care record may need to be reviewed, in order to provide a full response.

It is good practice for us to explain what information may be shared, why it might be needed, and who may have access to it. Only staff directly involved in investigating the complaint will see this information, and it will be used solely for that purpose.

If a service user prefers that their information is not shared, this will be respected. However, this may limit what can be investigated or the outcome. In some cases, the investigation may have to continue, if there is an overriding public interest, such as a concern for safety.

Complaints by a third party should be made with the verbal or written consent of the individual concerned. There will be situations where it is not possible to obtain consent, such as when the:

• Individual is a child and not of sufficient age or understanding to make a complaint on their own behalf
• Individual is incapable (for example, rendered unconscious due to an accident)
• Individual has impaired judgement as a result of a learning disability, mental illness, brain injury or serious communication problems)
• Subject of the complaint is deceased, and
• Delay in the provision of consent may result in a delay in the resolution of the complaint.

What does the Service User Feedback Department do?

The role of the Service User Feedback Department and staff is to provide support, advice and general assistance both to complainants and to services to ensure that complaints are answered in accordance with the established Service User Feedback procedure. Importantly, the Service User Feedback Department and its staff do not investigate complaints. When a complaint is received, this is investigated by the service about which the complaint has been made.