This Complaint Policy applies to the supply of medical services by Kinvara Private Hospital Ltd, company number 11248045, registered office 2 Clifton Lane, Rotherham, South Yorkshire, S65 2AJ.

In the event of any inconsistency between this Complaint Policy and other documentation on the handling of complaints, this Complaint Policy shall prevail. On all other matters, our Terms and Conditions take precedence.

Kinvara Private Hospital ("KPH") prides itself on providing patients the best available care. We recognise there may be times when expectations are not met. If you are not satisfied with the service you have received at Kinvara Private Hospital, it is your right to have your concerns investigated and to be given a full and prompt reply.

By reporting concerns, you help us make sure we have listened to what has been said and acted upon the feedback. This helps us create a culture of continuous quality improvement and improve the service we provide to patients in the future. All complaints are recorded in the KPH Complaint Register, and learning points are shared after every investigation.

Making a complaint will not affect the care or treatment you receive at Kinvara Private Hospital, and it will not be held against you. You will not be treated differently because you have complained.

We will deal with your complaint courteously, fairly and without unnecessary delay. We will tell you who is handling your complaint and how to contact them. If we get something wrong, we will say so, apologise, explain what happened and tell you what we are doing to put it right.

The purpose of the Complaint Policy is to make it easy for patients, or the person acting on their behalf, who are dissatisfied with our service, to raise a complaint or provide constructive criticism.

The Complaint Policy applies to both clinical and non-clinical complaints, and to complaints about the performance of healthcare professionals working at KPH.

Patients can request a copy of the Complaint Policy at any time, and it may also be downloaded from the KPH website. We will provide it in a different format on request.

A complaint may be made by a patient, by a person acting on behalf of a patient, or by anyone who has been affected by any action, omission or decision of Kinvara Private Hospital.

Where a complainant is acting on behalf of a patient, they must provide written consent from the patient before we can share confidential information with them. We will acknowledge the complaint straight away, and will explain what consent we need and why.

Where the patient has died, the complaint may be made by the named next of kin, or by a person nominated by the named next of kin.

You can complain in whatever way is easiest for you. You may write to us by letter or email, complete the Complaint Form on our website, telephone us, or speak to a member of staff in person. We will not turn away a complaint because it was not made on a particular form or sent to a particular address.

The online Complaint Form provides a structured format for setting out a complaint and helps us make sure we have the information we need to investigate thoroughly. We will offer it to you, and our Admin Team will help you complete it if you would like them to, but using it is your choice and not a condition of your complaint being investigated.

If you raise a concern verbally, we will try to resolve it there and then. If we cannot, we will write down what you have told us, send you a copy, and ask you to confirm that we have captured it correctly.

Our timescales run from the day we first receive your complaint, in whatever form it reaches us.

If your complaint is about a Consultant or an independent practitioner, please address it to KPH and to the Consultant or practitioner concerned.

Please raise your complaint within twelve months of the event you are complaining about.

We may investigate a complaint made later than this where there is good reason for the delay and it is still possible to look into the matter fairly and effectively, for example where the records and the staff involved are still available to us. If we decide not to investigate a complaint because of the time that has passed, we will tell you in writing and explain why.

This time limit does not apply to complaints about how we have handled your personal data. Those are dealt with by our Data Protection Officer under our Data Protection Policy.

Complaints about the service provided by another clinic, hospital or practitioner will not be investigated by KPH. Where we can, we will tell you who to contact. Where the care was arranged through KPH, we will help you make contact with the organisation concerned.

Complaints from employees about their employment are dealt with under our Grievance Policy rather than this policy.

Where your treatment at Kinvara Private Hospital is directly funded by the NHS, your complaint is handled under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 rather than under Stages 2 and 3 of this policy.

In those cases we will acknowledge your complaint within three working days and, at the same time, offer to discuss with you how your complaint will be handled and the period within which we expect to complete our investigation and send our response. If you would prefer not to have that discussion, we will decide the response period ourselves and confirm it to you in writing.

Our final response will be signed by the responsible person for the purposes of the Regulations, who at Kinvara Private Hospital is the Chief Executive. It will explain how we considered your complaint, the conclusions we reached and any action we are taking as a result.

If you are not satisfied with our final response, you may ask the Parliamentary and Health Service Ombudsman to consider your complaint. There is no charge for this.

The time limit for NHS-funded complaints is twelve months from the event, or from becoming aware of it, with discretion to accept a later complaint where there is good reason for the delay.

Where your treatment at Kinvara Private Hospital was arranged through another organisation that holds an NHS contract, for example where you were referred through an NHS pathway operated by an independent provider, your care is still NHS-funded and your complaint will be handled under the NHS complaints procedure rather than under Stages 2 and 3 of this policy. We will investigate the matters that concern the care you received at Kinvara, and we will work with the organisation that arranged your treatment so that you receive a single coordinated response. You will not be charged, and if you remain dissatisfied you may ask the Parliamentary and Health Service Ombudsman to consider your complaint.

For privately funded and insured patients, the Kinvara Private Hospital Complaint Procedure has three stages:

• Stage 1: Local Resolution
• Stage 2: Internal Appeal
• Stage 3: Independent External Adjudication

At the Local Resolution stage, we aim to investigate and respond as quickly as possible.

Acknowledgement

We will send you a written acknowledgement within three working days of receiving your complaint. The acknowledgement will tell you who is handling your complaint and how to contact them.

Where we are able to send you a full response within five working days, we may do that instead of a separate acknowledgement.

Agreeing the Scope of the Complaint

When we acknowledge your complaint, we will ask you to confirm that you have raised all the matters you wish us to investigate.

Where a complaint is very long, covers an unusually large number of matters, or restates the same point in several forms, we may ask you to condense it into a short statement of the issues and to tell us which three or four matter most to you, before the investigation begins.

Before the investigation begins, we will contact you in writing, by telephone or at a meeting where possible, to agree on the key issues to be investigated and the outcomes you are seeking. We will confirm this to you in writing as our understanding of your complaint. If any part of your complaint is unclear, we will ask you to clarify it.

If you believe we have misunderstood your complaint or left something out, please tell us within five working days of receiving our written summary and we will amend it. If we do not hear from you within that period, we will take the summary as agreed and begin the investigation on that basis.

The agreed summary defines the scope of the investigation and of our written response. If you raise a new matter after the scope has been agreed, we will treat it as a new complaint under Stage 1 and confirm this to you in writing. New information about the agreed issues will be taken into account where it is new and material.

Investigation Process

To determine whether your complaint can be resolved at Stage 1, we will consider four things:

• What exactly is the complaint? It is important that we have a clear understanding of your concerns, and we may ask you for further information.
• What do you wish to achieve? Clarifying the outcome you are seeking at the outset helps us establish expectations and whether they can be met.
• Can that outcome be achieved at Stage 1, for example by way of an apology or by some other means?
• Can the matter be resolved immediately?

In-Person Meetings

If you would like a meeting to help resolve your complaint, we will endeavour to arrange one between you and a representative of the Hospital. If we are unable to arrange a meeting, the investigation will still continue and we will provide a full written response.

Response Timeline

We will send you a full written response within twenty working days of receiving your complaint.

In exceptional circumstances, where there are clear and justified reasons for doing so, we may extend the timescale for Local Resolution. Where the number or complexity of the issues raised means that twenty working days is not enough to investigate them thoroughly, this is itself an exceptional circumstance justifying an extension. If we extend the timescale, we will write to you before the deadline passes, explain the reason for the delay, and tell you when you can expect our response. We will keep you updated at least every twenty working days until the investigation is complete.

If you are unhappy with our written response, you may ask us to escalate your complaint to Stage 2. Please make that request in writing within seven calendar days of the date of our response. We may accept a later request where there is good reason for the delay.

Requesting Escalation

If you remain dissatisfied following our Stage 1 response, you may request escalation to Stage 2. Please tell us in writing what it is about our response that you are dissatisfied with, so that the reviewer knows what to focus on. Reasons might include, for example, that the response did not address a particular issue, that you disagree with a finding, or that new information has come to light.

We will not refuse a request for escalation because we disagree with your reasons. Whether your complaint is well founded is a matter for the review itself.

Stage 2 considers only the issues that formed part of the agreed Stage 1 scope. If your request to escalate raises matters that were not part of that scope, we will treat those matters as a new complaint under Stage 1 and confirm this to you in writing.

Requirement for Clear Articulable Reasons

Patients who request escalation of their complaint to Stage 2 must provide clear, articulable reasons for escalation, in writing, to KPH. These reasons should be logical, transparent and easily understandable, allowing KPH to comprehend why the complaint warrants further investigation. Kinvara Private Hospital reserves the right to determine what is considered clear articulable reason(s).

Acknowledgement and Investigation

We will send you a written acknowledgement within three working days of receiving your request to escalate.

Stage 2 will be conducted by a member of the Senior Management Team who was not involved in Stage 1. They will form an independent view of your complaint and respond to you directly, setting out what they have considered, what they have found, and whether your complaint is upheld, partly upheld or not upheld.

Response Timeline

We will provide a full and final response as soon as possible, and no later than twenty working days from the date you asked to escalate. In exceptional circumstances, where there are clear and justified reasons for doing so, we may extend that timescale. If we do, we will explain the reason for the delay and tell you when to expect our response.

Surgical Outcome Complaints

If your complaint relates to the outcome of surgery, the responsible surgeon will be asked to provide a response. If the surgeon is unable to respond within twenty working days because of personal circumstances, or is precluded from responding on the advice of their medical indemnity provider, we will tell you. In the first case, we will give you an indication of when the surgeon will respond.

Kinvara Private Hospital is not required by law or by regulation to provide a third stage of independent external adjudication. We nevertheless offer this stage to patients who remain dissatisfied at the end of Stage 2, because we believe an independent view is sometimes the fairest way to close a matter.

If you wish to pursue independent external adjudication, please confirm this to us in writing within seven calendar days of receiving our final written response at Stage 2. Adjudication is available only where both Stage 1 and Stage 2 have been completed. We may accept a later request where there is good reason for the delay.

Adjudication will be sought from the Dispute Resolution Ombudsman (or suitable alternative), and the adjudication fee will be shared equally between you and Kinvara Private Hospital. We will confirm the amount to you in writing before the referral is made, so that you can decide whether you wish to proceed.

Referring your complaint for adjudication does not affect your right to take legal advice or to bring a claim.

You may raise concerns with the Care Quality Commission at any time, at any stage of this procedure. The CQC regulates the Hospital. It does not resolve individual complaints or award redress, but it may use the information you provide in its regulation of the service.

Some complaints concern events that KPH also treats as a patient safety incident, for example an unplanned return to theatre, an emergency transfer to another hospital, or unexpected serious harm. Where this is the case, the incident is recorded and investigated under the KPH incident reporting and clinical governance procedures, separately from and in parallel with the complaint.

Where an incident meets the threshold for the statutory duty of candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, KPH will tell the patient what happened, apologise, explain what further enquiries will be made, and confirm this in writing. This is done as part of the duty of candour process and does not depend on a complaint being made.

The complaint response will be consistent with the findings of the incident investigation. Where the investigation has not concluded within the complaint response timescale, KPH will explain this, respond on the matters that can be answered, and confirm when the remaining matters will be addressed. KPH may seek advice from its medical indemnity provider or legal advisers before responding to a complaint of this kind, and the timescale may be extended for that reason.

Questions Raised in a Complaint

KPH will respond to the substantive issues agreed with the patient at the start of the investigation, rather than to every question individually. Where a complaint contains a large number of questions, KPH will group them by subject, theme or in chronological order and answer them within that structure. Our response will make clear where each of the issues you raised has been dealt with. If you believe a material point has been missed, please tell us and we will consider it.

Where we have asked you to tell us which issues matter most to you, we will investigate and respond to those issues in full. Related or subsidiary questions will be answered more briefly, in proportion to their significance, rather than line by line.

For the purposes of this policy, information about the agreed issues is "new and material" only if it (a) could not reasonably have been raised when the scope was agreed, and (b) would be likely to change the outcome of the investigation. Restating, elaborating on, or drawing further inferences from matters already investigated does not meet this test. This test does not apply to a new matter, which is always treated as a new complaint.

Use of AI and Other Drafting Tools

We recognise that you may use letter-writing tools, including AI, to prepare your correspondence. This does not affect your right to have your complaint investigated. Where correspondence is lengthy, repetitive, or restates the same point in several forms, we will identify and respond to the substantive issues rather than to every restatement.

Questions About Clinical Decisions

Questions about why a clinical decision was made will be put to the clinician responsible, and our response will set out their account or, where the clinician is unable to respond, what the clinical records show.

We will tell you what our policies and professional standards required, whether they were followed, what our investigation found, and what has changed as a result. Where we find that something fell short of the standard you were entitled to expect, we will say so plainly.

We will not answer hypothetical questions about what might have happened had different decisions been made. We will not express a view on whether there has been negligence or a breach of duty, as those are legal questions that fall outside the complaint procedure and are matters for your legal advisers and for our indemnity provider.

Your Clinical Records

Patients have a right under the UK General Data Protection Regulation to a copy of the personal data KPH holds about them, including their clinical records. This is known as a subject access request and is handled separately from the complaint. There is normally no charge, and we will respond within one month. We may refuse a request, or charge a reasonable fee, where the request is manifestly unfounded or excessive, for example because it repeats a request that has already been fulfilled. Where a complaint would benefit from you having a copy of your records, we will tell you how to request them.

Meetings and Additional Questions

We will offer no more than one meeting at Stage 1 and one at Stage 2 to discuss your complaint. Meetings will have an agenda agreed in advance, limited to the issues in the agreed summary, and we will provide a written note afterwards. Further meeting requests will be declined where the issues have already been discussed or answered in writing, and we will explain why.

Questions about the agreed issues that are raised after the scope has been agreed will be added to the investigation only where they are new and material. Questions that repeat, reword or expand on matters already agreed or answered will not be added, and we will tell you so. A question about a new matter will be treated as a new complaint under Stage 1. Once our written response has been issued, further questions on the same issues will be dealt with through the escalation process rather than by further correspondence at the same stage.

KPH Policies and Procedures

Kinvara Private Hospital is an independent provider and is not subject to the Freedom of Information Act 2000. There is no general right to copies of internal policies, procedures or other hospital documents. We will, at our discretion, provide copies of, or relevant extracts from, the policies and procedures that directly govern the care complained of, where doing so helps you understand our response. Requests for all policies, or for documents that are not relevant to the matters complained of, will be declined.

Investigation Documents

Internal incident reports, statements taken from staff, root cause analyses, correspondence with indemnity providers or legal advisers, and other documents produced for the purposes of the investigation are not disclosed as part of the complaint response. Our response will set out the findings of the investigation and any actions taken.

Employees and healthcare professionals are not authorised to make any statement accepting responsibility or admitting liability until the complaint has been fully investigated and any statement has been authorised by Kinvara Private Hospital.

If you begin legal proceedings, indicate an intention to do so, or if we receive a Letter of Claim or a Letter of Notification, we will continue to handle your complaint. Where a particular issue cannot properly be answered while a claim is being considered, because it goes to the question of liability, we will tell you so, explain why, and answer the remaining issues.

Where it is necessary to pause the complaint, or part of it, we will confirm in writing which issues are paused, the reason, and when we expect to return to them. Our obligations under the duty of candour apply whether or not a claim is in prospect.

Where your treatment was funded by the NHS, your complaint will be investigated and responded to in accordance with the 2009 Regulations whether or not a claim is in prospect.

We will handle your complaint in confidence. Complaint records are kept separately from clinical records, so that your complaint does not form part of your medical record and is not accessible to staff who do not need to see it.

Confidentiality does not mean secrecy. We will normally tell a member of staff when a complaint has been made that relates to them, so that they have a fair opportunity to respond.

Complaint records are retained in accordance with our records retention schedule and are then securely destroyed. Our Privacy Notice explains how we handle your personal data and your rights in relation to it.

If you need help to make or pursue a complaint, please tell us. We can provide this policy and our correspondence in other formats, communicate with you in the way that suits you best, and make other reasonable adjustments to our process to meet your needs. If you ask for an adjustment that we are unable to make, we will explain why.

You are welcome to be supported by a family member, friend, advocate or representative at any stage. Where they will be communicating with us on your behalf, we will need your written consent.

Complaints are reviewed by the Senior Management Team and reported to the Medical Advisory Committee. We record the themes arising from complaints, the actions taken as a result, and whether those actions were completed.

Where a complaint identifies a failure in our service, we will take proportionate action to put it right, and we will tell you what that action is. We provide the Care Quality Commission with information about complaints and our responses to them when it asks us to do so.

Kinvara Private Hospital is committed to dealing with all complaints in a fair and impartial manner. We recognise that patients may act out of character in times of frustration or distress, and that there may have been upsetting or distressing circumstances leading up to a complaint.

However, we reserve the right to take action where a complainant behaves in a way that hinders the consideration of their complaint, because of the frequency or the nature of their contact with the Hospital.

Examples of Unreasonable Behaviour

Examples of unreasonable behaviour include, but are not limited to, a complainant who:

• refuses to articulate their complaint, or to specify the grounds of the complaint or the outcomes sought, despite offers of assistance;
• refuses to cooperate with the complaint investigation process;
• refuses to accept that certain issues are not within the scope of the complaint procedure;
• insists on the complaint being dealt with in ways that are incompatible with the complaint procedure or with good practice;
• introduces trivial or irrelevant information that they expect to be taken into account;
• insists that unrelated questions be answered immediately and to their own timescales, after the scope of the complaint has been agreed and explained;
• makes unjustified complaints about staff who are trying to deal with the issues raised, and seeks to have them replaced;
• changes the basis of the complaint as the investigation proceeds;
• repeatedly reframes or resubmits the same substantive complaint in expanded form after receiving a response, without new information that could not reasonably have been raised earlier (raising a genuinely new matter is not unreasonable, and will be treated as a new complaint);
• repeatedly makes the same complaint, despite previous investigations or responses concluding that the complaint has no merit or has been addressed;
• refuses to accept the findings of the investigation despite proper implementation and completion of the complaint procedure;
• seeks an unrealistic outcome, or expresses an intention to pursue the complaint until that outcome is achieved;
• makes excessive demands on staff by frequent, lengthy and complicated contact, in person, in writing, by email or by telephone, while the complaint is being dealt with;
• uses abusive, discriminatory or intimidating language;
• knowingly provides false information;
• publishes false or misleading information on social media or other public forums.

We ask that you limit your correspondence with us while your complaint is being progressed. Repeated contact by letter, telephone or email can delay the outcome being reached.

Actions We May Take

The decision on whether a complainant is behaving unreasonably rests with the Senior Management Team. Wherever possible, a member of the team will discuss the concern with the complainant first. If the behaviour continues, the Senior Management Team will write to the complainant explaining which aspect of their behaviour is unreasonable and what action we will take. This may include, but is not limited to:

• asking that they communicate with us by email only;
• asking that they contact one particular named member of staff;
• restricting telephone calls to specific days and times;
• asking that they adhere to a Code of Conduct setting out expectations for future contact;
• terminating contact.

Any restriction will be decided by the Senior Management Team, explained in writing with reasons, and will use the least restrictive option that addresses the behaviour. Restrictions will be time-limited, with a review date stated at the outset, and will be reviewed at least every twelve months while they remain in place. Before imposing a restriction we will consider whether the complainant has a disability or other need that requires a reasonable adjustment. A complainant may ask for a restriction to be reviewed by a Director who was not involved in the decision.

A restriction relates to the way in which contact takes place. It does not prevent us from considering a genuinely new complaint, and it does not affect the patient's care or treatment.

Where we have responded fully to all the issues agreed with the complainant and the complaint procedure has been completed, we will write to confirm this and to explain that further correspondence on the same issues will be acknowledged but not answered unless it raises new and material information.

Kinvara Private Hospital and its consultants may decline to accept a patient for treatment, or may end a course of treatment. This is a clinical and professional judgement. Reasons may include, but are not limited to:

• the proposed treatment is not clinically appropriate, or is not in the patient's best interests;
• the outcome the patient is seeking cannot realistically be achieved;
• the patient declines a further consultation, investigation or assessment that the consultant considers necessary before proceeding;
• the patient is unable or unwilling to follow the pre-operative or post-operative instructions on which safe treatment depends;
• the relationship of trust between the patient and the treating team has broken down;
• the patient has behaved in a way that is abusive, intimidating, discriminatory or violent towards our staff or other patients.

Making a complaint, or expressing dissatisfaction with any aspect of our service, is not a reason to decline or end treatment and will not be treated as one.

Where we decline to treat a patient, we will tell them in writing and give the reason. Where the decision is a clinical one, we will advise the patient to discuss the alternatives with their GP or to seek a further opinion elsewhere, and we will provide any information reasonably needed to allow another provider to take over their care.

A patient who believes such a decision was reached unfairly, or was communicated poorly, may complain about it under this policy. The complaint procedure cannot, however, require a consultant to carry out an operation that they do not consider clinically appropriate.

While all surgeons and healthcare professionals must meet certain education, training and experience requirements to practise at KPH, the Hospital is not responsible for, and does not necessarily agree with, opinions they express on their personal platforms such as social media.

This is version 3.0 of the Complaint Policy, last updated on 26 September 2026. It is due for review on 26 September 2028.