Much of the NHS is failing to implement basic measures to prevent and resolve complaints, a watchdog has said.
The commission cited the case of a 91-year-old woman
The Healthcare Commission analysed 16,000 complaints which it had received since July 2004, with many involving poor communication from NHS staff.
The management of care for elderly patients was a significant issue.
The commission cites the case of a 91-year-old woman in its report. Her family made a complaint about the way she was discharged from hospital.
She had been admitted to hospital with pneumonia, but was the main carer for her husband who was blind and who has arthritis.
After a week she was discharged from hospital at short notice.
Her family were concerned she had been made to leave her bed and sit around for hours waiting to be discharged, even though her mobility was still limited.
She also had problems with the drugs she would need to take.
Her family cared for her, but she had to be readmitted to hospital after four days after an emergency call from her GP.
The family complained to the trust, who arranged a meeting.
But this did not take place until seven months later, partly due to the trust's failure to respond to the family's concerns about bed-blocking - which was what they believed lay behind their relative's speedy discharge.
When the two parties did meet, the trust admitted it had failed to follow the correct procedures in discharging this patient.
Although doctors maintained she had been fit enough to go home, the trust did admit that there had been no consideration of recuperative care or of her social circumstances.
The complaint was then referred to the Healthcare Commission which found the discharge had been handled badly, with too little notice given to the patient and her family of the plans to discharge.
The commission told the trust it should improve its procedures and inform the patient's family of the outcome.
The trust then brought in more robust policies and staff training as well as promising to create a new information booklet for patients.
It also met the family and wrote a letter of apology to the patient.
The patient's son wrote to the Healthcare Commission saying that the review had resulted in "an unequivocal apology... and a clear statement of intent to produce a booklet which will go a long way to avoid a repetition of the problems we had".