Why do patients complain? • Diagnostic problems - around 30 per cent • Following a bereavement - 24 per cent • Long term monitoring of chronic diseases - around 17 per cent • Perceived rudeness of the doctor or other members of staff - around 10 per cent
BG born January 2001 • I was a registrar in practice • I knew mum well, she attended fairly frequently and usually with low mood • First visit within a couple of weeks of birth, he had an URTI, mum mentioned his stools were a bit hard.
The first error! • BG was visited prior to registration on the computer system, the record of this visit never made it into his computer notes and was in fact lost.
I did BG’s 6 week check. He was developing normally, I gave advice about his hard stool and advised re fluids
The second error! • Once more – the entry was made into the child’s ‘red book’ and written on a Lloyd George card to be entered into the records once the child was ‘put on’ the computer. The record was not transferred.
The child attended for routine vaccinations, teething, ear wax, URTIS, otitis media. • The health visitors assessed the child at home for routine appointments – comment was made of constipation and advice re diet given.
The third error! • Health visitors made no computer notes, their records were kept separately and were inaccessible to other members of the primary health care team
Sept 2002 – BG was now about 18 months old and attended with diarrhoea + vomiting over 7 days, the rest of the family were also affected. He was not dehydrated. Stool was sent for culture and he was well and eating normally at review 4 days later.
November 2002 child was seen with a history of constipation, and occasional diarrhoea. Bowels were opening every 6-8 days, he was given lactulose.
Error number 4 • No attempt was made to explore the duration of the history of constipation, no follow up was arranged.
February 4th 2003 I saw BG for his next CHS check. I recorded that height and weight were both above the 75th centile, he was taking lactulose once daily and that his stool was soft and regular. I noted that reducing his medication lead to constipation. • February 25th I reviewed his bowel habit, his stool was still soft, though at times he might go a week without opening his bowels. He was not in any discomfort. I continued lactulose.
June 2003 BG was seen by a colleague constipated + overflow. Lactulose was ‘restarted’ with fluids and an appointment made for reivew in 2w • Mum returned to report that the lactulose had not helped and she wanted a referral. A paeds referral was made and senna was added to the regimen.
Error number 5 • The referring doctor did not examine the patient though mum expected him to do so. This later became one of the points which angered mum most.
October 2003 – child was seen by paediatrician, diagnosis of constipation was made and he was continued on current therapy. • December 2003 – I reviewed him, mum was titrating the laxatives with support from the community paediatric nurses, no soiling or distress, bowels open once a week.
January 2004 mum brought BG to surgery with history of 11 days without stool and some overflow. No discomfort, abdomen soft but distended and non tender. Bisacodyl supps given, f/u arranged later that week with community nurses, re-referred back to paediatrician and parents advised TCI if BG distressed.
Later that day BG admitted by Westcall to RBH. Treated with enemas for constipation. Condition worsened, transferred to JRH, where diagnosis of short-segment Hirschprung’s disease was made and child underwent surgery.
The complaints • Failure to diagnose (situation exacerbated by inflammatory comments made by paed surgeon in JRH) • Failure to examine • Failure to take mum’s concerns seriously
What happened next • Meeting with mum + a friend + GB (as our complaints partner) + practice manager + me
Error number 6 • I was NOT prepared. Did not know full facts of the case as had not been involved in latter part of the story. • Was unprepared for mother’s reaction • Other partners involved were not there
The GMC requires doctors to give a patient who complains (or their proper representative): • "a prompt, open, constructive and honest response. This will include an explanation of what has happened, and where appropriate, an apology."
Consider patient confidentiality • There is a time limit • Type the response • Identify yourself
The response should be capable of standing on its own. • Give a factual chronology of events as you saw themSpecify which details of your account are based on: (1) memory, (2) contemporaneous notes and (3) "usual" or "normal" practice • Say not only what you found, but also what you looked for, and failed to find • Respond to each and every concernIf a complaint involves more than one clinicianSay sorry where appropriate
Enclose a photocopy of the contemporaneous clinical notes • Do not alter the notes. • Style • Avoid the use of jargon or medical abbreviations • Write in the first person. • Finally, advise the complainant of their right to seek an independent review by the Healthcare Commission
Complainants who are not satisfied with the outcome of local resolution may request an independent review by the Healthcare Commission (the Commission).
The complainant must request a Commission review within two months (or as soon as is reasonably practicable) of the date on which the written response under local resolution procedures was sent to the complainant. The request can be made direct to the Commission, or to the NHS trust or PCO, which was the subject of the complaint. These bodies are required to forward such requests to the Commission immediately, together with a copy of the local resolution response and any other relevant documents. • In its initial stage, the review will be carried out by a member of the Commission staff (a case manager) who is able to seek advice from expert patients as well as clinicians.
The case manager has a range of options available which include: • taking no further action • referring the complaint back to the NHS body or primary care provider with recommendations of action that might be taken to resolve it • referring the complaint for further action or investigation, to the GMC, employing trust or the Health Service Ombudsman for example • investigating the complaint further which can include referring it to a panel.
The Ombudsman can also consider complaints brought by the subject of the complaint about the independent review stage, complaints referred by the Healthcare Commission and grievances about the administration of the complaints procedure itself. • The complaint must be referred to the ombudsman within 12 months of the final correspondence from the independent review stage.
Investigation • If an investigation goes ahead, the practical aspects are usually undertaken by the Ombudsman's representative, who will interview all those involved. While a professional "friend" may accompany a doctor to the interview, a detailed discussion with one of the MDU's medico-legal advisers in advance of the meeting is usually the most appropriate and useful form of assistance.
The Ombudsman's final report is sent to all interested parties. It is also sent to the chief executive of the trust or PCO for action on any recommendations made. A copy is also sent to the Secretary of State and published, in anonymised form, on the Ombudsman's website
A confidential draft report is prepared for the complainant and doctor to check for accuracy. The parties may need to obtain professional advice at this stage and doctors may seek the MDU's assistance in preparing any statement to correct errors of fact. A doctor may not challenge the conclusions that the Ombudsman draws from the agreed facts of the case, though representations can sometimes be made in relation to the conclusions and recommendations.
Complaints Procedure at T.S. • Tilehurst Surgery conforms to the NHS requirement of having in place a Complaints Procedure that is comprehensive, thorough and sympathetic. • Upon receipt of a complaint you will receive an acknowledgement from a member of the administrative staff within 48 hours and a letter from the designated complaints partner at Tilehurst Surgery, currently Dr. Boulos, within 7 days outlining the plan of action and proposals to deal with your complaint. • An initial interview would be offered to explain the nature of the grievance and a meeting is convened with the clinician involved and this is normally held at Tilehurst Surgery at 7.00 p.m. on a Monday evening. On that occasion the in-house records are fully displayed for inspection by the patient or their relatives upon consent of the patient. This is known as Stage 1 or in-house procedure.
Should the matter not be resolved to your satisfaction by the end of that stage you will be directed by the Complaints Partner to the next stage in the procedure which is Stage 2 and that is to be invoked within 28 days of receiving a letter from the Complaints Partner closing Stage 1. The letter will explain to you how to contact the West Berkshire Primary Care Trust who will decide whether to convene an Independent Review Panel or alternatively appointment a conciliator to take the in-house procedure one step further. • Stage 3 would be to approach the NHS Ombudsman having failed to be satisfied with Stages 1 and 2 to that point and subsequently it would be a matter for the courts should the grievance still not be settled • The Healthcare Commission is an independent body established to promote improvements in healthcare through the assessment of the performance of those who provide services. The Healthcare Commission's complaints team can be contacted at: • Peter House • Oxford Street • MANCHESTER • M1 5AN • Tel: 020 7448 9200 • www.healthcarecommision.org.uk
All doctors at Tilehurst Surgery strive to practise to the highest professional degree and we all appreciate the stress and trauma of making a complaint but we would encourage our patients to air their views should they be dissatisfied with our service and by taking the time and trouble to do so we can hopefully improve our services further still. You will be assured of a prompt, constructive and honest response, which will include an explanation of what has happened, and where appropriate, an apology. You are strongly assured that the complaint will not prejudice the care or treatment we provide or arrange for you or your family. The doctors are under duty to co-operate fully with any formal enquiry regarding the treatment of any of our patients and with any complaints procedure, which applies to their work, and by doing so we comply with the General Medical Council Regulations (can be viewed on the GMC website www.gmc-uk.org.).
Ensuring all patients registered on computer Improving communication – asking HV to enter data on computer Documenting history and examination Examining the patient Listening to concerns of the patient / parent Safety netting – arranging follow up within a set time Preparing for meetings with complaining patients BG’s case
…so, it basically boils down to …. • Communication • Documentation • Preparation ……and good insurance!!!!!
Colleagues (PHCT, secondary care) practice manager peers family defence body Appraiser Trainer/VTS GMC (guidance) BMA Who can help?
Educated PHCT re Hirschprung’s disease at complaints review Changed registration system Changed HV record keeping Significant event analysis