Significant event review – Patient complaint

(Being Open)

Pete Wilkinson

Clinical Governance Leads Meeting

24th May 2006

Shared knowledge

Only patient knows

Only doctor knows

the unknown

area

knows doesn’t know

knows

Doesn’t know

Doctor

Patient

Patient History

• Mr E

77 years old

Traveller

Enjoys outdoor life

Previous Medical History

# Dislocation RTA right hipType 2 DiabetesPVD (left fem-pop bypass)Asthma -> COPDLifelong smokerIHDGeneralised moderate OAPsoriasis

Presented c/o pain in Achilles region right legNo h/o injury, gradual onsetNo new clinical signs (cf records inc DM annual review documenting reduced/absent peripheral pulses)No signs suggesting DVTManaged conservatively with analgesics-

some benefit

Seen 3 times in next 2 weeksPhone advice twiceSymptoms and signs unchangedUntil significant worsening over W/EPresented at A&EAdmitted under Vascular SurgeonsDiagnose with ischaemic right lower legB/K amputation performed

Consultant advised patient GP care was“Sheer negligence”

Other hospital staff reinforced this“He should sue”“He should complain”

Patient made a complaint via PCT

Complaint received by PracticePM acknowledged receipt and outlined response planComplaint passed to PW (patient’s usual GP and involved in recent care)GPs contacted Defence organisationsGPs compiled single amalgamated responseDefence organisations advised,and the report was amended accordingly

Patient requested home visit from PW

Discussion re appropriateness of visit

PW visited:- Discussed events

“Sorry” re effects on him, his wife,

loss of lifestyle, future health

Avoided criticising others

Avoided accepting responsibility or negligence

Parted on good terms

Response to complaint sent to PCT

Patient accepted response -Would prefer not to take complaint

further -Did not feel all points had been completely addressed -Wished to remain registered with

the practice -Was grateful for the way the

complaint was handled

Practice SEA Meeting (Multidisciplinary)

Importance of good documentationPersisting unexplained symptoms warrant careful (re-)assessmentA complaining patient still registered still entitled to full Medical ServicesDiscussing issues with complaint pending is ok - whoever initiates itSatisfied patient = best outcome for doctorsFollow up needed with Consultant

PW discussed both clinical and complaint issues with Consultant

Problems of criticising others without full facts

A patient always has the Right to complain- but not necessarily the Reason to complain

Patient remains registered with the practiceWheelchair dependent most of timePhantom limb painNo longer “travels”- furthest trip is to L&D Limb Fitting Centre

Doctor-Patient relationship enhanced by having dealt with the issues

“More Open”

OPEN BLIND

HIDDEN UNKNOWN

Dr knows this Dr Doesn’t know this

Patient knows this

Patient doesn’t know this

10 Key Principles of Being Open

1 Acknowledgement

2 Truthfulness, timeliness and clarity of communication

3 Apology

4 Recognising patient and carer expectations 5 Professional support

6 Risk management and systems improvement

7 Multidisciplinary responsibility

8 Clinical governance

9 Confidentiality

10 Continuity of care

Key Steps to Being Open

1 Identify Senior Professional Lead and Patient Advocate (if appropriate)

• PW Fulfilled criteria for first role• PCT ie PALS manager able to fill second role if needed

Key Steps to Being Open

2 Meet with relevant multidisciplinary team who were involved in the incident to gather facts

• GPs involved in care• PM and Lead GP re response to complaint• GPs and Defence organisations

Key Steps to Being Open

3 Assess level of incident and response Incident Action

No harm (including prevented patient safety incident) 

Patients are not usually contacted or involved in investigations and these types of incidents are outside the scope of the Being Open policy. Individual healthcare organisations decide whether ‘no harm’ events (including prevented patient safety incidents) are discussed with patients and/or their carers, depending on local circumstances.

Low Harm Unless there are specific indications or the patient requests it, the communication, investigation and analysis, and the implementation of changes will occur at local service delivery level with the participation of those directly involved in the incident. Communication should take the form of an Open discussion between the staff providing the patient’s care and the patient and/or their carers. Reporting the risk will occur through standard incident reporting mechanisms and be analysed centrally to detect high frequency events. Review will occur through aggregated trend data and local investigation. Where the trend data indicates a pattern of related events, further investigation and analysis may be needed.

Moderate harm, severe harm or death

A higher level of response is required in these circumstances. The Director of Patient Services (BHPCT) or Director of Care (BPCT) should be notified immediately and be available to provide support and advice during the Being Open process if required. The policy that relates to a Serious Untoward Incident should be implemented.

What should a GP Practice do?

• Comply with Practice Complaints Procedure

• SEA Review Meeting

• Individual Reflection (Appraisal)

• Act on conclusions

• Share learning with colleagues via PCT

• Inform NPSA via PCT Incident Form

Key Steps to Being Open

4 Notify relevant persons

• Patient• Carer• Colleagues involved in incident• Defence Organisation• PCT• NPSA

Key Steps to Being Open

5 Identify staff who will meet with patient/carer PW in this caseAlternatives and additions were offered

Key Steps to Being Open

6 Discuss with patient/carers the option of meeting to discuss the incident and agree with them who they wish to have present

Patient and his wifeThey were asked if they wished to have anyone else

present

Key Steps to Being Open

7 Plan and arrange the meeting at a convenient time for both parties

Key Steps to Being Open

8 Document the meeting

Consultation recorded in patient’s medical recordsRecorded as part of SEA MeetingRecorded in separate documentation for medicolegal

purposes

Key Steps to Being Open

9 Communicate the outcome of the meeting to the patient/carer and other relevant professionals

Patient and his wife aware of outcomes at end of consultation

But no further documentation sent to them from practice

Key Steps to Being Open

1. If the case if concluded then no further action is required

 2 If the case requires further investigation this should be

done using the PCT’s Root Cause Analysis template or for more serious incidents the CRU London Protocol (both available on PCT website)

 3 Communicate the results of the investigation to

patient/carer and other relevant professionals

QUESTIONS??