When the inevitable day

arrives….how to keep your cool!

Rachel Chadwick & Sarah HerbertGPVTS

27th November 2013

Learning ObjectivesO What can go wrong?O Receiving & handling a complaint

O In practice / hospital / commissioning bodyO Via GMC

O Called to an inquestO Other scenarios (sued / police)O Raising concernsO AOB

O Handouts: Chaperone, Consent, MPS handout & contact information

What can go wrong?

Clinical ScenarioO Friday afternoon, busy clinic, running lateO Mrs P, 48 yr, struggling to get appointment, rude

receptionistO PC (* 3!) Reoccurrence of ? dermatomal rash over

left buttockO ICE not fully exploredO Second opinion sought

O GP registrar: likely eczematous rash, seek advice from colleagues

O Confirmed: call pt back +/- refer to dermatologyO 4/52 later, written complaint received as no pt F/U

despite messages left at reception

Group Work

O Why do you think the patient complained?

O What would you do now?

O What outcome may the patient be expecting?

Clinical ScenarioO Friday afternoon, busy clinic, running lateO Mrs P, 48 year old lady, struggling to get an

appointment, rude receptionistO PC (* 3!) Reoccurrence of ? dermatomal rash over

left buttockO ICE not fully exploredO Second opinion sought

O GP registrar: ? eczematous rash but would seek advice from other colleagues

O Confirmed would call pt back +/- refer to dermatology

O Two weeks later, written complaint received as no pt F/U

O 70% - Poor communicationO Deserted, devalued, lacked information,

misunderstood

O Predisposing factors:O Rudeness, delays, inattentive, miscommunication,

apathy, no communicationO More than 50% were so turned off that they wanted

to sue the doctor before the alleged event occurred (Mangles 1991)

O Precipitating factors:O Adverse outcomes, iatrogenic injuries, failure to

provide adequate care, mistakes, providing incorrect care, systems error (Bunting et al 1998)

What motivates patients to complain?

Negative communication behaviour by doctors

increases litigious intent – even when there has been

no adverse outcome!! (White 2005, Lester and Smith 1993)

Handling complaints

In practice / hospitalor commissioning body

From the GMC

O Complaints manager, procedure, sign offO Validity of complaintO ? Need for investigation O Timescales

O 12 months from date of incident or complainant first knew about the matter

O Unless otherwise agreed

O 3/7 to acknowledge written complaintsO How investigate, how complainant can get advice

O 6 months, complaints manager required to explainO Unless otherwise agreed

To GP practice / hospital or commissioning body

O Discuss with your trainerO Download “Guide to the NHS and Social Care

Complaint Procedure”

O Acknowledgement letter to the complainant O unless verbal & resolved within 1/7

O Review the patient’s recordsO Draft a detailed response to each point

O Discuss the complaint at a practice meeting, especially if it involves several doctors

O Send to your Defence UnionO The complaint, your draft response, the

relevant notes & any other relevant information (Anonymous)

O Reflect! O Review the complaint: significant event analysis

O Two stages O Stage 1 Local resolution – i.e. within the

GP practice or hospital (90%)O Most complaints: resolved quickly &

efficiently

O Stage 2 Parliamentary and Health Service OmbudsmanO If complainant remains dissatisfied after stage

one may complain to the Ombudsman. O Doctors who are being complained about can

also take the case to the Ombudsman: O not satisfied with a response provided on their

behalf by a commissioning body

Complaints procedure

From the GMCO Most resolved without GMC actionO 2008: 5,000 complaints

O 80%: public, 17%: NHS, policeO Stream 1 (1,500) Serious

O Letter +/- employers details form to doctor O If proven may lead to Fitness to Practice

O Stream 2 (1,600) Refer for local investigation / No concern

O Remainder: No concern of GMC

O Contact your Defence UnionO Don’t contact GMC before you seek adviceO Gather relevant correspondence, records &

important details of the case O Statement (explained later)

Principles of good complaint handling

O Getting it rightO Being customer focused O Being open and accountableO Acting fairly and proportionatelyO Putting things rightO Seeking continuous improvement

Saying sorry....O A thorough investigation and explanation

of what happened and why

O Assurance it won't happen again

O An apology – a sincere expression of regret

O Disciplinary & criminal proceduresO Handled separately

O Negligence claims

COMPLAINTSO They will happen!!O Undoubtedly stressful. Try and stay focused.O Seek advice from someone more seniorO Follow your GP / hospital’s policiesO Quite often the patient/family

O What happened & whyO Who was to blameO Changes in practices and procedures to be

madeO Sometimes the aim is compensation.

O Emotional support – doctors for doctors BMA. Confidential counselling service. 08459 200 169 - 24 hours a day,7 days a week

Case Discussion

O Very fit and active 82 year oldO Bladder ca- resection 3x3courses

Intravesical BCGO Info leaflet of side effects and when to

seek medical advicePresentation Post BCG1.-3 Days- Dysuria frequency and low mood-

Trimethoprim2.-6 days - dip stick msu-Nitrofurantoin

3.-10 days-OOH –patient felt improvement- family felt was worse SOB- rest fluids see

GP4.-14 days- dwelling on sx- antidepressant5.-18 days- called by family- unwell in bed

SOB ?anxiety- request DN for bloods and dipstick

6.-19 days-home visit- admit Ward-HDU-ITU-RIP

1. What do you think the coroners inquest is for?

2. What do you do now?3. What do you think the

family want?4. What do you think the

outcome is-For the GP?

-For the hospital?

What its ForO Cause of death unknown or violent or unnatural

death or in prison or police custody.

O Purpose is to enable the Coroner to answer 4 questions:

Who? Where? When? How?

NOT ABOUT BLAME.

O Inquisitorial, not adversarial.O The Coroner controls the evidence from witnesses.

Usually full medical records.O Sometimes independent experts report to assist the

coroner. O Pre prepared a statement. Don’t normally read this

out. The Coroner will ask questions

What do you do first?

Write a StatementO Find out as much as you can about the

purpose of the statementO Copy of the relevant clinical records /

documents O Check that your report is factually

accurate and detailedO Based on the clinical records?O Based on your recollection of events?

O Send your draft statement, the relevant clinical records, and any associated correspondence to the MDU.

Outcomes

Natural causes. Accident/Misadventure.

Neglect. System neglect. Unlawful Killing

OCoroner can make a report to the appropriate authority

OCause of death found-Situation reflected on- Change implemented.

Case OutcomeO Misadventure with real concerns over

the knowledge of the medical professionals over this rare but recognised complication of BCG instillation

O Hospital- MDT discussion encouragedO Gp- had shared the info in SEA analysis

in practice and local GP meetings-requested info leaflet

O Education of medical professionalsO Family happy- still registered at the

practice.

I’m being sued!O Do not write to the patient’s

solicitorsO Gather together all correspondence

and a copy of the patient's records. O Contact your Defence UnionO Send them the notes and other

documents they ask for straight away.

O Review relevant guides on websites

Investigated by the policeO Call your Defence Union immediately!

O Vital if you have been arrested or are being interviewed under caution

O If interview, ask whether it is an interview under cautionO Do not:

O Agree to an interview under cautionO Make voluntary comments to the police without seeking

advice first

O Gather together any information that is relevant to the investigation O Patient records, workplace emailsO Note of events to help jog your memory later O Don’t write a statement or sign one prepared for you by

the police before seeking our advice. O Do not contact any witnesses or discuss the allegations

with anyone other than your Defence Union

Concerns about colleagues-GMC

GuidelinesO GMC- You must protect patients from risk of harm posed by another colleague’s conduct, performance or health. The safety of patients

must come first at all times. If you have concerns that a colleague may not be fit to practice you

must take appropriate steps with out delay.

O GMC-You must not make malicious and unfounded criticisms of colleagues that may

undermine patients’ trust in the care or treatment they receive, or in the judgement of

those treating them.

Raising a concernO Online Tool- guides you through your concern

and tells you who to report it toDon’t forget you can get advice from MPS/MDU

BMA +- your supervisor.O Where possible speak to manager or appropriate

officer. (whilst in training-post graduate dean)O Clear honest and objective. Acknowledge

personal greivance- but focus on issue of patient safety.

O Keep a written record of concern and steps taken

O GMC-Directly (or Confidential helpline)

HandoutsO ChaperoneO ConsentO MPS document

O Contact numbers:O GMC Confidential Helpline:0161 923

6399O MDU: 0800 716 646O MPS: 0845 605 4000

Conclusion!O Communication is key (written and oral)

O If you have made a mistake – report it and tell the patient

O Document – if it isn’t documented….did it happen….?

O Work as a team

O Seek advice if unsure/bounce off ideas

O Use your defense union….you pay enough for them!!!