• You are here:
• Home /
• Speeches

Speeches

Handling Complaints in the Health Services (05.03.2002)

Address by Kevin Murphy (Ombudsman) at Eastern Regional Health Authority Regional Conference

Introduction

At the outset I would like to say how pleased I am to be speaking to you today. I know that the Authority has invested considerable time and resources in laying the foundations on which a quality system of dealing with complaints in the region can be built. I have a considerable interest in these developments and indeed over the past number of years staff in my office have engaged in a number of initiatives in relation to complaint handling in the bodies within my jurisdiction. In addition I have published a guide to internal complaints systems which sets out the essential features of a good system and the benefits of having a good system as well as outlining what needs to be done when setting up and operating such a system, and achieving and assessing the benefits which a good system offers. I would also like to acknowledge the level of co-operation that has been developed between my Office and the Authority in this area.

The conference comes at a very appropriate time in the history of the health services in the Eastern Region. It is a time of great change. The public focus on quality in the health services is increasing and the public, generally, is becoming more demanding in all areas of public health services. A new level of awareness has developed among the users of hospital services e.g. in 2001 complaints to my Office in relation to the health services are almost double those of the previous year. A momentum towards clarity of objectives, effective communications and individual accountability is being fostered by Government and this is being driven by ever increasing media attention on the inter-action between the health services and individuals or classes of individuals. In addition the demographics of this country mean that a large chunk of the population is moving into middle and later life which are the life stages normally associated with hospitals/nursing homes etc.

The new national health strategy Quality and Fairness - A Health System For You has considerable implications for my Office. The strategy confirms the Government's belief that my Office is the appropriate mechanism for dealing with complaints relating to the health system as a whole and also confirms the Government's intention to extend my remit to the public voluntary hospitals and other voluntary agencies in the health area. The strategy also provides for the development of a statutory framework for complaints to achieve greater clarity and uniformity of approach in dealing with complaints, structured local resolution processes as well as an opportunity for independent review. The strategy has also identified, as meriting particular attention, the perceived inability to question the actions or decisions taken by individual practitioners in regard to clinical matters, Whilst acknowledging the need for freedom in exercising clinical judgement, the Government has equally accepted the need for a stronger framework for questioning and investigating clinical decisions in particular circumstances. The strategy envisages, for example, that proposed legislation on the statutory registration of health professionals will contain adequate machinery for the investigation of complaints against individual professionals.

In my experience many complaints, which at first sight appear to relate to the exercise of clinical judgement, actually relate to administrative failures such as a lapse in communications or a failure to observe proper procedure. A piece in last weeks Irish Medical Times is apposite: A health authority in Holland was reported as being in the process of investigating an incident where a patient's healthy leg was amputated in a hospital mix up. The focus of the investigation was not on any aspect of clinical decision making, but on how such an incident could have happened despite a number of safety measures in place designed to prevent such occurrence. The really sad aspect of the story was that the patient must now undergo a second operation to have the other leg, which should have been removed in the first operation, taken off. In recent years the powers of the British Health Services Ombudsman and the Northern Ireland Ombudsman have been extended to embrace clinical judgement. Of course a well established statutory complaints system had already been put in place in the National Health Service some years previously. To extend the Ombudsman's jurisdiction to clinical judgements in this country ( as has been proposed ) without a well established and functioning statutory complaints system would, in my view, be premature although it should not be ruled out of consideration at a future date.

Why have I chosen the title When Things Go Wrong for this presentation? As you all know there are two certainties in life, taxes and death. I would like to add a third, which is a derivative on Murphy's law that anything that can go wrong will go wrong. The derivative is this: things can and do go wrong in every organisation. There is nobody in this room, including myself, who can say that nothing ever went wrong in their section, office, surgery, clinic, ward or operating theatre. We all make mistakes. The critical question is how do we react when we make such mistakes and things go wrong. Let me explore this question under a number of headings: Culture, Expectations, Communications and Remedies, with a particular example from my own work in the past year. Although most of what I have to say is based on complaints about hospital services, and the providers of those services, it is equally applicable to other services provided by health agencies in the Region.

Culture

Culture manifests what is important, valued and accepted in an organisation. It is not easily changed when it is deeply held, and not susceptible to change by a pronouncement, command or an emotionally laden description of a new vision. I think most of us instinctively regard complaints as unpleasant and not something to be welcomed, because they are a very personal comment on performance. In the hospital context once the word complaint is used there is always the danger of a personal and usually negative reaction. In a study of consultants' responses to complaints in the UK, they talked about their sense of fear and hurt, concern about their reputation, distress at the lack of understanding of their action and motives, and their vulnerability. Worry, surprise, annoyance, anger, disappointment, anxiety and distress were amongst the most common reactions cited.

Clearly, there may be a fear that complaints will have a significant and lasting impact on those to whom blame is attributed. The challenge to the practitioner's expertise is likely to be construed as greater than the content of the particular complaint, resulting in an almost symbolic resistance to such challenge. Responses can, and do, exacerbate a complainant's sense of grievance by appearing defensive, using technical language, commenting on the failure of complainants' attempts to manage illness, casting doubt on the complainants' account by labeling them a 'bad patient' and arguing that dissatisfaction is a symptom of the illness being treated. In a separate study of complaints about GPs in the UK , it was found that, in almost 80% of responses to complaints, medics blamed either the disease process or other people.

We do not have the benefit so far as I am aware of similar studies in this administration but my own experience would not tend to indicate that things would be very different. Complaint handling is very much dependent on the goodwill and co-operation of medical staff in the heath sector. I have rarely found that health professionals, particularly doctors and consultants, engage wholeheartedly with patients' complaints. In some cases complaints are seen as a consequence of irresponsible dissemination of information by the media. This, when allied to a reluctance by patients to complain, usually because they are very dependent on the system, makes for a very unsatisfactory situation. Complaint handling is invariably seen by medical staff as very much a matter for the administrators, even though the kernel of the complaint might well involve particular doctors or consultants. In recent complaints made to my Office, I observed a marked reluctance on the part of the relevant doctor or consultant to engage in the complaint process. In none of the cases was there a procedure which obliged them to engage fully in the process.

The other end of the cultural spectrum is one where the satisfactory resolution of complaints is seen as a very important objective and information generated by the complete process is valued. In this culture front line staff are adequately trained, and supported, with complaints investigated promptly and with authority.

The culture of an organisation is set by the chief executive and senior management, and it is essential that they view the handling of complaints as an integral part of clinical governance and risk management. My understanding of clinical governance, and I am, of course, a layman in this context, is that it is about using information so as to manage processes in a way which will ensure the effectiveness and safety of clinical outcomes. Information may come from clinical audit, untoward incident reporting, risk management and complaints procedures.

The culture of any modern public service organisation must reflect the fact that the organisation is accountable for its performance and that its management processes are increasingly open to scrutiny by the Oireachtas, the general public and, indeed, the media. This accountability and openness extends to how it handles complaints, and this, in turn, requires that staff are adequately trained to deal with complaints and supported in the event of a complaint being made against them. Ideally training in handling complaints should be a compulsory part of induction and continuing education. The acceptance of regular reporting on the complaint handling process would also feature prominently in this culture, not merely as a record of the number of complaints received without any adequate analysis or comment, but rather with a view to monitoring arrangements for complaint handling, considering trends in complaints and lessons which can be learned particularly for service improvement. In this culture the process must be close to the chief executive. It does not work where it is stuck out as an add-on to something, several levels down in the organisation with no robust mechanism for getting the message through.

A good internal complaints system provides essential feedback from the public on the services provided by indicating where problems may exist in the provision of services. It can also act as a means through which the public can tell the health service provider how well it is, or is not, succeeding in its efforts to provide an improved quality service. Satisfaction with grievance procedures is closely related to the quality of apologies, levels of defensiveness and the perceived accuracy of explanations given. There is also a strong positive correlation between satisfaction and the complainants' belief that providers intend to improve things for the future. You often only get one chance to satisfy complainants. Dissatisfied patients/clients who do not appeal are often guided by a loss of confidence in the system's ability to deal fairly and impartially with them.

Expectations

In a recent meeting with the Irish Hospital Consultant's Association I was given to understand that almost 900,000 in-patients and day-patients passed through the health system in the year 2000. Added to this would be the number attending Accident and Emergency departments and Out-Patient clinics. No matter what way you look at these figures they amount to several million interactions between the public and the health system in any given year. Whilst I have no equivalent statistics for Ireland, indications from the USA, Australia and the UK indicate that at least 4% of all admissions to hospitals suffer an adverse effect at some point during their stay. Even a minimum figure of 1% reflects a very significant source of complaint.

Patients and their carers, however, experience a number of difficulties in complaining. I think that it is commonly accepted that the majority of grievances about medical services go unvoiced. Service users may prefer to put negative experiences behind them or avoid confrontation, but for others it is structural inequalities in the user-provider relationship which discourages them from pursuing a grievance. Patients tend not to make formal complaints, particularly when they have a long-term relationship with a service provider. I think that the results of a survey conducted by the Irish Society for Quality in Healthcare is of interest in this regard. 92 % of those surveyed (recent in-patients) did not complain. 74% were unaware of the existence of a complaint procedure. Of those who did complain 66% considered that their complaint had not been acted upon or rectified. Another finding is highly significant in my opinion; 79% would complain in the first instance to the Ward Sister/Nurse and then on a sliding scale of 6% Matron, 5% Consultant, 3% Non consultant 3% Manager and 4% Other. This is very important information in the context of local resolution and training. Reluctance to complain may be seen as a good thing to providers but problems may remain concealed and overall dissatisfaction with service may intensify as a result.

I have found that complainants have a variety of expectations in making their grievances known. In my experience it is rare for a complainant to be motivated by prejudice or malice. Some complainants may be very difficult, sometimes because their complaints are made out of feelings of grief or guilt. This does not mean that their complaints are not justified, but it can mean that it may be very difficult to satisfy their expectations. However, they all want to be taken seriously, to have their views - and the fact that they had reason to complain - to be acknowledged and they want remedial action. It is my experience that complainants rarely seek financial compensation in the first instance, nor do they seek disciplinary action against staff. In their calls for redress they place emphasis on 'soft' remedies such as apologies and explanations rather than 'hard' remedies like compensation, I have never had a complaint presented to me which escalated into a legal claim or a request for disciplinary action. I recently heard a representative of the Medical Council confirm that the majority of their complainants also place great emphasis, without malice, on explanations, prevention, learning lessons and apologies.

Communications

Patients, in general, are vulnerable while in hospital. They may be disoriented, they may be frightened, they may be dependent on others to assist with basic functions for the first time in their adult lives. In other words they have had to surrender control to the medical system whose language they may not understand and that makes them impatient and perhaps a little less receptive than normal. Their relatives will also be on edge and will be resisting their loss of control over the welfare of their loved one.

At the same time hospital professionals are working with many constraints on their priorities and energy; they are also operating in an environment which is familiar to them in terms of its procedures and language. Medical and nursing staff may have their sensibilities blunted to some extent by having to deal with thousands of patients. However, what is humdrum and shorthand to them is unique to the patient, and they do represent a caring profession.

In such conditions it is very important for all health professionals to appreciate the patient's perspective, to make all exchanges as sensitive, meaningful and humane as possible and to understand that effective communication means more than simply saying something to somebody. Failure or inability to communicate (and allowance must be made for the capacity of the patient to hear) or the method by which something is communicated ( and there are non-verbal dimensions) can lead to upset and misunderstanding and can be the reason why a complaint is made. It can also be some time before the consequences of some action or inaction in this delicate area become apparent.

Complaints from individuals following an unexpected death in a hospital have unique characteristics. The psychology of grief following death or serious incapacity will involve, at some point, an apportionment of blame in some direction. Apportionment of blame will not necessarily be rational but that does not diminish its reality. It can be very difficult when blame is directed at a hospital professional and one way of avoiding this is to try to appreciate all the sensitivities of individual situations including the family and to tailor communications accordingly.

Remedies

The appropriate remedy should aim, in so far as this is possible, to restore the complainant to the position he or she would have been in had things not gone wrong. I accept that this is sometimes not possible in the health area and the patient in Holland exemplifies this. However, in the main complainants look for honest answers, expressed sensitively and in understandable terms, with an apology and action to prevent similar complaints in the future. The remedies available should reflect this and include the provision of clear and comprehensive information, detailed explanations, apologies, reversing the action complained of if possible, changes in procedure and compensation. I would like to elaborate on three of those

Apology: A simple apology can be a very important remedy for complainants. If an apology is not provided, or is delayed, the complainant is less likely to be satisfied: all too often a failure or unwillingness to say "sorry" at an early stage is the reason for complaints proceeding further through the system than is really necessary or appropriate. Apologies can be given without an admission of blame or liability in relation to the substance of the complaint. At the same time, apologies should not be used simply to brush complainants off. An apology, however gracious, without answers or follow-up action and information, is not going to be sufficient response to the most serious complaints, and can too easily be used as an attempt, which usually fails, to get everyone off the hook.

Information: Complainants usually want information, an explanation of what happened and why. This explanation must be in a language which the patient can understand. If an explanation attempts to deny the complainant's experience of events, it is unlikely to be accepted. Explanations can also degenerate into a form of making excuses. The other side of the coin is that dissatisfied people may not complain if they feel nothing will happen as a result and, as experience shows, problems which might have been nipped in the bud, accumulate with disastrous consequences.

Compensation: Financial compensation may sometimes be warranted e.g. where specific financial loss has occurred. Where the complainant has had to spend a considerable amount of time in pursuing the matter, payments in respect of " time and trouble " may need to be considered, although normally these would be for small amounts. Exceptional worry, distress or inconvenience may also be factors to be considered. In the past few years I have reported on such cases in my annual reports.

A Particular Example

The following example of an investigation recently completed by my Office is a microcosm of the various issues outlined above. A family complained to my Office about the response of a general hospital in relation to the following matter ( the particular hospital is not situated in the Eastern Region ).

Their father had been admitted to hospital complaining of severe pain in his lower back and legs. During the following days he was examined by various doctors but he remained in severe pain and discomfort and became increasingly agitated. His family became concerned and distressed and continually sought explanations from both nursing and medical staff as to the cause of their father's pain and discomfort. The family considered that the attitude and response by a particular doctor was very unsatisfactory. They described his attitude and demeanour as dismissive and stated that he refused to give them information on their father's condition and proposed treatment. Eventually, they became so concerned about their father's condition that family members remained with him in the hospital. Their father was subsequently the subject of an emergency transfer to another hospital where he died shortly after his admission as a result of a ruptured aneurysm.

The family were at a loss to understand the standard of medical care he received after having these concerns raised. They were particularly aggrieved that they were not informed of the nature and severity of their father's condition and of the proposed treatment to alleviate it. Despite raising concerns with the nursing and medical staff on a number of occasions, the family remained aggrieved that his condition remained untreated until his emergency admission to another hospital.

My investigation revealed the following deficiencies in the manner in which the complaint was handled by the hospital;

• a lack of emphasis on the family as human beings rather than on their position as possible adversaries in future legal proceedings.
• a practice of referring a complainant whose loved one had recently died, solely to the hospital's Complaints Officer, which did not assist in addressing the concerns raised. The concerns raised by the family were referred to the relevant consultant. He had earlier referred the family to the hospital's Complaints Officer, thus initiating a circular approach rather than undertaking to have the family's complaint examined by himself in conjunction with the senior hospital administrators.
• a response by the hospital which left the family somewhat confused as to what precisely had happened to their father, what treatment he received and why his vascular condition was not diagnosed earlier, given the observations the family had made to the nursing and medical staff. The family also had genuine concerns about the way in which their father was transferred to the other hospital, although I was able to reassure them, on the basis of the investigation, that this aspect appeared to have been dealt with properly.
• a paucity of records covering critical treatment junctures,
• a stark failure to meet the standards of medical record keeping expected of medical staff following their contact with patients.
• an absence of relevant entries on the nursing notes during a period of significant nursing intervention.

Overall it was clear from the investigation that the family's concerns had not been adequately addressed and consequently I upheld their complaint in his regard.

My intervention provided answers to most of the questions raised by the family. I went further, however, and made a series of recommendations centering on procedures in relation to nursing records, medical notes, complaint handling with particular reference to the role of the consultant in dealing with complaints and the importance of good communications procedures in responding to the concerns of complainants, and most importantly the delivery of a personal apology to the family.

Although I could not deal with the aspects centering on clinical judgement, I considered that the case identified a particular issue for joint consideration by the management of the Health Board, the Hospital and the Medical Staff viz; the need for consideration to be given to greater clarification in the respective roles and relationships of junior and senior medical staff. In particular, I recommended that consideration should be given to an administrative protocol outlining the circumstances in which a junior member of a medical team should consult with his or her consultant when a patient's condition gives cause for concern, and the corresponding obligation on consultants to be accessible for such consultation

The outcome of these recommendations included the delivery of the personal apology, the establishment of a new management structure that would include consultant medical staff and so incorporate the role of the consultant medical staff into the complaints procedure, the establishment of a new programme of nurse education in relation to best practice in the maintenance of nursing notes, the establishment of a chart review and audit of nursing documentation to determine effectiveness of the programme and generally to monitor documentation, the inclusion of a new module in the NCHD induction programme to address the protocol for medical notes ( other acute hospitals within the Board were requested to develop similar best practice in relation to these initiatives), the development of a new complaints procedure and an administrative protocol relating to the respective roles and relationship of junior and senior medical staff.

It is very important to note that the family in this case did not pursue their complaint in a vindictive way or with a view to litigation. In essence, all they were seeking was clear answers to their questions about their late father's treatment, appropriate apologies for the shortcomings they perceived and assurances that lessons would be learned for the benefit of future patients and their relatives. My report tried to provide this for them, and the outcome of the case is a very good example of how an effective complaints process, embedded in the proper culture, could have enabled the particular hospital to provide appropriate redress for the family in a non adversarial manner, whilst at the same time effecting quality improvements in the service which would benefit other users and help to prevent similar problems occurring in the future.

Conclusion

I hope that the foregoing observations will be of use to you as you go forward in this area and I am hesitant to introduce a less that optimistic note at the end. However, I consider that the importance of embedding the culture of quality complaint handling in the health service is so important, that we must learn from every experience and lesson available to us in this regard. In this context a recent evaluation of the NHS complaints procedure in the UK provides food for thought.

At local resolution stage almost half of complainants did not consider that their complaint had been handled well, with a similar percentage dissatisfied with the outcome and the length of time involved. In addition the same percentage considered the process to be unfair and biased. At independent review stage almost two thirds of complainants did not consider that their complaint had been handled well. Less than 15% were satisfied with the time taken to deal with the matter with only a little over 10 % satisfied with the outcome. Over 70% considered that the process was unfair and biased and almost 90 % considered the process to be distressing and stressful.

A common and pervasive source of dissatisfaction among complainants was poor attitudes of staff, both medical and administrative. Complainants often mentioned lack of respect, sympathy and understanding coupled with patronising, aggressive and arrogant attitudes. A call for staff to listen to complainants and to be more honest was common. A second common theme was the need for complaints to be dealt with quickly and for better communication. Complainants believed that their complaint could best be settled by a face-to-face meeting arranged as quickly as possible after the event. The evaluation considered that there was compelling evidence that a complaint can be escalated and positions entranced by poor initial handling by front-line staff or managers. The single most important changes which would have improved complainants' experience were:

• A more personal, quicker response
• A better, more honest attitude by staff
• Perceived independence in the handling of the complaint
• Better information/Support
• An explanation /apology

By contrast the majority of staff felt very positive about their experience of the complaints procedure, although the process was acknowledged to be stressful. A majority of staff thought the complaint against them had been handled well and they were satisfied with the outcome and the time taken to resolve the complaint. They were well supported by professional and managerial colleagues. The majority agreed that the process was both fair and unbiased. The only response that indicated significant dissent was about being kept informed throughout the process.

I do not put this information before you as any comment on the quality of the NHS complaint procedure. The evaluation document is most comprehensive covering many issues. I put it before you as encouragement to you not to consider that the work is done when the form and structure of a complaints system is in place. The culture of quality must also be embedded if you are to succeed. The trust placed in you to deal with complaints has to be supported by a demonstrated capacity to deal with such complaints in a timely, unbiased, fair and efficient manner, whilst simultaneously maintaining the confidence of the complainant and the respect of the individuals and organisations who are the subject of the complaint. An investigation should neither be a white wash nor a witch hunt. In relation to my own Office, it remains one of my strongest concerns that our credibility with our complainants should be matched by our credibility with the public bodies within our jurisdiction.

Thank you

Back to contents