Complaint procedures. Tom McFarlane.
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List of contents.
1. Introduction
assistance for the complainant
3. More detailed explanation for the MRCOG and to help facts stick
assistance for the complainant
Return to "Expanded Explanation"
One's natural instinct is to be of no help to anyone making a complaint.
Especially if you are the focus of the complaint!
Why give them sticks with which to beat you?
However, you must put your human frailties behind you and act professionally.
The patient is entitled to complete and impartial advice.
If you appear to be "economical with the truth" or evasive, the patient will see you as dishonest.
This means that when you try to explain difficult facts, like what happened, they won't believe a word.
Indeed, seeing you as dishonest may reinforce their belief that the complaint is valid.
And heighten their desire to see you "hung out to dry".
In addition, many people suspect that hospital staff close-ranks and will do anything to make a complaint go away.
So you must avoid anything that could heighten this suspicion.
If you are completely open and give them all the information they need, they will see that you are an honest person.
The will make dealing with the complaint much easier and more likely to be satisfactory to all parties.
This could be a MCQ in the DRCOG.
Or a choice in an EMQ or "best of five" question..
It could come up in any part of the MRCOG.
It would be a perfect OSCE station, either viva or role-play, of which more below.
You would probably get by with the information in the "key facts" section.
But I recommend that you also read the expanded information section.
As the subject is not part of your daily routine, I would strongly advise that you make out cards.
The use of cards is dealt with in "How to pass the MRCOG first time".
As you go through, you will find lots of links to external sites.
Some of them are just one page and give useful summaries.
E.g. the links to PALS and ICAS.
Some of the links may be useful to pad out the information on this web page.
This will particularly apply to doctors who have not worked in the NHS.
However, this section of the web page is designed to give you all the information you need.
Don't spend days wading through the external sites.
In the MRCOG OSCE you might be asked to explain complaint procedures to an examiner in a viva.
Remember that the examiner is not allowed to prompt you or give any other encouragement.
That would make the station quite stressful, unless you knew the subject well.
Even worse, you might be asked to deal with a complaint in a roleplay.
To make a tasty OSCE, the complaint would be against you!
You need to clarify if the patient is making a formal complaint.
Or is she just unhappy about some aspect of her treatment and wanting to have more information and some kind of explanation?
The technique for dealing with it is absolute honesty and no attempts to justify yourself.
It is vital to avoid the temptation to put the blame on someone else.
Do not make up any fairy stories:
“it was an exceptionally difficult operation and you bled much more than normal…..”.
First you apologise for them being caused distress.
Note, you don’t pre-empt assessment of the situation by apologising for what you have done.
Clinical incidents happen without you doing anything wrong.
You say that matters of this kind are always treated very seriously by the Trust.
“When an operation does not go entirely to plan, a clinical incident form is filled out.
This records details of what happened.
The form is sent to the risk management team.
It is their job to investigate the incident.
They find out what happened.
Then they ensure that everything is done to make things as safe as possible for patients in the future”.
You tell them that the incident will also be fully investigated by the consultant.
You offer to arrange for them to meet the consultant.
If there
are disciplinary or training consequences for you, the consultant will let them
know.
You must explain that they are entitled to make a formal complaint, if they wish to do this.
You will explain how they go about it - basically they complain to the complaints manager.
You give them the address and contact phone number of the complaints manager.
The
complaints manager will be responsible for dealing with the
complaint.
Advise them to sit down and decide the detail of the complaint.
Most will find it useful to have someone help them with this – a relative or a friend.
They
may want assistance from PALS or ICAS.
They should concentrate on the main issues and not include irrelevant stuff.
Like disapproving of the colour of the nurses’ uniforms or the quality of the food.
Some mistakenly feel that complaining about a host of issues demonstrates how universally useless the Trust is.
The effect in real life is to dilute the complaint, submerge the main issues in trivia and make the complainant appear a professional malcontent.
They also need to be clear about what they hope to achieve by making the complaint.
Many will just want recognition of the hurt inflicted on them and an apology.
With an assurance that everything possible will be done to ensure it does not happen to someone else.
Others
may want punishment of the “guilty” and others financial recompense.
In the OSCE you would offer to phone the complaints manager and arrange an appointment.
Depending on the scenario and the time available, you would explain about the other aspects of the complaints procedure.
These are
outlined in "key facts".
Return to "Expanded Explanation"
This is the basic information needed for both the DRCOG and MRCOG.
MRCOG candidates should also read the expanded explanation.
assistance for the complainant
Return to "Expanded Explanation"
This subject changed significantly in 2009.
The Healthcare Commission was abolished.
I am not sure how quickly the exam committee will get to know of these changes.
The result is that you will need to know the old system just in case.
But be able to tell the examiner that the Healthcare Commission ceased to exist on the 31st. March 2009.
And that the Care Quality Commission that replaced it will not deal with complaints.
Instead, the Ombudsman will take on its role in dealing with complaints.
In a roleplay, you would mention the old system to make sure that you got the mark.
But add that the system has changed and you can no longer appeal to the Healthcare Commission.
The old system had three tiers:
a local process within the Trust to attempt to deal with the complaint,
a second level in which the Healthcare Commission made a judgement about the complaint,
a third level in which the Ombudsman would make a judgement about how the complaint had been processed.
The new system has two tiers:
a local process within the Trust to attempt to deal with the complaint,
a second level in which the Ombudsman makes a judgment about the complaint, including clinical matters.
Return to "Expanded Explanation"
Background:
Major changes were made to the complaints procedures in the past few years, most recently 2006.
These developed the existing system.
The need for change was outlined in the DOH: "NHS Complaints Reform. Making Things Right".
You don't need to read it in detail!
Most hospitals should have established a Patient Advice and Liaison Service, PALS, by 2002.
Patient
support was strengthened via the creation of the Independent
Complaints Advocacy
Service, ICAS, of which more below.
If local resolution fails, patients may request review by the Healthcare Commission.
This is an independent body which has taken over the process of independent review to make it fairer and genuinely independent.
See
below for fuller details.
Return to "Expanded Explanation"
Assistance
for the complainant:
It is important in a roleplay to let the "patient" know this exists.
Making a complaint, however well-justified, is stressful for the ordinary individual.
The Patient Advice and Liaison Service, "PALS", is the local, in-house, support scheme.
Its main weakness is that it is run by staff belonging to the Trust.
Some patients may not trust it because of this lack of independence.
The Independent Complaints Advocacy Service, "ICAS", is a completely independent service.
Return to "Expanded Explanation"
This means getting complaints sorted out via the mechanisms within the Trust.
The hope is that the vast majority of complaints will be dealt with in this way.
A
member of the Trust Board has to ensure a proper system is in place.
A
complaints manager must be appointed to run the system & investigate complaints.
Time
limit on complaints: usually 6 months.
Acknowledgement
of the complaint within 2 working days.
Response
to the complaint within 20 working days.
Complaints
against Foundation Trusts notified to
Monitor,
Return to "Expanded Explanation"
Review by the Healthcare Commission:
Up to the end of March 2009, the complainant could request involvement of the Healthcare
Commission if local resolution failed.
A
named case-manager was appointed to handle the case.
Acknowledgement
of receipt of the complaint had to be made within 2 working days.
Time
limits existed on other aspects of investigating the complaint.
The
Commission might
recommend a panel to consider the complaint.
This
superseded the old “Independent Professional Review” under the Trust’s
control.
A panel
comprised 3 trained lay people.
The
standard
of proof was “balance of probabilities”, not “beyond reasonable doubt”.
A complainant had the right to ask for assessment by a panel.
The Healthcare Commission ceased to exist on the 31st. March 2009.
Its role in providing a second-level to the process of assessing complaints was taken over by the Ombudsman.
Return to "Expanded Explanation"
A complainant can complain to the Parliamentary and Health Service Ombudsman.
The current Ombudsman is Ann Abraham.
In
the old system (pre-2009) the Ombudsman could be asked to pass judgement on the administration of the complaint.
The
Ombudsman would
investigate complaints that NHS organisations “have not acted properly or
fairly or have provided a poor service”.
Allegations of excessive delay, failure to follow proper procedures etc. could be investigated.
But not allegations about clinical matters.
Since the abolition of the Healthcare Commission on 31st. March 2009, the Ombudsman has taken over clinical matters too.
So she will come to a judgement about whether care was appropriate, timely etc.
And make recommendations about how Trusts could improve clinical care, care systems etc.
The Ombudsman publishes an annual report.
This can be highly embarrassing for any Trust or manager named in it.
Return to "Expanded Explanation"
A
complainant may request that their MP look into the case.
The MP can pressure the Trust:
ask questions of the Trust Chairman or Chief Executive,
ask questions in the House of Commons,
ask questions
of the Secretary of State for Health.
Return to "Expanded Explanation"
You might think that this would support the complainant.
However, this is not its role.
It is a charity with a small staff, so it would not have the resources.
It defines its role as promoting the "voice of patients in healthcare".
It mounts campaigns on various subjects.
If sufficient patients informed it of flaws in the current procedures, it might make representations for improvements.
But it does not act directly in support of the individual complainant.
It has a web page giving advice about how to make a complaint.
At the time of writing, May 2009, this advice had not been updated to adjust to the abolition of the Healthcare Commission.
This is a bit worrying!
But provision of advice, even if out-of-date is the extent of its help to the individual complainant.
Return to "Expanded Explanation"
Complainant may complain to the GMC about a doctor.
The doctor could be disciplined, suspended or "struck off".
There are also GMC procedures for doctors who are sick or addicted to drugs.
Return to "Expanded Explanation"
Complainant
may take legal action.
This does not
adversely affect future treatment by the NHS.
But it stops further NHS
complaint procedures e.g. review by the Ombudsman.
Expensive.
Advise the
complainant of the following:
complainant
should see lawyer specialising in medical litigation,
some
lawyers offer free initial assessment interview,
some
offer “no-win, no-fee”,
low-income complainant may be eligible for Legal Aid.
Return to "Expanded Explanation"
Newspapers and television and radio programmes love a medical story.
They will often sensationalise the facts.
Hospitals and individual members of staff can be subjected to a lot of adverse comment.
The desire to create a "good" story, means that the truth may not be represented.
It doesn't usually achieve a lot, unless there is really a story to uncover.
If the complainant has gone through all of the other procedures, this is unlikely.
There is also the risk of the process backfiring on the complainant.
It
may turn out that they have a prison record, are known to their neighbours as a
drunken nuisance etc.
Return to "Expanded Explanation"
Expanded explanation for the MRCOG and to help facts stick.
The "Key Facts" section is the essence of what you need to know.
The following "fleshes out" the detail.
assistance for the complainant
the Parliamentary and Health Service Ombudsman
Return to "Expanded Explanation"
Assistance
for the complainant:
The NHS Plan was introduced in 2000.
One aspect was that every Trust would have a Patient Advice and Liaison Service, "PALS" by 2002.
PALS is part of PPI. (Patient and Public Involvement.)
PALS' staff provide patients with information about services, where best to get treatment for specific conditions etc.
They play a part in resolving complaints e.g. by:
talking things over with patients,
explaining things,
arranging meetings with consultants.
Formal complaints are dealt with by the complaints manager, who is a Trust employee.
A patient
wishing to complain will be put in touch with the complaints manager and also
support such as PALS & ICAS.
The Independent Complaints Advocacy Service, "ICAS" is part of the NHS.
But the service is provided by three organisations which are not part of the NHS.
They are:
This is intended to ensure that ICAS functions independently of the NHS.
The staff of these bodies are not NHS employees.
They will provide support such as discussing a problem and its possible solutions.
They could accompany a patient to a meeting with a complaints manager.
Keeping it separate from the NHS is intended to prevent “clashes of interest”.
Would an
NHS employee acting on behalf of a complainant ever be compromised in their dealings
against the NHS?
Return to "Expanded Explanation"
A member of the Trust Board is responsible for ensuring that a complaints mechanism is in place that fits with all the regulations.
The Chief Executive is accountable for the smooth running of the procedure.
The Trust
must appoint a complaints manager.
It is hoped that most problems will be solved at local level.
This may be the complaints manager clearing up some confusion or misunderstanding.
It
could be the result of the complainant meeting with the consultant / head of
midwifery etc.
The complainant can be:
an aggrieved patient,
or someone complaining on behalf of someone else:
a child,
someone who is mentally ill
or someone who has died.
A complaint can be made to any member of staff, who should then direct it to the complaints manager.
The complaint must normally be made within six months of the event or the complainant becoming aware of the matter at issue.
Exceptionally, a longer interval will be accepted.
The manager will acknowledge receipt of the complaint within 2 working days and will make full notes of it.
A reply will be sent within 20 working days.
The reply
will normally come from the Chief Executive.
This will detail the results of the investigation.
If local resolution fails, the complainant must be informed of the second level of the complaints procedure.
Up to the 1st. April 2009, this meant
referral of the complaint to the Healthcare Commission.
The Healthcare Commission was abolished on the 31st. March 2009.
The second level of the complaints procedure is now with the Parliamentary and Health Services Ombudsman.
Return to "Expanded Explanation"
The Healthcare Commission was an independent body, set up in 2002, but abolished in 2009.
It provided the second stage in the procedure, if local resolution failed.
Before 2002, the complainant could ask for an Independent Professional Review (IPR).
For an IPR, a panel of two or three independent specialists from appropriate specialties was appointed.
The panel came to the hospital, read the notes, interviewed everyone they thought they should and drew up their findings.
The
findings were then relayed to the complainant
and the Trust.
The problem with this system was that the decision about whether or not to allow an IPR was for the Trust to make.
There was understandable criticism that the system was inherently flawed because of this.
But if the Trust could not make the decision, who would?
To overcome this problem, the IPR system was taken over by the Healthcare Commission, which was independent of the Trust.
On completion of the investigation, the case manager would make a recommendation about what to do next.
It could be concluded that the attempt at local resolution was adequate and that nothing further needed to be done.
I. e. the complainant is being unreasonable.
It could mean referring the problem back for another attempt at local resolution.
This could be accompanied by advice regarding the Trust’s policies that might help resolve the problem.
The case manager's recommendation could be to set up a panel to make a judgement about the case.
The panel consisted of three, trained lay people, which was a major change from the IPR panel.
The panel did not work in the adversarial way of a court, with opposing legal teams.
The standard of proof was “the balance of probabilities”, not “beyond reasonable doubt”, which is used for criminal cases.
The panel would make two recommendations:
one to provide redress for the complainant, if appropriate,
the other to improve the
service if need be.
The Healthcare Commission was abolished in 2009.
The Ombudsman took over its role in providing a second tier to the complaints procedure.
Return to "Expanded Explanation"
Return to MCQ5, answer 18: "Confidential Enquiry into Maternal Death"
Return to "Saving Mothers' Lives, the ten top recommendations"
Return to "How to pass the MRCOG 1st. time"
The Ombudsman up to 1st. April 2009.
The next section is what used to apply to the Ombudsman.
This changed radically in April 2009.
I have left the old information in case any College answer might be based on it.
In effect, you need to know the old system and how it has evolved.
Note that the Ombudsman originally just dealt with the processes involved.
She made no judgement about clinical matters.
But, from the 1st. April 2009, she makes judgements about clinical matters too.
The following is what I originally wrote.
There is a lot of misunderstanding about the role of the Ombudsman.
The usual misconception is that she is some kind of super-judge who will make a final decision about whether the complaint is valid or not.
In fact, the ombudsman makes judgements about whether an organisation handled a case properly.
It is about the administrative processes.
So, she might say that the Trust did not follow standard procedures for dealing with the complaint:
there were unacceptable time delays,
the staff were rude and intimidating and so on.
She will not say that the baby came to harm because:
the CTG was abnormal at 14.00 hours,
or the Caesarean section was unwisely delayed until 18.00.
This might make the Ombudsman seem fairly toothless and useless.
However, she publishes an annual report.
To be named in it is a huge embarrassment for a Trust and a humiliation for its senior managers.
They
definitely do not want that on their curricula vitae!
The Ombudsman since 1st. April 2009.
The above was true of the Ombudsman until 2009.
Since then the Ombudsman has taken on clinical issues as well.
So now she will say that the CTG was abnormal at 14.00 hours.
And that staff were slow to act upon the findings to the possible detriment of the baby.
She would be likely also to provide some recommendations about the problem could be avoided in the future.
The obvious example being improved, documented staff training.
In effect, the Ombudsman has taken on the role in the complaint procedures that used to belong to the Healthcare Commission.
Return to "Expanded Explanation"
In real life or an OSCE station telling a patient about complaint procedures, you would tell them the following.
1.
The
claimant may seek legal redress,
2. If they do, it has an impact on the NHS complaints procedure, which goes “on hold”,
3.
Taking legal action will not adversely affect any future treatment by the
NHS.
In practice, a consultant who had been sued might decline to treat that patient again on the grounds that trust has broken down.
So
long as there is a suitable alternative consultant, that would be acceptable.
4. They need the advice of a lawyer who specialises in medical litigation.
A specialist in house conveyancing would be little use to them!
5. Litigation is very expensive.
If their income is low, they may qualify for legal aid.
This
means the government paying the legal costs.
6. Many solicitors will provide an initial free assessment consultation.
The complainant should check this out.
7. Some solicitors now provide a "no-win, no-fee service".
This takes away the fear of paying out tens of thousands of pounds and getting nothing back.
However,
if the case is settled in the claimant’s favour, a larger slice of the
compensation will go to the solicitor.
8.
They can be referred to PALS and ICAS for support and further advice.
Return to "Expanded Explanation"
In real life you would have given the patient too much information for them to remember easily.
The hospital should have an information leaflet with all of this information in it.
If you can’t find it, ask PALS!
In the exam,
OSCE stations often have a mark for mentioning
information leaflets.
Return to "Expanded Explanation"