When the inevitable day arrives….how to keep your cool!

1. When the inevitable day arrives….how to keep your cool! Rachel Chadwick & Sarah Herbert GPVTS 27th November 2013

2. Learning Objectives • What can go wrong? • Receiving & handling a complaint • In practice / hospital / commissioning body • Via GMC • Called to an inquest • Other scenarios (sued / police) • Raising concerns • AOB • Handouts: Chaperone, Consent, MPS handout & contact information

3. What can go wrong?

4. Clinical Scenario • Friday afternoon, busy clinic, running late • Mrs P, 48 yr, struggling to get appointment, rude receptionist • PC (* 3!) Reoccurrence of ? dermatomal rash over left buttock • ICE not fully explored • Second opinion sought • GP registrar: likely eczematous rash, seek advice from colleagues • Confirmed: call pt back +/- refer to dermatology • 4/52 later, written complaint received as no pt F/U despite messages left at reception

5. Group Work • Why do you think the patient complained? • What would you do now? • What outcome may the patient be expecting?

6. Clinical Scenario • Friday afternoon, busy clinic, running late • Mrs P, 48 year old lady, struggling to get an appointment, rude receptionist • PC (* 3!) Reoccurrence of ? dermatomal rash over left buttock • ICE not fully explored • Second opinion sought • GP registrar: ? eczematous rash but would seek advice from other colleagues • Confirmed would call pt back +/- refer to dermatology • Two weeks later, written complaint received as no pt F/U

7. What motivates patients to complain? • 70% - Poor communication • Deserted, devalued, lacked information, misunderstood • Predisposing factors: • Rudeness, delays, inattentive, miscommunication, apathy, no communication • More than 50% were so turned off that they wanted to sue the doctor before the alleged event occurred (Mangles 1991) • Precipitating factors: • Adverse outcomes, iatrogenic injuries, failure to provide adequate care, mistakes, providing incorrect care, systems error (Bunting et al 1998)

8. Negative communication behaviour by doctors increases litigious intent – even when there has been no adverse outcome!! (White 2005, Lester and Smith 1993)

9. Handling complaints From the GMC In practice / hospital or commissioning body • Complaints manager, procedure, sign off • Validity of complaint • ? Need for investigation • Timescales • 12 months from date of incident or complainant first knew about the matter • Unless otherwise agreed • 3/7 to acknowledge written complaints • How investigate, how complainant can get advice • 6 months, complaints manager required to explain • Unless otherwise agreed

10. To GP practice / hospital or commissioning body • Discuss with your trainer • Download “Guide to the NHS and Social Care Complaint Procedure” • Acknowledgement letter to the complainant • unless verbal & resolved within 1/7 • Review the patient’s records • Draft a detailed response to each point • Discuss the complaint at a practice meeting, especially if it involves several doctors • Send to your Defence Union • The complaint, your draft response, the relevant notes & any other relevant information (Anonymous) • Reflect! • Review the complaint: significant event analysis

11. Complaints procedure • Two stages • Stage 1 Local resolution – i.e. within the GP practice or hospital (90%) • Most complaints: resolved quickly & efficiently • Stage 2 Parliamentary and Health Service Ombudsman • If complainant remains dissatisfied after stage one may complain to the Ombudsman. • Doctors who are being complained about can also take the case to the Ombudsman: • not satisfied with a response provided on their behalf by a commissioning body

12. From the GMC • Most resolved without GMC action • 2008: 5,000 complaints • 80%: public, 17%: NHS, police • Stream 1 (1,500) Serious • Letter +/- employers details form to doctor • If proven may lead to Fitness to Practice • Stream 2 (1,600) Refer for local investigation / No concern • Remainder: No concern of GMC • Contact your Defence Union • Don’t contact GMC before you seek advice • Gather relevant correspondence, records & important details of the case • Statement (explained later)

13. Principles of good complaint handling • Getting it right • Being customer focused • Being open and accountable • Acting fairly and proportionately • Putting things right • Seeking continuous improvement

14. Saying sorry.... • A thorough investigation and explanation of what happened and why • Assurance it won't happen again • An apology – a sincere expression of regret • Disciplinary & criminal procedures • Handled separately • Negligence claims

15. COMPLAINTS • They will happen!! • Undoubtedly stressful. Try and stay focused. • Seek advice from someone more senior • Follow your GP / hospital’s policies • Quite often the patient/family • What happened & why • Who was to blame • Changes in practices and procedures to be made • Sometimes the aim is compensation. • Emotional support – doctors for doctors BMA. Confidential counselling service. 08459 200 169 - 24 hours a day,7 days a week

17. Case Discussion • Very fit and active 82 year old • Bladder ca- resection 3x3courses Intravesical BCG • Info leaflet of side effects and when to seek medical advice Presentation Post BCG 1.-3 Days- Dysuria frequency and low mood-Trimethoprim 2.-6 days - dip stick msu-Nitrofurantoin 3.-10 days-OOH –patient felt improvement- family felt was worse SOB- rest fluids see GP 4.-14 days- dwelling on sx- antidepressant 5.-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

18. What do you think the coroners inquest is for? • What do you do now? • What do you think the family want? • What do you think the outcome is -For the GP? -For the hospital?

19. What its For • Cause of death unknown or violent or unnatural death or in prison or police custody. • Purpose is to enable the Coroner to answer 4 questions: Who? Where? When? How? NOT ABOUT BLAME. • Inquisitorial, not adversarial. • The Coroner controls the evidence from witnesses. Usually full medical records. • Sometimes independent experts report to assist the coroner. • Pre prepared a statement. Don’t normally read this out. The Coroner will ask questions

20. What do you do first? Write a Statement • Find out as much as you can about the purpose of the statement • Copy of the relevant clinical records / documents • Check that your report is factually accurate and detailed • Based on the clinical records? • Based on your recollection of events? • Send your draft statement, the relevant clinical records, and any associated correspondence to the MDU.

21. Outcomes Natural causes. Accident/Misadventure. Neglect. System neglect. Unlawful Killing • Coroner can make a report to the appropriate authority • Cause of death found-Situation reflected on- Change implemented.

22. Case Outcome • Misadventure with real concerns over the knowledge of the medical professionals over this rare but recognised complication of BCG instillation • Hospital- MDT discussion encouraged • Gp- had shared the info in SEA analysis in practice and local GP meetings-requested info leaflet • Education of medical professionals • Family happy- still registered at the practice.

23. I’m being sued! • Do not write to the patient’s solicitors • Gather together all correspondence and a copy of the patient's records. • Contact your Defence Union • Send them the notes and other documents they ask for straight away. • Review relevant guides on websites

24. Investigated by the police • Call your Defence Union immediately! • Vital if you have been arrested or are being interviewed under caution • If interview, ask whether it is an interview under caution • Do not: • Agree to an interview under caution • Make voluntary comments to the police without seeking advice first • Gather together any information that is relevant to the investigation • Patient records, workplace emails • Note of events to help jog your memory later • Don’t write a statement or sign one prepared for you by the police before seeking our advice. • Do not contact any witnesses or discuss the allegations with anyone other than your Defence Union

25. Concerns about colleagues-GMC Guidelines • 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. • 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.

26. Raising a concern • Online Tool- guides you through your concern and tells you who to report it to Don’t forget you can get advice from MPS/MDU BMA +- your supervisor. • Where possible speak to manager or appropriate officer. (whilst in training-post graduate dean) • Clear honest and objective. Acknowledge personal greivance- but focus on issue of patient safety. • Keep a written record of concern and steps taken • GMC-Directly (or Confidential helpline)

27. Handouts • Chaperone • Consent • MPS document • Contact numbers: • GMC Confidential Helpline:0161 923 6399 • MDU: 0800 716 646 • MPS: 0845 605 4000

28. Conclusion! • Communication is key (written and oral) • If you have made a mistake – report it and tell the patient • Document – if it isn’t documented….did it happen….? • Work as a team • Seek advice if unsure/bounce off ideas • Use your defense union….you pay enough for them!!!