significant event review – patient complaint (being open) pete wilkinson clinical governance leads...
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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??