What we can learn from complaints
Fee complaints received by the Independent Sector Complaints Adjudication Service were highlighted in a news story in our July-August issue. Here Independent Practitioner Today reports on other complaints received – and learning points – relating to consultants and medical care.
In the financial year of 2021-22, the Independent Sector Complaints Adjudication Service (ISCAS) reviewed 75 heads of complaint about consultants and/or medical care and has analysed its key areas of concern.
Its code covers:
Complaints about doctors and other health care professional staff working in subscribing organisations, including consultants with practising privileges;
Complaints made by or on behalf of patients regarding all aspects of their care or the services provided by or in a subscribing organisation. These include complaints about medical care or treatment or a clinician’s behaviour.
At the same time, there may be parallel procedures relating to the same events; for example, involving a professional regulator or in the courts.
In recent years, ISCAS has identified an increase in the number of complaints made about consultants and other doctors and the medical care provided.
Gaining informed consent
ISCAS’s review for the last year reminds consultants of their obligations to comply with the GMC document Good Medical Practice (2013) and to follow all its guidance about Decision-making and consent (2020).
Consultants and doctors are also reminded about their obligation to comply with record-keeping guidance.
It says consultants should work in partnership with patients, act with integrity, and listen to and respond to their concerns and preferences, ensuring any information is provided to patients in a way they can understand and to respect their decisions about treatment.
ISCAS found consent forms completed by consultants were not always properly finished and specialists did not always clearly document details of the proposed procedure to be carried out and the intended benefits.
‘From the cases that have come to ISCAS, we note that the consent forms also often lack information relating to the potential risks and complications,’ it says.
‘ISCAS wishes to remind consultants that it is neither sufficient nor acceptable for them to list a small number of risks followed by “etc” in the relevant section of the consent form, nor is it appropriate for them to refer in the consent form to other documents that have been shared or discussed with patients rather than clearly documenting the relevant risks and complications.’
Written information
Patients were not always provided with written information about their proposed procedure either at their initial consultation or as the consent process progressed.
ISCAS says this information, which could be in the form of a general patient information leaflet relating to the proposed procedure or specific written advice, should be provided as early as possible, ideally at the initial consultation.
It stresses that all written information provided should be reviewed regularly and kept up to date.
Consultants are also criticised in the review for not always adequately documenting details of conversations held with patients, including those relating to the consent process.
Phone conversations should be included too.
The complaints service highlights that patients sometimes feel ‘rushed’ during the consent process and ‘under pressure’ to sign the relevant consent forms, while others felt they had undergone procedures without fully understanding any associated risks.
It reminds consultants to ensure patients get time to consider and reflect on their proposed procedure and ensure they know about any associated ‘cooling-off’ period.
Managing expectations
Patients do not always fully understand the potential benefits from procedures, ISCAS found. This can result in their expectations often not being managed when the outcome is not as anticipated.
‘ISCAS notes that consultants should be clear with patients from the outset about the intended benefits that may be obtained from treatment or surgery and encourage them to ensure that patients understand that there can be no guarantee that a specific outcome will be achieved.’
Information and advice about procedures
An increasing number of patients have complained about the level of pre-operative instructions and postoperative advice and guidance that they have been given and about the lack of the provision of associated written information.
ISCAS reminds consultants in its review of obligation as directed by the GMC (2020) to ensure patients are provided with all relevant information to enable them to make an informed decision about treatment.
It says consultants should ensure they:
Clearly document in the patient’s record all relevant post-operative advice and guidance;
Ensure patients are given written information, including contact details of the relevant person to contact for assistance or in an emergency.
Record-keeping and documentation
Concerns are also growing about the standard of record-keeping among consultants and doctors.
The inadequacy and lack of comprehensiveness of some clinical records are highlighted and also an increasing trend in the number of entries by consultants and doctors in clinical records that are illegible.
In another ‘reminder’, ISCAS states consultants are obliged to ensure they keep accurate records of all interactions with patients, including when complaints have been made.
‘This includes keeping detailed records of any and all consultations and communication, including consultations that have been held virtually and phone conversations.’
All doctors should ensure each entry in the patient’s clinical record is dated, timed and signed as per the requirements.
Consultants are also asked to remember the importance of providing the treating hospital or organisation with a copy of all records relating to their interactions with patients, including consultation notes and correspondence to the patient’s GP.
‘Where agreed with the organisation, this could take the form of uploading consultation notes and correspondence to the patient’s electronic record.’
Communications
Increasing complaints about the conduct and attitude of some consultants and doctors are also noted.
While recognising difficulties in communication can sometimes arise for various reasons, ISCAS draws attention to doctors’ obligation under the GMC to listen to patients, respond to their concerns and preferences, treat them with integrity and respect, and provide them with reassurance when required.
It says some patients might sometimes perceive the consultant’s attitude as being patronising, disinterested, dismissive or lacking in empathy and, in some cases, patients think they have been treated aggressively.
ISCAS emphasises the need to treat patients politely, considerately, professionally and with dignity at all times and to respect their confidentiality.
It adds that it’s important to agree with patients at the outset the mode and frequency of communication with them to enable their expectations to be managed effectively.
Apologies
More complaints have also been looked into where people were after an apology from the treating consultant. Increasing numbers of cases claim apologies were insincere and lacking in empathy.
ISCAS draws attention to guidance issued by Ombudsman Offices in the UK on what constitutes an effective apology and how this may be delivered.
When providing an apology, doctors should acknowledge any wrongdoing or offending action or behaviour, accept responsibility for the offence and any harm done and acknowledge the impact of any wrongdoing on the complainant.
It is also important to explain any steps or actions taken to prevent a recurrence.
‘ISCAS considers that an apology should be issued as soon as possible after wrongdoing has been established and should be meaningful, unconditional, and empathetic. ISCAS also considers that that the language used when making an apology should be clear, plain, direct, sincere and unambiguous.’
Most patients who are seeking an apology require this in writing. ISCAS highlights, however, that an apology, including a written apology, is not the same as an admission of liability.
