Understanding decision making - Assessing complaints Ian Thurgood Director of Assessment and Resolution Health Care Complaints Commission Dr Stuart Dorney Medical Director, Medical Council of NSW

Regulatory Framework National Registration Boards/Australian Health Practitioner Regulation Agency (AHPRA) NSW Health Care Complaints Commission NSW Health Professional Councils NSW Civil and Administrative Tribunal and Professional Standards Committees

The Commission’s role  The Commission is an independent body dealing with complaints about health service providers in NSW.  The Commission is a co-regulator with the health professional councils.  The Commission receives, assesses, attempts to resolve, investigates and prosecutes health care complaints in NSW

Role of the NSW Health Professional Councils Co-regulator with Commission – every complaint is notified to the other body and consulted on before action taken Manage complaints about the conduct of practitioners in NSW where the conduct is below the acceptable standard Manages health and performance issues of practitioners in NSW Have emergency powers to impose conditions or suspend a practitioner in NSW (Section 150) in serious complaints.

Assessing complaints  A complaint must be in writing  Complaints are required to be assessed within 60 days  A copy of the complaint is usually provided to the health provider to assist them prepare a response  The response is usually given to the complaint with the consent of the health provider  The Commission may seek records or other relevant information (power to require: Sec 20A Health Care Complaint Act)  Internal medical or nursing opinion may be sought  All information collected is considered when making the assessment decision  All decisions are made in consultation with the relevant Council.

Outcome

Case 1 – Missed appendicitis The complaint The patient was referred by GP to emergency department with ‘a couple of days of abdominal pain’ and signs of blood in urine. Reviewed by surgeon who orders blood, urine and ultrasound to be taken. Patient was admitted for observation. Patient was monitored for three days, further blood and urine tests run, pain did not increase -> patient was discharged with verbal instructions to see GP or return to Emergency, if condition worsened. Patient noticed syringe under her bed lying there for two days Visitor who came after patient had left hospital, asked nurse where to find the patient and was pointed to ward, was then referred to her bed and when asking where the patient was, received the answer : ‘she must have gone then’ Patient presented to GP next day, who referred her to a different hospital, where a surgeon diagnosed appendicitis and performed operation the next day.

Case 1 – Missed appendicitis Commission actions Requested response from the surgeon regarding medical management Requested response from the hospital regarding level of nursing care and cleanliness of the ward Obtained internal medical advice

Case 1 – Missed appendicitis What the surgeon said Appendicitis is not always an easy diagnosis to make, particularly where the initial pathology, other investigations and clinical examination do not support such a diagnosis. Patient’s pathology results were normal, including white cell count (WCC) 5.8 (normal range (NR) 4-11), neutrophils 3.4 (NR 2-7.5), CRP <4 mg/L (C reactive protein NR < 6), ESR 6 mm/hr (NR<30) and Beta HCG < 2. urinalysis showed a trace of blood and MSU (mid-stream urine) subsequently grew a mixed growth likely to be due to contamination. the pelvic and renal ultrasound was performed and this was normal with no free fluid. The appendix was not visualised. Mild tenderness in abdomen on review, repeated blood and urine tests came back normal, patient tolerated diet and fluids, analgesia was decreased Surgeon apologised for late diagnosis, but on review defended the conservative management

Case 1 – Missed appendicitis What the internal medical adviser said 1.Doctor appropriately performed blood tests, MSU and pelvic and renal US. Of note there was no increase in patient’s WCC or CRP which is usually seen in appendicitis. The only abnormality was haematuria which was investigated with a renal US. 2.The patient’s analgesia requirements reduced over day 2 and 3 prior to her discharge. She had not required any analgesia for 19 hours when confirmed for discharge by the doctor. 3.It is not uncommon for appendicitis to be difficult to diagnose, as there are many other causes of abdominal pain. In the absence of any confirmatory investigations to support the diagnosis and in the presence of improving symptomatology, it was reasonable practice to have discharged the patient. 4.The fact that the patient’s pain worsened requiring her to attend the GP the next day indicated to the second surgeon that a grumbling appendix, which was not going to settle, was the underlying aetiology of her pain. Conclusion: Based on analysis, doctor’s care did not depart from appropriate standard.

Case 1 – Missed appendicitis What the hospital did Reviewed diagnoses and management by doctor as well as discharge arrangements Responses from the surgeon was reviewed by a second surgeon Medical records and their accuracy were reviewed Nursing staff interviewed and established that the nurse who spoke to the visitor had not been involved in the patient’s care and was therefore not aware of patient’s discharge -> apology provided to patient Issue of cleanliness and disposal of hazardous material enforced with all stafff

Case 1 – Missed appendicitis Decision Patient was sent a copy of the both the surgeon’s and the hospital’s response and was advised of the internal medical adviser’s conclusions. Patient advised that she considers this complaint to be resolved Commission consulted with Medical Council regarding the complaint about the surgeon

Case 2 – Delayed surgery The complaint Parents presented with 10-week old son to public hospital with an inguinal Hernia. They waited at the emergency department for six hours before being taken to the Paediatric Emergency Department. As the surgeon was in theatre, her son only saw him the next day at his private rooms. The Paediatric Surgeon confirmed that it was a large hernia, and her son required surgery to remove the hernia as soon as possible, but the next available date was three weeks away a private hospital, or six weeks away at the public hospital. The paediatric surgeon informed that the surgery should be done much sooner due to risks the hernia presents to a 10 week old baby, but their theatres were absolutely booked out. Parents eventually agreed to surgery at private hospital after taking out a home loan to pay for the surgery, as they did not have private health insurance. They were concerned about the limited capacity at the public hospital.

Case 2 – Delayed surgery Commission actions Requested response from the hospital Requested medical records

Case 2 – Delayed surgery What the hospital said Case was reviewed by Director of surgery who advised that the hospital theatres were not contacted by the surgeon in relation to the patient. In case it was deemed an urgent case, space could have been found or another surgeon engaged. The practice of referring patients under the care of the paediatric surgical team to private rooms from the hospital’s emergency department resulting in them being charged as private patients will not occur in the future. Hospital offered a sincere apology for the distress the family had experienced

Case 2 – Delayed surgery Commission actions As a result of the hospital’s response that the surgeon had not contacted the hospital’s theatre to check for an earlier time, the Commission re-assessed the complaint and added the surgeon as a provider Surgeon was asked for a response to the complaint

Case 2 – Delayed surgery What the surgeon said Patient had an inguinal hernia – a condition requiring surgery in semi- elective time frames. As the surgeon on-call, I was consulted and my recommendation to the doctor who phoned me was that he did not need emergency surgery and to proceed with a surgical referral. It is always entirely up to the family which surgeon they choose to see for follow up and it is absolutely my policy not to recommend or even imply a recommendation that the family be reviewed by me. For whatever reason, the family contacted my rooms, made the appointment of their own volition and were told about the financial implications of that.

Case 2 – Delayed surgery What the surgeon said Regarding dates for semi-elective surgery, surgeons vary a little in terms of how they approach this. All surgeons are given a roster of allocated theatre times and they choose either to allocate patients to those dates themselves or to allow the admissions office to do this. In an emergency situation, surgeons negotiate additional operating time with relevant managers of the operating theatres. In this case, the surgery was semi-elective, not emergent and there was therefore no reason to contact the operating theatres. Semi-elective conditions often seem to fall somewhat “between the cracks” in that they are potentially serious but, fortunately, we are able to deal with them before that actuality arises.

Case 2 – Delayed surgery Decision Patient was sent a copy of the both the surgeon’s and the hospital’s response. Commission consulted with Medical Council regarding the complaint about the surgeon The complaint about the hospital was referred to the Commission's Resolution Service that ultimately negotiated for the family to receive a reimbursement of the operating costs The complaint about the surgeon was referred to the Medical Council.