1. Significant event review – Patient complaint (Being Open) Pete Wilkinson Clinical Governance Leads Meeting 24 th May 2006

2. Shared knowledge Only patient knows Only doctor knows the unknown area knows doesn’t know knows Doesn’t know Doctor Patient

3. Patient History Mr E 77 years old Traveller Enjoys outdoor life

4. Previous Medical History # Dislocation RTA right hip Type 2 Diabetes PVD (left fem-pop bypass) Asthma -> COPD Lifelong smoker IHD Generalised moderate OA Psoriasis

5. Presented c/o pain in Achilles region right leg No h/o injury, gradual onset No new clinical signs (cf records inc DM annual review documenting reduced/absent peripheral pulses) No signs suggesting DVT Managed conservatively with analgesics- some benefit

6. Seen 3 times in next 2 weeks Phone advice twice Symptoms and signs unchanged Until significant worsening over W/E Presented at A&E Admitted under Vascular Surgeons Diagnose with ischaemic right lower leg B/K amputation performed

7. 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

8. Complaint received by Practice PM acknowledged receipt and outlined response plan Complaint passed to PW (patient’s usual GP and involved in recent care) GPs contacted Defence organisations GPs compiled single amalgamated response Defence organisations advised,and the report was amended accordingly

9. 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

10. 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

11. Practice SEA Meeting (Multidisciplinary) Importance of good documentation Persisting unexplained symptoms warrant careful (re-)assessment A complaining patient still registered still entitled to full Medical Services Discussing issues with complaint pending is ok - whoever initiates it Satisfied patient = best outcome for doctors Follow up needed with Consultant

12. 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

13. Patient remains registered with the practice Wheelchair dependent most of time Phantom limb pain No longer “travels”- furthest trip is to L&D Limb Fitting Centre Doctor-Patient relationship enhanced by having dealt with the issues “More Open”

14. OPEN BLIND HIDDENUNKNOWN Dr knows this Dr Doesn’t know this Patient knows this Patient doesn’t know this

15. 10 Key Principles of Being Open 1Acknowledgement 2Truthfulness, timeliness and clarity of communication 3Apology 4Recognising patient and carer expectations 5Professional support 6Risk management and systems improvement 7Multidisciplinary responsibility 8Clinical governance 9Confidentiality 10 Continuity of care

16. Key Steps to Being Open 1Identify 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

17. Key Steps to Being Open 2Meet 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

18. Key Steps to Being Open 3Assess level of incident and response IncidentAction 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 HarmUnless 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.

19. 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

20. Key Steps to Being Open 4Notify relevant persons Patient Carer Colleagues involved in incident Defence Organisation PCT NPSA

21. Key Steps to Being Open 5Identify staff who will meet with patient/carer PW in this case Alternatives and additions were offered

22. Key Steps to Being Open 6Discuss with patient/carers the option of meeting to discuss the incident and agree with them who they wish to have present Patient and his wife They were asked if they wished to have anyone else present

23. Key Steps to Being Open 7Plan and arrange the meeting at a convenient time for both parties

24. Key Steps to Being Open 8Document the meeting Consultation recorded in patient’s medical records Recorded as part of SEA Meeting Recorded in separate documentation for medicolegal purposes

25. Key Steps to Being Open 9Communicate 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

26. 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

27. QUESTIONS??