Learning From a Complaint: Advice for Individuals and Organisations

Dr Honor Merriman Outlines Procedures and Approaches for Responses to Patient Complaints and Recent Guidance on Recording Notes About Complaints for Appraisal Portfolios

Complaints from users of NHS services are common and when they occur can lead to negative feelings in those who receive them. It is understandable that service providers should feel discomfort: everyone sets off each working day to do the ‘best job’ they can, often working far in excess of their contracted hours. Complaints can seem to health professionals to be wholly negative; an unbalanced response from patients focusing on a part of care that provoked dissatisfaction while not recognising that the rest of the care offered was of an adequate standard. Changing how we feel about complaints can help us gain from the experience. This gain should be making our response one of learning and professional development.

Learning from complaints is not only essential for individuals but also for the whole practice, and anything that needs to be changed should receive an action plan.

It is rare for clinicians to receive no complaints at all—most get a few, and negative feedback should be seen as an opportunity to develop, not ruin, a medical career. It is important to understand that people can respond individually to trauma in a way that leads to increased personal resilience and even growth,¹ and so descent into low mood and professional dysfunction after a complaint is not inevitable.

Complaints Procedures

There are well defined ways in which to respond to complaints and this article will signpost how to learn from a complaint both as an individual and as a practice.

The whole process is set out in NHS England (NHSE) guidance_,² NHS Scotland guidance,³ on the Health in Wales website,⁴ and the nidirect website for Northern Ireland.⁵

Response by GP Practice

Complaints received at GP practices need a response from the practice to acknowledge the receipt of the complaint within 3 days (2 days in Wales).⁶ A full response to the complaint is then needed (Box 1).

All practices should ensure that information about their process for managing complaints is easily available to patients and should allow for both a verbal or written approach. If the complaint is verbal, a rapid verbal response may allow resolution within 24 hours. The incident should be recorded for further learning. Complaints should be made within 12 months unless there is a good reason for the delay e.g. the patient’s illness, or bereavement.⁷

Written Complaints

For written complaints, an early contact with the patient or representative (Box 2) can determine what the complainant wishes to get out of the complaint investigation and a plan can be agreed. Some practices have a complaints lead (a complaints manager) but in most practices the practice manager and the doctors and/or nurses involved in the complaint should investigate the complaint and then work together to write the response.

It is helpful to discuss the complaint in the meetings held at the practice; where these are held every week (or daily), the team approach to investigation and system change really helps the process at an early stage. Writing a good response to a complaint will help with a satisfactory resolution. Adopting an empathic approach in the letter from the start, offering apology for the patient’s feelings before explanation, is good practice.

The two most important elements of a good response are to address all of the concerns in the letter and to explain if any changes are planned to prevent a recurrence of whatever it was that caused the complaint. Details of how these changes are to be made should be included in the letter.⁷If the complaint is made by someone other than the patient, consent for release of information should be sought; if this is not obvious, advice from a medical indemnity provider may be needed.

The response should avoid medical jargon and give an account of the events complained about, including the medical background of the patient and on what basis medical decisions were made. Additional guidance on what to include in a written response can be found in Box 3.^8,9

The tone of the letter should be both professional and sympathetic. Saying sorry does not admit liability.¹⁰

Recording Personal Learning from Complaints

It is a professional requirement that complaints should be recorded in the portfolio of information about the GP and discussed at appraisal.¹¹ Compliments should also be submitted and discussed; most GPs do not submit every letter of thanks, but every complaint should be submitted.

General Medical Council advice is that there should be a note of involvement in any investigation and response to a complaint.¹¹ If any actions have been taken as a result of the complaint, these should be in the note and if there are any professional development needs, these should be discussed and added to the personal development plan (PDP) if not actioned already. Withholding information about complaints from the appraisal process is considered a breach of probity.¹² How much to include in appraisal paperwork in personal reflection and the manner in which it should be recorded has recently been discussed in Responsible officer and appraisal leads network information sheet 8, which states:¹³

‘Simple rules to help doctors to reflect on their practice with confidence:

1. Ensure that everything you write is couched in professional and neutral terms. Think professional, not confessional and avoid being judgemental of yourself or others. For sensitive matters it may help to draft your initial thoughts separately and then distil these into your written reflection.
2. Diligent anonymisation of all written material in appraisal is as important for the writer as for others. It is essential to ensure that third parties, be they patients or colleagues, cannot be identified.
3. Talk before you write. If unsure what to write on a sensitive topic, make a non-specific reference in your appraisal submission as a reminder to discuss it at your appraisal. You can then agree with your appraiser what to record in the appraisal summary.’

Reflections in a Legal Context

In light of the recent case of Dr Bawa-Garba, the GMC has pledged to the British Medical Association that it will not ask doctors to provide reflective statements as part of their own investigations.¹⁴ The GMC has also prioritised the development of clearer guidance on reflective practice.¹⁵

On 11 June 2018 a report was published following a rapid policy review by Professor Sir Norman Williams on Gross negligence manslaughter in healthcare.¹⁶ Overall the report aims to support ‘a just and learning culture in healthcare, where professionals are able to raise concerns and reflect openly on their mistakes but where those who are responsible for providing unacceptable standards of care are held to account.’¹⁶

The GMC has issued a response stating that the report was a missed opportunity to recommend giving doctors’ reflections legal protection in the criminal courts. Professor Sir Terence Stephenson, Chair of the GMC, said: ‘We are disappointed by the Review’s recommendations. We wholeheartedly support the Secretary of State’s desire to create a learning culture. The best way to achieve that is to legally protect doctors’ reflective notes. We are concerned that, in accepting these recommendations, the Government is missing an opportunity to protect all doctors by not going ahead with a recommendation to enact this legal protection.’¹⁷

Practice Learning From Complaints

The response to the complaint needs to be timely, discussed in the team, and investigated promptly. Lessons are often learned and there needs to be process for ensuring that any errors cannot be made again. Complainants often seek assurance that the practice will ensure the same error is not repeated. Discussion about complaints should be a regular item in practice meetings, both to discuss new complaints and to ensure progress with actions resulting from previous complaints. The Care Quality Commission, under regulation 16, will ensure that the practice has a process for investigating and responding to complaints.¹⁸

Complaints Made Directly to NHS England

Sometimes patients or their representatives will submit their complaint directly to NHSE (or equivalent in Scotland, Northern Ireland, or Wales). The practice or individual GP will always be informed when this happens and prompts sent to request a practice response; access to records will be requested if an external opinion is needed in the form of a notes review or an investigation. The full process is described in their guidance.^2–5 Complaint managers at NHSE can provide support, for example:¹⁹

• advice and help to staff on handling difficult situations
• help with wording letters and patient information
• obtaining feedback from patients on particular practice issues
• patient focus or customer care training
• arranging for a conciliator
• acting as an ‘honest broker’.

There are lessons learned from complaint reviews and different area teams are sharing these through their local networks.

Involvement of the Parliamentary and Health Service Ombudsman

The Parliamentary and Health Service Ombudsman (PHSO) can make final decisions about complaints that have not been resolved by NHSE and sometimes patients contact the organisation directly.²⁰ In general, the PHSO prefers that the complaint is investigated locally first of all.

Summary

Receiving a complaint is an unwanted and disconcerting experience. Gaining the support of colleagues, the local medical committee, or defence organisation is helpful in responding appropriately. It is important to regard it as an opportunity to learn and to have a supportive discussion about it at your appraisal. Many complaints investigated by NHSE are not founded on clinical errors but stem from misunderstandings or poor communication with patients.⁹ Addressing this type of complaint can result in the healthcare professional gaining insight into how they communicate with patients and relatives and developing new skills in this part of professional practice. These skills will improve clinical care in the future. Publicising how a GP practice has responded to feedback or a complaint can demonstrate a culture of responsiveness, the ‘you said, we did’ approach.¹⁹

Honor Merriman

GP and Senior Appraiser, Oxfordshire