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
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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
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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
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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 .
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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
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Patient had an inguinal hernia – a condition requiring surgery in semielective 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
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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.