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The nature of complaints and litigation

Patients' letters often do not reveal the true seriousness of their complaint or their real reasons for complaining. Usually a serious clinical incident is combined with poor communication, leading to anger and distress often exacerbated by impersonal and defensive replies from hospitals [1]. Recommendations from our study anticipated the Wilson committee emphasis on a personal response to complaints, preferably from clinical staff. The motivations of litigants have also been found to be complex, involving not just a need for compensation, but also for explanation, for accountability and, above all, a wish that lessons were learnt from their experiences to prevent similar incidents in the future [2].

  1. Bark P, Vincent CA, Jones A, Savory J. Clinical Complaints: A means for improving the quality of care. Quality in Health Care 1994; 3:123-132.
  2. Bark P. Providing Support for Doctors When Things go Wrong. Health Care Risk Report 1995; Aug:21-24.

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Experiences of injured patients

The incidents that give rise to litigation are often of a serious nature and have profound effects on the lives of the patients involved and their families. Long term effects on work, social life and family relationships are common as are feelings of anger, bitterness, betrayal and humiliation. Both patients and relatives are often intensely distressed years after the original incident. Patients and relatives dissatisfaction with care often extends beyond the original mishap. They are disturbed by the absence of explanations, a lack of honesty, the reluctance to apologise and being treated as neurotic. Where explanations are given they are frequently thought to be unclear, insufficiently informative and unsympathetic. In most cases these secondary problems contributed to a decision to take legal action [1,2,3,4].

Much more could be done after the original incident to meet the needs of patients and their relatives. Compensation might, where appropriate, be offered at a much earlier stage. A clear, full and honest explanation is fundamental. Patients' wishes, to prevent future incidents and to know that changes have been made, should be taken seriously. Where appropriate patients could be informed of disciplinary action or re-training of staff. The degree of emotional distress resulting from the incidents will often be sufficient to warrant formal treatment, in addition to sympathetic help from the staff involved [5].

  1. Vincent CA, Pincus T, Scurr JH. Patients' experience of surgical accidents. Quality in Health Care 1993; 2(2):77-82.
  2. Ennis M, Vincent CA. The effects of medical accidents and litigation on doctors and patients. Law and Policy 1994; 16: 97-121.
  3. Bark P. Providing Support for Doctors When Things go Wrong. Health Care Risk Report 1995; Aug:21-24.
  4. Church J, Vincent CA. Psychological consequences of medical accidents in personal litigants. British Journal of Health Psychology 1996; 1:167-79.
  5. Vincent CA. Caring for patients harmed by treatments. In Vincent CA. (ed) Clinical Risk Management. London: BMJ Publications. 1995, 433-452.

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The impact of adverse events and litigation on clinicians

A survey of 1011 North Thames clinicians found that over 70% of consultants or senior registrars had been sued in some high risk specialties, 79% in orthopaedics and 76% in obstetrics [1]. Although risk management programmes were, in 1994, seldom mentioned specifically, there was strong support for a proactive approach to adverse events in which many of the themes of risk management, such as early explanation and intervention with injured patients, were advocated [1,2,3]. The need for staff support is also apparent. 19% of the senior clinicians had considered giving up their medical careers as a result of their experiences of litigation [1]. Studies of junior doctors' mistakes suggest that making a serious mistake can be one of the most stressful events in a doctor's career, especially if they are not supported by colleagues and, where litigation is concerned, by managers. The impact of adverse events, complaints and litigation has been further explored in a recent chapter [4].

  1. Bark P, Vincent CA, Olivieri L, Jones A. Impact of litigation on senior clinicians: implications for risk management. Quality in Health Care 1997; 6:7-13.
  2. Vincent C, Bark P, Jones A, Olivieri L. The impact of litigation on obstetricians and gynaecologists. Journal of Obstetrics and Gynaecology 1994; 14:381-7.
  3. Vincent CA, Olivieri L, Bark P, Jones A. Psychiatrists' views of litigation and risk management. Clinical Risk 1996; 2:103-6.
  4. Vincent CA. Fallibility, uncertainty and the impact of mistakes and litigation. In Firth-Cozens J. and Payne R, (eds.) Stress in Health Professionals (3rd edition). Wiley (in Press).

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The effectiveness of incident reporting

With the encouragement of the CNST and the implementation of An Organisation with a Memory, adverse incident reporting is being introduced throughout the United Kingdom, yet there are currently no studies in the UK assessing its value and reliability. To examine the reliability of adverse incident reporting systems, a retrospective review of the mother and baby medical notes from a series of 500 deliveries in two London obstetric units was carried out [1]. Medical notes were screened by a senior research midwife for the presence of adverse incidents defined by clinical indicator lists of incidents to be reported in accordance with unit protocols.

Staff reported 23% of 196 reportable incidents and the dedicated maternity risk managers identified a further 22%. The remaining 55% of incidents were identified only by retrospective case note review and were not known to the risk manager. Staff reported about half of the serious incidents (48%), but comparatively few of the moderately serious (24%) or minor ones (15%). Incident reporting systems may produce much potentially valuable information, but seriously underestimate the true level of reportable incidents. Where one risk manager covers an entire Trust, rather than a single unit, reporting rates are likely to be very much lower than in the present study.

  1. Stanhope N, Crowley-Murphy M, Vincent C, O'Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. Journal of Evaluation in Clinical Practice 1999; 5(1):5-12.

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Reasons for not reporting incidents

In the study outlined above less than a quarter of designated reportable incidents were reported to the risk manager. A further questionnaire study at the same two obstetric units, explored the reasons for low rates of reporting [1]. Views on the necessity of reporting the ten designated incidents varied. For example, almost all staff stated they would always report a maternal death, whereas less than half would report a baby's unexpected admission to the special care baby unit. Midwives said they were more likely to report incidents than doctors, and junior staff were more likely to report than senior staff. The main reasons for not reporting were fears that junior staff would be blamed, the high workload and the belief (even though the incident was designated as reportable) that the circumstances or outcome of a particular case did not warrant a report. Recommended measures to increase reliability include clearer definitions of incidents, simplified methods of reporting, designated staff to report incidents, and education, feedback and reassurance to staff about the nature and purpose of such systems.

  1. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. Journal of Evaluation in Clinical Practice 1999; 5(1):13-21.

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Serious Incidents in Mental Health

For community mental health trusts, suicide and homicide are the areas of greatest concern. In recent years there have been a number of major enquiries into suicides, homicides and other serious incidents. Some, such as the Confidential Enquiry into Suicide and Homicide, have reviewed a large number of incidents using a questionnaire methodology. Others have analysed a single event in detail. For instance, the Ritchie inquiry into the care of Christopher Clunis, a young man with schizophrenia who killed a stranger in the street, found that his care was a "catalogue of failure and missed opportunity". Human factors analysis was developed in highly procedural industries, and requires considerable adaptation to be effective in the fluid and often uncertain mental health environment. In a preliminary analysis, the basic principles however were still found to be valid. A series of incidents were analysed each one providing information of specific management problems and contributory causes. For instance supervisory practice, training needs, equipment maintenance, shift systems and the design and maintenance of the ward were all implicated [1]. Future work is planned to develop a comprehensive, integrated approach to risk assessment in community units drawing both on existing quality strategies and on the human factors tradition.

  1. Vincent CA, Stanhope N, Taylor-Adams S. Developing a systematic method of analysing serious incidents in mental health. Journal of Mental Health 2000; 9(1):89-103

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Assessment of Risks in Paediatric Cardiac Surgery

This study investigates professional judgement in judging the risk of early mortality for total cavopulmonary connection and is being run in collaboration with the Cardiothoracic Unit at Great Ormond Street. Total cavopulmonary connection is a modification of the Fontan operation, used for repair of univentricular hearts. Sufficient experience with this operation has been gained over the last ten years to allow larger centres to produce multivariate risk factor models analysing the determinants of early and late outcome. Such models are held up as what is best in the professional literature, and thus presumably inform professional judgement to some extent. However, they are never used rigorously for their quantitative predictive powers in clinical situations when management decisions are made. We are exploring the process of professional judgement in an area identical to that examined by these statistical models, to understand what contributes to clinical judgement in practice, and thus determine whether the statistical models or the predictive performance of clinicians in this area might be improved.

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The Perception of Risk in Obstetric Care by Obstetric Healthcare Professionals

The aim of this study was to pilot a questionnaire to determine staff's perception of risk and whether they over-estimated or under-estimated obstetric risks. A set of risks that represent daily obstetric practice were identified following discussions with two obstetric consultants. Their expertise and a literature review verified the most up-to-date figures for each of these obstetric risks. A short questionnaire required staff to indicate their perception of risk frequency and their sources of risk information. The study was conducted at two London hospitals, a teaching hospital and a district general hospital (DGH). Obstetricians from both hospitals and midwives from the teaching hospital were invited to participate in the study. In general, obstetricians and midwives accurately predicted obstetric risks, but they tended to over-estimate some risks and under-estimate others. Some staff made quite extreme estimations, with greater errors when estimating risks per 100,000 pregnancies. Both professions reported that they learn about risk frequency information to a greater extent from journals & newspapers and from colleagues. These results have implications for consent, in that if a women is given inaccurate risk information this could affect her decision.

    Woloshynowych M, Taylor-Adams SE. The perception of risk in obstetric care by obstetric healthcare professionals. The Healthcare Risk Resource 1999; 2(3): 14-17

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Patients' perceptions of risk associated with elective cardiac surgery

The aims of this study were to investigate: i) the accuracy of patientsí recall of information presented to them at outpatient consultation; ii) Patient perception of risk information provided during this consultation; and iii) Patientsí understanding of information provided and their satisfaction with the consultation. This study piloted a questionnaire sought information on patientsí perception of the risks associated with Coronary Artery Bypass Graft surgery and their recall of the information provided. The questionnaire was given to patients immediately after their consultation. A follow-up questionnaire was administered by telephone after a three-week interval to those patients who agreed to participate. We found that patients retained only a part of the information provided to them, but that this information is retained over time. Patients reported high levels of understanding and satisfaction. Patients tended to base their perception of the risks associated with surgery on the risk of death rather than the risk of suffering any other adverse outcome or morbidity (e.g. stroke).

    Seymour L, Woloshynowych M, Taylor-Adams S. Patient perception of risk associated with elective heart surgery. The Healthcare Risk Resource 2000; 3(1):8-11

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Patients' desire for risk information in relation to elective cardiac surgery

The objective of this study was to examine patients' individual requirements for risk disclosure prior to surgery. 50 patients were interviewed following coronary artery bypass grafting or valve replacement/repair. Main outcome measures were patients' assessment of the nature and probability of risks they would have wished to be informed of from a pool comprising death and 13 postoperative complications. Findings showed that out of 50 patients, 21 (42%) wanted no risk information at all, 25 (50%) did not want to be advised of the risk of death and 27 (54%) did not want information about the risk of permanent stroke. This contrasts with standard practice of routinely informing patients of the risk of death and stroke. However, there were marked individual patient preferences. Three groups of patients emerged: those requiring little or no risk information, those requiring information about major risks and those requiring full risk disclosure. Patients were not generally concerned about the specific probabilities of any risk. Clinicians counselling patients prior to operation should routinely discuss patient preferences prior to risk disclosure, distinguishing between a preference for 'no risk information', 'all potentially relevant risks' or 'those risks considered significant or likely to occur'. The fact of individual patient preferences may undermine the concept of the 'reasonable patient' in determination of the legal requirements for risk disclosure.

    Beresford N, Seymour L, Vincent C, Moat N. The Risks of Elective Cardiac Surgery: What do Patients Want to Know? Heart (in press)

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This page was last updated on 8 October 2002. Comments.