Patient complaints: the written response

All staff will come across patients who are dissatisfied with health care they have received. If it’s recognised early enough, there may an opportunity to correct misunderstandings or address care that has been deficient. If this isn’t done, patients will often resort to complaints through feedback forms, the hospital’s client liaison service, direct email or even through external means such as social media or local members of parliament.

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This previous post gives an overview of the broad approach to complaints, adverse outcomes and litigation, in particular how to deal with the complaint when it first hits your desk and the decision process about whether it can be resolved via telephone call, written response or if clinical or open disclosure is necessary. Here I am going to go into some detail about the written response.

It's worth considering the reasons why people complain, or what the drivers are for complaints and litigation in general. These might include:

  • To find out what happened and why. It can be a sign that they haven't had their concerns addressed elsewhere.
  • Acknowledgement, acceptance of responsibility and an apology
  • To enforce accountability
  • To correct deficient standards of care
  • Financial compensation – for accrued and future costs

Before writing the letter, you need to understand exactly what happened by accessing patient records and speaking with staff involved if possible. Is there a deficiency in care or has the complaint highlighted an area where change in practice could avoid future adverse events or dissatisfaction? Is the complaint reasonable or does the complainant have unrealistic expectations? It’s rare that there is nothing to learn from a patient who has taken the time to write a complaint and the approach to understanding the situation must be with an open mind.

Once you have all the information and have decided a plan to address the individual’s concerns, you can write the response.

Communication style
When writing, it’s important to pitch the tone of the letter appropriately and bring to our writing elements of communication skills we use in face-to-face care. The style needs to be professional, empathic and convey genuine, heartfelt concern about the issues raised, and a desire to address any deficiencies that have been identified. It’s important to avoid excessively technical language.

When constructing your response, it can be helpful to constantly imagine yourself in the patient’s shoes as they read your letter, having experienced what they have, their level of knowledge about medical matters and their lived experience of the event. As you write, think about how the words you choose make them feel, add to their understanding of the situation and help them psychologically heal.

Outline
The following structure may be used when writing letters:

  1. Acknowledgment of the problem, impact on the individual and distress caused and apology.
  2. Summary of events
  3. Explanation & clarification of misunderstandings or misconceptions, and acknowledgment of deficient care if appropriate
  4. Actions that will occur as a result of the complaint and investigation
  5. Close with final apology and details of who to contact in the case of further questions

I will discuss each of these parts in some detail. There are a wide range of skills in written and spoken word and not all doctors have English as their first language, so I’ll include some example sentences to convey an appropriate style.

Acknowledgment, impact, apology
In the opening paragraph, you will acknowledge receipt of the complaint and thank the patient for taking the time to submit it. An apology for the experience is included. Note that this is not the same as apologising for wrongdoing or accepting fault. Examples might include:

‘Thank you for your feedback regarding the care of your daughter Jane. I’m sorry to hear that some of the interactions with our team didn’t meet your expectations and were upsetting for you. Please understand that we take complaints very seriously and investigate thoroughly.’

‘Thank you for taking the time to write to me. I was sorry to hear that you were unhappy with the consultation when you came to clinic last month.’

‘Thank you for the opportunity to respond to your concerns about….’

 ‘…I’m sorry to hear that your recent experience didn’t meet our usual standards of care.’

‘I’m sorry that you found the staff involved to be unsupportive. As a first-time mother who has been through a complex birth, you would need their care and attention more than ever.’

There’s no need to go into specific explanations or justifications at this stage. The opening paragraph of the letter must be about demonstrating that you have been open to genuinely hear and understand the patient’s concerns.

Summary of events
In this section, you will briefly summarise what has concerned the patient and the crux of the complaint. If the complaint is extensive, you don’t need to repeat the whole timeline here. The reason for summarising into your own words, is to show your open enquiry has resulted in true understanding of what is important to them. They will feel heard.

‘I understand that after your initial surgery, you became unwell later that evening and needed to return to theatre for another operation. This unexpected complication must have been a distressing experience for you.’

‘I understand that when you saw Dr. Jones in the clinic, the information that you received made you anxious and scared for your baby. You believe that a different tone in her voice and choice of words may have made the consultation less stressful.’

Explanation, clarification, acknowledgment
This constitutes the main of the letter and in these paragraphs you will address each of the patient’s concerns, explain any misunderstandings, clarify why events occurred as they did and acknowledge any deficiencies you’ve identified in your case review. Where care has been appropriate, indicate so by stating that it was consistent with expected medical practice.

It's important to be honest. If in your assessment a different course of events might have changed the outcome for the patient, it's right to acknowledge that and apologise that it didn't occur. There is a fine balance between concerns about admitting medico-legal liability and being honest in your explanation. Often we don't know for sure that outcomes would have improved and we need to be clear about that too. The more significant the harm to the patient, the greater the imperative to involve local patient safety and legal teams before sending correspondence.

Communication complaints are common. It’s important to hear your staff member’s version of events. Sometimes they will agree that on that occasion their professionalism slipped and they may be able to explain why (e.g. long working hours, heavy patient load or recent professional or personal distressing event). It is appropriate to tell that patient that you have spoken with the member of staff concerned and that they express regret about what happened. If the staff member outright denies any communication issue, they still need to reflect on the fact that whatever took place, it resulted in an upset patient. Sometimes differences are unresolvable, however we can still express regret at their unhappy experience.

If the patient has a long timeline of events that need explanation – consider whether writing a letter is actually the best approach. When situations are very complex, it can be difficult to convey all the nuances of decision-making and answer secondary questions which will inevitably arise. Sometimes, however, patients specifically request a written reply or decline a face-to-face meeting.

‘As explained by Dr. Jones when he saw you in clinic, persistent attempts at removing small areas of tissue carries the risk of causing injury to the uterus, especially if there is infection present. The operation that was carried out during your admission was done correctly. As documented on the consent form that you signed, there is always the small risk of persistent tissue remaining and scarring inside.’

‘I fully appreciate that the demeanor and individual approach of a doctor can affect how you feel after a consultation. Dr. Jones understands that you were upset after seeing him and he apologises for the distress caused. He also acknowledges that the situation escalated when you insisted that other doctors suggested a different approach. He regrets raising his voice and the confrontation that followed.’

‘We have spoken about alternative ways that the information might be framed to avoid undue distress.’

‘Dr Jones was upset to hear that you were distressed by the consultation on that day, as he felt the discussion went well. I was surprised to hear about your experience, as I have worked with Dr. Jones for a long time and know him to have very good communication skills. He has nevertheless reflected on how you felt on that occasion.’

‘I’m sorry that you went through all of this; it must have been extremely upsetting to deal with, both physically and psychologically.’

‘I have spoken at length to the doctors involved, they have reflected on it and understand where the care we delivered might have been improved. I would have expected a more senior doctor to be involved earlier. I don’t know for certain that things would have been different, but I believe your situation was complex and it’s always helpful to have someone experienced directly involved in that situation.’

Actions
In these section, summarise the actions that have arisen from the complaint including a time by which you will complete them if they aren’t already done. Many complaint responses do not have outstanding actions. If relevant, these might include:

  • Changes in department policy or guidelines to avoid similar issues with a future patient
  • Escalation of the complaint to another internal body (e.g. Patient Safety committee)
  • Communications to remind your team about established policies that were not followed. This could include an anonymised case presentation to emphasise the learning points.
  • Referrals to appropriate specialist or support services
  • Communication to GP

Close with final apology
In closing a final apology and arrangement for follow up and how to get back in contact if there are any further questions.

‘Once again I apologise for your prolonged stay and recovery. I hope you are well on the way to feeling better now. As I mentioned, I can organise a clinic appointment to discuss any further questions you have about this, or future pregnancy planning. If you would like an appointment to be arranged, please telephone Jane, my Support Officer on 44331279.’

‘I’m sorry but we are unable to make payment for a second opinion or further surgery carried out in the private sector. A second opinion is always available with a different team at our hospital. Please let me know and I will arrange this for you.’

‘Thank you for the opportunity to address your concerns. If there is anything else I can do, please do not hesitate to let me know’

Summary
Dealing with patient complaints is complex and can be stressful, but when done well is likely to restore the patient’s faith in the health care provider and organisation. People need to have their concerns heard and to be dealt with in an open, empathic way. Complaints are an opportunity to both maintain our community's confidence and improve the care we deliver.

Feed the fire: a challenge to all doctors

The ills of the medical profession are well documented: we are prone to burnout, anxiety and depression; suicide is twice as common in doctors as compared to the general population. We aren't very good at talking about our emotional problems, not very good at decompressing or comfortable revealing what we feel may be perceived as a weakness.

Other factors contributing to burnout are a loss of control in daily work life, more and more to fit into the same work hours and greater knowledge than ever to incorporate into practice. Junior doctors are subjected to changes in rosters, pressure to complete seemingly pointless mandatory competencies and training pressures with sometimes a bleak outlook for career prospects. Work pressures lead to less social interaction with colleagues and fewer relationships in our home life. 
 

Where is the solution?

Doctors understandably look to the hospitals and management to provide support and bring change to the workplace culture that seems to be responsible for this situation. Some of these are absolutely organisational issues and there needs to be work by medical and non-medical managers to address them directly.

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But, I put a challenge out there to all of us as a profession - from Intern to Consultant: What are YOU and I doing about it?

Contrast the fresh-faced medical student or new intern on their first day of the job, compared to the PGY 6 medical registrar or consultant running a 1:2 service. That first day we started work, holding the shiny badge that finally labeled us ‘Doctor’, did we not have a fire inside our belly that was insatiable. We knew exactly why we were there and what we had to do - or at least we were driven to find out. Our fire is what motivates us to come to work every day, it inspires us to grow, to invest deeply in what we do and the teams around us, it helps us create meaningful therapeutic relationships with our patients.

And then came the long hours, the shame culture of medicine, the loss of autonomy, unreasonable patient expectations, the bureaucratisation of our daily work, electronic medical records, personal debt and the social exclusion. Unsurprisingly, for many that fire inside is now but a smouldering ember. 

We spend our career focusing on education, research, acquiring clinical skills and post graduate qualifications. A good senior, a good peer is someone who helps in one of these areas. But who takes care of the fire inside? This internal quality, the unnamed essence of our WHY needs just as much support and nourishment as our intellectual development receives. Yet we neglect it, assuming that the smothering of the fire is an inevitable consequence of modern medicine. And this is where our responsibility to ourselves and each other lies.

We need to give attention to the fire in ourselves and our colleagues. The same actions that feed the fire, provide a shield of resilience around it. They make the daily work pressures manageable and protect us from burnout (now you know why it's called that!). We will still be busy, but how we are with ourselves, each other and our patients is fundamentally maintained.
 

How do we do this?

  Image: France Corbel, with permission.

Image: France Corbel, with permission.

  1. Praise the good. When did you last have someone go out of their way to tell you how good a job you did at work? Forget the feedback sandwich: we need to actively seek out the positive to praise in peers, those more junior to us, including medical students and the wider healthcare team around us. On our radar, every single day. When so much of what we hear is negative, how good does it feel when someone acknowledges your hard work with a compliment? You can feed the fire of the team around you through recognition of a job well done. The more genuine and specific the feedback can be, the better. And the positivity will make you feel good too.
     
  2. Self-care. You know about this - taking time out for recharge. We tend to think of resilience looking like a boxer in the ring, broken yet fighting through one more round. In fact, resilience is about working hard, taking dedicated time out for rest, and then working hard again. Rest periods mean both within a busy day and time off using recreation leave allowances each year. Your work is never ending, taking time out for lunch away from the workplace will re-engergise you for a more effective afternoon than had you just worked through or eaten lunch at your desk. Exercise, diet, meditation, rest and social support networks outside of work are the cornerstones of self-care.
     
  3. Reflection. Take some time to reflect on the good that you do each day. A journal can be powerful for this, and journaling has other benefits related to problem solving and well being. Each day write down the positive that happened, how you helped people, your successes. When I was a registrar, I had a folder of ‘Thank you’ cards that patients had given me. After a stressful event or when my confidence had taken a hit, I would read through the cards to remind me of the good that I do, of the positive effect I have on people’s lives.
     
  4. Compassion and kindness. It sounds simple and corny but sustained kindness and compassion in the care we deliver, along with the mentoring of compassionate care and values-based practice is imperative for doctors to grow into lifelong happy, resilient practitioners. Be willing to call out bullying and harassment when you see it. If you are junior and aren’t able to directly address it, then tell someone who can. 
     
  5. Team-building and social events. The time we spend together when we aren’t under the pump gives us the unity and trust to take the knocks together, look after each other and work together effectively as a team. How this looks in practice can vary, from team coffees before clinic, lunch together or drinks after work or in the evening.
     
  6. Mentoring. You need a mentor. Someone who you can open up to, talk about your first death on the ward, the kid that died in ED after you worked on her for 2 hours and your fears about whether you can cope with the next rotation. Emotional support comes in many forms and a mentor can be important for more than just career advice. For senior doctors, being a mentor will help you realise how much your experience is valued; there is little that is more rewarding in this life, than being an inspiration to others.
     
  7. Support each other. When your work is done, do you look to help your colleagues? Can you make your night registrar’s evening easier, ensure the script rewrites and discharge summaries are done by 5pm Friday to help the weekend team or lend a hand when your work is done and the clinic is still going? These are the small sacrifices and compassionate support that helps all of us feel better about our hard working day.
     
  8. Gratitude. Research strongly correlates gratitude and individual wellbeing and happiness. An attitude of gratitude can be applied to the past by re-living positive memories and in the present by not taking our own good fortune for granted - we need only look to our patients to see how fortunate we are. Gratitude helps us maintain an optimistic and hopeful attitude for the future.

    Gratitude can be cultivated by writing a thank you note of appreciation to someone who has had a positive effect on your life. It can be a brief daily journal entry, where you explicitly reflect on and write down the good things that happened to you and what you are grateful for. Gratitude may be cultivated through prayer if that is important in your life.
     
  9. Re-write the shame tapes. Brené Brown is a social sciences researcher who has extensively studied shame and vulnerability and her research is very relevant to the culture in medicine. Shame tapes are the messages of self-doubt and criticism: ‘If I was a good doctor, I would have got that arterial line in.’ ‘I’m never going to make it as a consultant.’, ‘I’m not good enough. I’m a fraud.’

    Brown defines shame as ‘An intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging. A fear of disconnection.’

    Shame is the difference between:

         ‘I made a mistake’ or ‘I had a complication’
         and
         ‘I am a bad doctor’  ‘I am such an idiot’  ‘I am a failure’

    To tackle the shame culture of medicine, when something bad happens:
     

    Reach out to someone you trust, someone who cares for you. Share the experience.

    Be kind to yourself and speak in the way that you would to reassure someone you care for: ‘You are OK, you're human. We all make mistakes.’ We would never speak to someone the way we speak to ourselves during a full on shame attack.

    Own it - you get to write the ending. You might have made a mistake or had a surgical complication or missed a diagnosis. Admission, acknowledgment and attention to growth from the event is highly correlated with a positive result next time. The alternative is to protect ourselves by blaming someone else, rationalising it away or internalising the feelings. This path leads to negative outcomes like depression, addiction and bullying.

  10. Be vulnerable. When the consultant surgeon speaks to his team about the time that he screwed up or the complication that he had, he lets down the shield that guards his vulnerability. Not only do others learn from the clinical story, but they feel validated in their own areas of perceived weakness. As Brené Brown discovered in her research: 'Vulnerability is the last thing I want you to see in me, but it’s the first thing I look for in you.' We all have shields to protect our vulnerabilities, but in truth we can only live a wholehearted life and positively influence those around when we let down our shields without fear of vulnerability.


We need to feed the fire inside ourselves and each other. We have to write this into the medical curriculum, talk about it with our teams, teach the medical students and bring the actions to our work every day. Then we will have truly done our part in addressing the dark side of modern medicine.

Danny Tucker