Saying sorry

THERE are many opportunities for mistakes to happen in the practice of medicine. Missed or delayed diagnosis, prescribing errors, forgotten referrals, failure to action abnormal results, breaches of confidentiality and communication errors are just a few examples.

High-profile scandals involving poor patient care, such as the failings at Mid Staffordshire Hospital, have reduced public trust in the NHS and doctors. It is hardly surprising that the number of complaints and claims is rising steeply.

In January, the health secretary Jeremy Hunt said: “Doctors and nurses must apologise for care failings and should be more open and honest when things go wrong, say sorry to patients and help win back trust in the NHS”. In response to the Francis inquiry into the events at Mid Staffs, the government plans to introduce a new statutory duty of candour this year.

Consider the following scenario:

The face at the reception window is angry and weary and pale. “My daughter is in ITU fighting for her life with a ruptured ectopic pregnancy. She saw one of your doctors yesterday who said at her age not to worry because her irregular bleeding was just the menopause. She nearly died.” My heart goes ice cold. I had seen the daughter yesterday, a lovely lady aged 47, but the mother doesn’t know this. What do I do? The mother is not complaining just reporting what happened. Should I speak to her and apologise or will that make it worse? If I say sorry will the family sue me, or should I just wait and see what happens next?

Open and honest

In its guidance Good Medical Practice, the General Medical Council is clear about what doctors should do if something goes wrong:

You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress you should:

• Put matters right, if that is possible

• Offer an apology • Explain fully and promptly what has happened and the likely short-term and long-term effects.

Importantly, the GMC goes on to advise: “Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology.”

Dr Dorothy Armstrong professional adviser to the Scottish Public Service Ombudsman (SPSO) supports this position. In a recent article for the SPSO, she says that in her experience a complainant’s biggest regret is often that the staff member involved in a mistake or wrongdoing simply was not honest or apologetic. In many cases, she adds, an apology or the truth about what had happened may have prevented a complaint being made or escalated to the Ombudsman.

Fear of liability

As GP trainees at the coalface of patient interaction and the delivery of primary care, you are ideally placed to try to defuse a situation that could escalate to a complaint. Be open, be honest, be truthful. Say sorry.

But, as shown in our scenario, doctors sometimes worry that an apology may be interpreted as an admission of liability in any potential litigation – a bit like with car insurance.

The NHS Litigation Authority, the body which oversees claims made against the health service, has published a four-page guidance booklet for staff called Saying Sorry.

It clearly states: “Saying sorry when things go wrong is vital for the patient, their family and carers, as well as to support learning and improve safety. Of those that have suffered harm as a result of their healthcare 50 per cent wanted an apology and explanation.

“Patients their families and carers should receive a meaningful apology – one that is a sincere expression of sorrow or regret for the harm that has occurred.

“Saying sorry is NOT an admission of legal liability, it is the right thing to do.”

This is a view shared by MDDUS and we would always advise doctors to offer an apology where appropriate. As a medical adviser, I often provide assistance to doctors who are facing upsetting and troublesome complaints. When advising how to draft a written response to a complaint, I usually recommend that the opening paragraph includes firstly an acknowledgment of receipt of the complaint and secondly an expression of condolence to the complainant and their family for the perceived harm suffered. It is good practice to then assure the complainant that their concerns have been taken seriously and also give an account of the investigation that has taken place. It is also helpful to include a paragraph detailing any lessons that have been learned by the doctors/practice to prevent a similar event happening again.

Dr Dorothy Armstrong advocates the 3 R’s approach to saying sorry:

Regret

It is important to recognise that something has gone wrong by acknowledging the wrongdoing, even if you are not at fault. Saying sorry, in a meaningful and sincere manner, is crucial. Often this first step is enough to de-escalate the situation.

Reason

Even if you feel criticised and hurt, it’s really important to provide a reason (if there is one) for the mistake, but to avoid being defensive. Make sure you are clear that the wrongdoing was not intentional or personal, so keep to the facts. Try to put yourself in the complainant’s shoes and step back from the situation. Stay objective.

Remedy

Try to resolve the mistake there and then, if you can. Ask the complainant what they would like to happen and take responsibility to investigate, if required, and to provide feedback to them as soon as is practicable. Encourage colleagues to be proactive too.

So, back to our opening scenario and what our doctor should do…

In this case, it would be appropriate to speak to the patient’s mother in more detail. Consider an approach such as: “I am very sorry to hear what has happened to your daughter. Why don’t you come in to my room for a minute?”

Before beginning a conversation, bear in mind that you cannot say anything that would breach the patient’s confidentiality. It may be worth thinking back to the consultation – did the doctor take a good history? Was the patient happy with the diagnosis and management plan that was discussed? Regardless of what happened in the consultation, it is important not to be defensive, after all something terrible has happened. Our doctor can be sorry without being guilty.

The conversation with the patient’s mother might go something like this: “You must have had a very distressing and stressful time of it last night. I was the doctor who saw your daughter yesterday, I am really sorry to hear what has happened to her after I saw her. I would like to assure you we will fully investigate what has happened to see if there is anything that I could have done differently at the time and, if so, to stop this happening to someone else. I am sorry for all the upset you have had. Is there anything you would like me to do at the moment to help?”

Each situation/complaint is different so advice will vary depending on the circumstances. If in doubt, contact MDDUS for advice on how to proceed.

Useful resources:

• The SPSO: http://tinyurl.com/mn88qar

• NHS Litigation Authority: http://tinyurl.com/o8zjqun

Dr Susan Gibson-Smith is a medico-legal adviser at MDDUS