Complaints

For Private patients

• The Dental Complaints Service assists private dental patients and dental professionals resolve complaints about private dental services.

• An independent dental complaints service funded by the General Dental Council.

Dealing with difficult people in the clinic

• They may have a point!– But may not be

expressing it well!

• Angry • Nasty • Demanding • Critical • Oddball • Indecisive

• Sarcastic • Intoxicated • Shifty • Argumentative

No one has to tolerate abuse or bad language!!!

Common reasons for being difficult

• Tired, frustrated, frightened

• confused or overwhelmed

• defending their ego• unfamiliar with

situation• feel ignored• under influence of

drink or drugs

• don’t understand• in bad mood• in a hurry• other reasons…..

Why do complaints occur?

•Error•Unaware of costs involved•Poor understanding/poor explanation•Unrealistic expectations•Failure to appreciate needs/wishes of

patient

Handling complaints in the clinic

• Take aside• Listen• Repeat • Apologise • Acknowledge • Thank • Follow up

• Don’t take it personally

• Remain calm • Focus on the

problem & not the person

• Try and turn the situation into a better one!

How to answer a complaint letter

Look at the complaint letter, clinical notes and response.

Acknowledge receipt & deal with promptly

1. Consider how you would answer it?2. What do you think of the response?3. How could it be improved?

Response• Aim

– Resolve concerns– Not about who’s right and who’s wrong

• Factual content– Chronology– Findings– Actions– Reasoning– Correct

• Tone– Non-confrontational– Sympathetic– Non-defensive

• Answer questions raised

Clinical Negligence

Clinical Negligence

Claimant must show

•Duty of care

•Breach of duty

•Causation

Breach of duty

•Bolam test•Guidelines and protocols

Bolam vs Friern Hospital Management Committee[1957]

“A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art

…a doctor is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion taking a contrary view.”

McNair, J

Breach of duty- Bolitho

Bolitho vs City and Hackney Health Authority[1997]

“If in a rare case it can be demonstrated that the professional opinion is not capable of withstanding logical analysis, the judge is entitled to hold that the body of opinion is not reasonable or responsible”

Clinical Guidelines

“If guidelines have been produced by a respected body and have been accepted by a large part of the

profession, a doctor would have to have strong reasons for not following

that guidance”

Causation

The claimant must prove that the breach of duty caused or

substantially contributed to the damage suffered.

Foreseeability

• The injury caused must have been foreseeable.

• “Reasonable anticipation”• E.g.

– Not taking an adequate medical history– Not using rubber dam

Concurrent negligence by the patient and the doctor, resulting in delayed recovery or harm to the patient.

Defence for the doctor in civil cases.

Burden of proof on doctor.

Contributory negligence

Liability of the master (employer) inspite of absence of blame worthy conduct on his part.

Negligence

Employer responsible for negligent acts of his servants.

Within the scope of his employment/range of services.

Tort of occupier’s liability (e.g. visitor injured on practice grounds).

Vicarious liability

Quantification of Loss• Compensation

- General Damages = Pain Suffering and Loss of Amenity- Special Damages = Actual loss until date of trial.- Future Loss = Predicted future loss- Bereavement award

Time Limits

• Limitation Act 1980

• 3 years– Date of

knowledge– Children– Mental Disability

For NHS cases normally limit of 1 year applies

How to avoid troublesimple answer

you won’t!

Areas for Good Practice

• Communication• Prescribing• Medical records• Training• Equipment• Guidelines/Professional

responsibilities

Communication Skills

• Most complainants and claimants mention communication as a problem

• Most health professionals think they communicate effectively

• Be especially clear when discussing fees/costs – NHS/private

Competence

• Always act within your limitations• Never undertake a task that is

beyond your competence

Chaperone

• Applies whether or not you are the same gender

Confidentiality

• 1998 Data Protection Act • GDC guidance (Confidentiality:

Protecting and providing information)• Take steps to avoid potential leaks

– Reception areas – overhearing sensitive info

– Restricted access to electronic records to only those who require it

– Encryption software

Consent

• GDC guidance• Capacity• Always obtaining consent – even for

the briefest of physical examinations!

• Civil claim in negligence/ assault

For “Valid” Consent

• Competence & Capacity • Voluntariness • Knowledge

“A dentist must explain to the patient the treatment proposed, the risks

involved and the alternative treatments and ensure that

appropriate consent is obtained”

GDC ethical guidance to dentists in relation to consent

“Informed” Consent

• Implied, verbal or written consent

• Type depends on risks of treatment

considered!• Children –

“Gillick”

Clinical Records

• “You must keep clear, accurate and legible records, reporting the relevant clinical findings, the decision made, information given to the patient, and any drugs prescribed or other investigation or treatment” GMC

• Never rewrite notes at later date – make clear any retrospective entries by signing and dating alterations

• Patients have legal right to access their records• Avoid derogatory statements, offensive patient

acronyms and criticism of colleagues!

Careful prescribing

• 25% of NHS claims from prescribing errors• Generic drug names• In accordance with BNF• Commonest errors

– Wrong dosage– Inappropriate medication– Failure to monitor treatment (SEs and toxicity)– Communication failure

Conduct

• 20% of all complaints about GPs were in response to poor attitude

• Calm, sympathetic and professional manner

• ‘Physician-Patient Communication’ – Drs who never received a claim used humour and laughed more and spent approx 3 min longer per consultation

Cover

• Check with your medical protection organisation for appropriate cover to reflect the work you do

Communication

• 43% of complaints to Healthcare Commission were related to limited discussion about treatment options

A dental professionals role in detecting systemic disease

• Asses head & neck• Exclude a dental cause• Referral as required • Give appropriate health

advice• Health assessment as

per training i.e. for sedation etc.

Cover your back

• Seek advice from senior colleagues or your medical protection organisation

• Respond promptly

• What % risk of a complication happening do you discuss with your patient?– Depends on severity/consequences if it

happens!

Cutaneous sinus tracts of dental origin….

• Are often misdiagnosed and inappropriately treated because of their uncommon occurrence and the absence of symptoms in ~ 50% of the individuals affected.

• Often referred with a recurrent or chronic cyst, a furuncle, or an ulcer on the face or neck.

• Correct diagnosis is based on a high index of suspicion and on radiological evidence of periapical pathology.

• Appropriate treatment usually results in predictable and rapid healing of these lesions

Take home messages

• Common things are common but rare things do exist!

• Quality of your radiography!• Tunnel vision• Review when things not happening

as expected• Get further opinion(s)

Things go wrong - What to do!Summary

• Keep good contempory records– & Keep the records!

• Be honest – – say sorry!, offer money back & put right at

your expense• Offer referral for a second opinion• Good communication skills are essential• Don’t inadvertently become an “expert

witness” against a colleague• Liaise with your defence society

– And follow their advice!

Finally…….

Accidents & misdiagnoses happen & are not necessarily negligence!

Its what you do and say that counts!

Saying sorry doesn’t necessarily equate to admitting liability!