Published on 12 May 2016

The Importance of Proper Apologies

Speech by Ombudsman Peter Tyndall at the HSE Healthcare Leaders Masterclass 2016

12 May 2016, Convention Centre, Dublin.

 ‘Sorry Doesn’t have to be the Hardest Word’

We have all had experiences in our personal and family lives where we recognise that we owe someone an apology. Indeed as children we are taught to say sorry for our mistakes. It can be a powerful tool for not only admitting and acknowledging one's own mistakes but can also serve to heal damaged relationships and help to restore one's own reputation. To illustrate this point I searched for examples of someone restoring their personal reputation by means of an apology. I was struck by one particular apology from 2014 which received wide spread positive media coverage, about a person who had been seen making racially abusive comments many years previously. When these were made public he issued the following apology

 ‘I'm very sorry....... I apologise for offending or hurting anyone with my childish and inexcusable mistake…… I hope the sharing of my faults can prevent others from making the same mistake in the future. I thought long and hard about what I wanted to say but telling the truth is always what's right’.

You may wonder who made this mature and thoughtful apology; it was none other than Justin Bieber.

Now the more cynical among us (or the non-beliebers) might suspect that it was drafted by a team of PR experts, but the apology still comes across as authentic and had the desired effect.

In the Ombudsman world complaints about poor apologies surface frequently but in particular in the health care environment. This may be due to the fact that errors or poor behaviour cause particular adverse effect on vulnerable patients or their families. Some of these cases may involve end of life care. In this situation these can have a deeply felt impact on relatives and leave long remembered emotional scars. Even relatively minor errors can be deeply felt when people are in the middle of a stressful experience.

I should say that difficulties and complaints in relation to apologies in the health sector are by no means confined to our own jurisdiction. In her annual report for 2014-15 Dame Judy Mellor, the UK Parliamentary and Health Service Ombudsman, indicated that not getting a good enough apology when things go wrong was the most common reason for complaints to her Office against the NHS from patients in England. It was the reason behind 34% of cases investigated by her Office in that year.

It is said that ‘to err is human’; unfortunately things can go wrong and do go wrong. As we can see most complainants are looking for a meaningful apology; they want to be listened to and reassured that lessons have been learned and that steps have been taken to make sure the same mistake does not happen again. On many occasions in our office we have been able to identify a specific time where had an apology been given by front line staff or a senior manager, the complaint would have been avoided.

A decision to make a formal apology normally arises at the end of a complaint examination process by the public service provider. It is important therefore that any complaint handling process is thorough, timely and comprehensive. Otherwise the apology itself is diluted and less effective and is not an effective remedy if the investigation process itself was flawed.

Benjamin Franklin once said you should ‘never ruin an apology with an excuse’. In my experience as Ombudsman here and in Wales and as is reflected in Dame Judy's annual report providing an apology that is patently insincere and formulaic, is heavily qualified or is so watered down as to appear meaningless, is possibly more infuriating for a complainant than getting no apology at all.

From my experience over the years it is clear that in framing an apology a number of considerations come into play. I think it is important that each apology should be a stand-alone response to deal with the individual complaint. It really is not appropriate to try and design a one size fits all apology template.  In some cases it will be entirely clear from the evidence why a mistake happened and while it is entirely reasonable to give explanations to the complainant it should not serve to dilute or lessen the apology especially where it is clear that an adverse effect has been suffered.

Avoid phrases which convey a sense of evasion or of transferring the blame. These would include phrases such as "I'm sorry that you may have felt offended".

An apology should be sincere and personal in nature, tailored to the circumstances of the complaint and the tone should be empathetic.

Where it is evident that the cause for complaint was valid and was prompted by the actions of an identifiable person then it should be made clear that the person was spoken to and an apology on their behalf should be made. 

If the complaint has given rise to organisational learning then this too should be acknowledged and welcomed. In my experience complainants want to know what changes it will bring about. It also impresses complainants if the service provider comes back at a later stage to confirm the implementation of promised changes.

Apologies, like mistakes, are both simple and complex. Getting the process of the apology right is as important as saying the right thing. Thought should be given to when an apology should be given, the timing of the apology and by whom. I believe these are important factors. Some things can be apologised for and dealt with at ward level or department level while, crucially, some events need to be apologised for at an organisation level.  

In cases of serious error some thought should be given to getting a senior manager to sign the apology. In more serious or complex cases where an apology is issued it is also a good idea to offer a face to face meeting with the complainant and/or their representatives. This shows a willingness to engage openly and to clarify any issues of doubt.

Unfortunately in the healthcare scenario sometimes an apology may be the only thing that can be done to put things right. For this reason I want to dwell for a while on the topic of empathy. The well-known writer Harper Lee passed way recently.

In trying to encapsulate what empathy means I think a quote from her classic novel To Kill A Mockingbird probably does it for me.  She wrote

"You never really understand another person until you consider things from his point of view - until you climb inside of his skin and walk around in it."

Scientific studies have shown that human beings, with the exception of persons who would be classified as psychopaths, have an in-built capacity for empathy. One would also expect that persons who set their career paths towards the caring professions probably have an even greater capacity for empathy. Yet it is not at all uncommon in health care complaints reaching my desk that complainants say that in their dealings with health care staff, be it in writing or in face to face dealings, that there has been a lack of compassion and empathy. This may have resulted from poorly written correspondence, poor one to one communication and misunderstandings or a lack of proper and sensitive engagement with complainants. In some cases the fact that the hospital facilities were inadequate, for instance where there was no quiet private space available for a sensitive conversation, gave rise to a feeling of an uncaring system.

It is perhaps somewhat simplistic to say that complaints about a lack of compassion and empathy in a care and treatment setting are always avoidable and should never happen. In fact, when you reflect on the matter it could be suggested that such incidents are more likely to happen in such a setting than anywhere else.

On the one hand you have the patient and family members and friends. The patient is ill and in pain and is in a very vulnerable state in an environment with which he or she is not familiar and does not understand. He or she may be in stress and fear. They feel that the only people who can help them are the health care professionals. The one concern for family and friends is the health and wellbeing of the patient and that is their one and only priority at a time of anxiety and emotion.

On the other hand you have the health care professionals working long hours in a sometimes frenetic environment with responsibility for the care and treatment of a number of patients and with a range of important tasks and duties where any errors may have serious consequences. They are expected to work calmly and professionally while surrounded by people who may be suffering and emotional.

Against this backdrop they may have to work in poor facilities in an overcrowded environment while at the same time dealing with some patients who present with challenging behaviour due to their own personal difficulties. All in all it poses a very real challenge to meet everyone's needs and to do so in a constantly empathetic manner.

As I said earlier a poor experience in a hospital can leave a lasting negative impact on a complainant. In 2014 I published A Good Death which was a look back report on end of life cases which my Office has dealt with over the years. Some of the quotations in that report perhaps illustrate the point I make here about negative impact.

The first is a quotation from the actor Gabriel Byrne who said;

  ‘I attended the bedside of a friend who was dying in a Dublin hospital.  She lived her last hours in a public ward with a television blaring out a football match, all but drowning our final conversation.’

In another case the remains of a deceased man were laid out in an undignified manner in a hospital mortuary. His organs had been donated. The complainant said;

"This was my father; he was a unique human being. After helping to save 3 other lives, it seems to us he was simply put to one side and given no more thought."

I fully recognise the almost impossible challenge for health care managers and health care practitioners in seeking to ensure that the experience of all patients and their families will always be a positive one. However, staff who are constantly aware of the need to be empathetic and understanding and who strive to be so on a daily basis can make a huge difference.

In my capacity as Ombudsman with responsibility for an Office which deals with thousands of complaints every year I attach great importance to the need to display empathy and understanding in our own work. For instance, it is stressed in induction modules which we deliver to new staff in their first weeks in the Office. We also quality assess a certain proportion of cases every month and staff who have displayed evidence of good empathy are singled out for praise and a note is circulated to staff. In our current Strategic Plan our Office values are stated as being;

Fairness, Independence, Innovation, Customer Focus, Empathy.

Each morning when our caseworkers log on to their computers the values are flashed on their screens. We also have posters throughout the Office highlighting the values. As an organisation we constantly reinforce the message of the importance of empathy. I would suggest that public service providers should also stress its importance for their own staff.

Empathy however is not only essential in the day to day care of patients, service users and interactions with their family.  It is an absolute necessity when something has gone wrong or there has been an unexpected poor outcome, which may or may not have occurred due to an unintended error.  The actions of staff and senior staff at the time and in the aftermath of an adverse event can make all the difference to patients and families.

If mistakes are made, there is nothing wrong with a member of staff empathising with a patient or their family when something has gone wrong. It is the most compassionate and humane thing to do.   This is not apologising for mistakes or admitting liability,  this is showing the patient that you care, this is saying ‘ I am sorry this has happened to you’ and assisting the patient or their family with their immediate needs, which could be as simple as helping with their car parking or offering a comforting cup of tea. In the longer-term this will be reviewing what happened and keeping the patient updated during that review. What is important is that when something goes wrong you do not’ run for the hills’ or allow a’ wall of silence’ to develop between the carers and the complainant.

If lessons are to be learned from the complaints received in my office or from previous high profile cases such as Mid Staffordshire in the UK or Portlaoise, and the experience of the patients and families involved;  it is imperative that when things go wrong that staff do the right thing by those who have suffered. When the unexpected happens, families need to know that you are sorry, whether it was due to your mistake or not.  You are sorry this has happened. Showing empathy, being sorry, allows both the staff and the organisation to stay connected with patients and their families. Equally staff need to know that showing empathy and saying they are sorry when something has gone wrong is not admitting liability.  It is their natural response and this is what is expected of them.

All too often we have seen organisations that when confronted with a problem distance themselves from the problem, deny it or defend it. But in reality an organisation needs to show empathy, be accessible to those harmed, address the problem.  And finally, apologise if it is found that their actions have caused the resultant harm.   

Whichever way you look at it, what is clear is that there needs to be a move away from the ‘deny and defend’ stance. I am not for a minute suggesting that you apologise or apportion blame before a review is completed or the full facts of the incident are known.  What is important is to stay in the empathy zone until all the facts are clear.

The Medical Council Guide for medical professionals on handling complaints, released last year, advised clinicians not to be defensive, to acknowledge the distress of the complainant and importantly to try to understand the situation from the complainant’s perspective. They advised clinicians to acknowledge any errors, to apologise if it was appropriate but in any event to be sympathetic

The experience of my office would show that if the response to an individual’s concerns is respectful, if it is positive and constructive, which may or may not include an apology, those concerns can be resolved satisfactorily. Often this can be enough to enable the person to ‘move-on’. Sometimes it can be seen that what causes the most grief or hurt is often not the original mistake or problem but rather how it was dealt with.  Sir Robert Francis, QC, stated in the forward for the ‘Learning to get Better Report’ that a failure to listen to and respond to complaints aggravates the grievance and suffering and undermines public trust’.

If the response is dismissive, defensive or negative, this is likely to result in an escalation of the problem which only serves to prolong and deepen the hurt experienced which can be detrimental to both the person making the complaint and to the staff involved.

The consequence of not listening to patients can be very serious not just for the patients themselves but for the reputation and survival of the services about which they have complained.

Sir Liam Donaldson, WHO Envoy for Patient Safety and formerly Chief Medical Officer for England wisely said ‘To err is human; to cover up is unforgiveable; and to fail to learn is inexcusable’

From an organisational viewpoint and for you as leaders, where unintended harm has occurred, by taking ownership of the issue, by proactively engaging with those harmed, investigating and where appropriate accepting responsibility, offering an apology and taking constructive steps to address the problem;  keeps your organisation in control of both the problem and the solution.  Importantly an apology shows an individual or agency taking moral, if not legal, responsibility for its actions and research shows that this is what people are looking for.

Last year the State Claims agency reported that they had 2,840 current claims. While it was reported that in the past 5 years €165 million was paid out as a result of incidents which occurred in HSE-run hospitals.  In the UK in 2015 it was reported that the rising tide of medical negligence against the NHS, was estimated to be costing in the region of £1.3bn a year in damages and legal fees. However it was also found that many patients only resort to legal action because they felt they have not been told the truth about a lapse in safety.

In our own jurisdiction we have seen the devastating effect that a lack of transparency or openness can have on patients and their families. We have seen it reported where patients felt ‘that backs were being turned; honest accounts were not given’.  It is clear that this lack of sensitivity augments the distress suffered.

Unfortunately the practice in some quarters is to seek legal advice as the sole solution when something goes wrong.   An approach such as this can often be more harmful and compound the original mistake. In reality this is a trend that needs to be reversed. A poor response to a complaint can add to the problems of someone who is unwell, struggling to take care of others or grieving. It can drive people to take legal or demand disciplinary action to achieve some accountability and learning to prevent the same thing happening to others.

The UK legislated for a ‘Duty of Candour’ in November 2014 on foot of the Francis Enquiry into failings in care at Mid Staffordshire NHS Trust Foundation.  While there is no legal duty of candour requirement here in Ireland, the former Minister for Health, Mr Varadkar, previously stated his intention to legislate to make ‘open disclosure’ a legal requirement.  In the absence of this requirement the National Guidelines on ‘Open Disclosure’, produced by the HSE in partnership with the States Claims Agency gives guidance to both staff and organisations on a transparent, patient centred, process for responding to patients safety incidents.

The message within these Guidelines is that disclosure is not about blame or apportioning blame but about integrity and professionalism. Disclosure is a process which needs to be handled sensitively for all involved in an incident, both staff and the patient or family affected.  We must be mindful that poorly executed disclosure will only frustrate the process.

Yes, apologies save money, but an apology is not just about reducing the costs associated with expensive court cases. Making a sincere apology is about recognising that something preventable has occurred in the care of the patient.  By thoroughly investigating adverse events, and by adjusting the processes that caused the event, lives can be saved.  In other words, apologising and resolving complaints helps prevent future errors. But more importantly, apologies save lives.

Sorry might be ‘the hardest word to say’ but it is also the most caring, the most empathetic word for patients, service users and their families to hear when things have gone wrong. I recently circulated guidelines to public service providers on how to make a meaningful apology.

As healthcare leaders you make difficult choices, within budgetary constraints every day.  Equally your staff face the challenge of caring for their patients and service users within these constraints. There is no doubt you have a sometimes unenviable, but ultimately rewarding task.  In the vast majority of cases patients receive excellent treatment and are grateful for the care of the healthcare professionals. However with the best will in the world and even with the best systems in place, things can and will go wrong. Therefore it is vital that you, as leaders, continue to take a unified approach to the adoption of the Open Disclosure National Guidelines and giving meaningful apologies, when it is appropriate.   ‘Being sorry and saying sorry’ needs to be the culture within the Health Service. It needs to become the way you do business, to become ingrained in the DNA of the Service.  When mistakes have caused unintended harm, being sorry and apologising, is not only good management practice, it is what the public expects but most importantly it is ethically and morally the right thing to do. 

I started with a Canadian and I will finish with a great American President

 ‘I now wish to make the personal acknowledgement that you were right and I was wrong’

-       Abraham Lincoln to General U.S. Grant (July 13, 1863, mid-Civil War)