Published on 13 November 2019

I am delighted to have been invited to speak to you today as part of the National Patient Safety Conference. We all have a shared commitment to improving the services that patients receive in our Health Service and to put patient safety and the patient experience at the forefront of service delivery. 

As Ombudsman, I deal with complaints from members of the public who are unhappy with the administrative actions of a wide range of public service providers. These include the HSE, public voluntary hospitals, public nursing homes and private nursing homes. My Office has been operating since 1984 and has dealt with over 90,000 complaints to date. My role as Ombudsman is to examine complaints and to recommend improvements where possible.


It is the nature of my role as Ombudsman that I usually only hear about activities within the health sector and hospitals when something has gone wrong, or is perceived to have gone wrong. I am well aware that that is not a true or complete reflection of the reality in our health service. I am well aware of the tremendous work that's being done in every hospital across the country by passionate, talented and committed clinicians and staff in often very challenging circumstances.

However, that being said, in terms of the health sector, my role is to examine and, hopefully resolve, complaints. The complaints which come to me can speak volumes about the way a service is being provided and a measure of how well the system is working.

I am still mindful of the some of the lessons learned from health scandals such as the Mid Staffordshire Trust scandal in the UK.   One of the main findings in this investigation was that Trust management had no culture of listening to patients. There were inadequate processes for dealing with complaints and there was a lack of importance accorded to complaints as a source of information.

Patients, their family and representatives are a highly motivated group and have privileged access to the health care system. In some ways patients and their relatives act as ethnographers as they observe the everyday interactions of the health service.

The source of complaints, how they are handled and their outcome provide an insight into the effectiveness of an organisation’s ability to uphold both the fundamental standards and the culture of caring.  In some ways complaints have been undervalued as a source of accountability and a basis for improvement. 

Importantly the learning from complaints must be identified, it must be disseminated and implemented, and it must be fed back into the system.

For example, although I am currently excluded from looking at issues of "clinical judgment" (the judgement used to diagnose a condition or decide on a course of treatment), the examination of healthcare complaints nevertheless serves to shine a light on instances of poor patient care and poor communication between patients and healthcare professionals.

Complaint example

Last year a complaint came to my attention concerning a man who waited over 12 days for a transfer to a regional centre for a urology consultation.  Sadly the man’s condition deteriorated before the transfer took place.  When my office looked into the complaint it became clear that despite daily contact between the hospitals, there had been a complete failure in communications.  The man’s name had not been added to the transfer/acceptance list of the regional centre even though he was accepted for transfer.  The transfer had been arranged over the phone between medical teams and unfortunately it appeared the man’s details were never passed to the bed managers.  In response to this complaint the hospital sites undertook to introduce a Bi-directional Patient Flow policy to streamline the process of transferring patients.  A valuable lesson was learned by the hospitals concerned but perhaps this could act as a learning opportunity for the whole sector.

Experience has shown the value of complaints and the importance of an effective complaint handling system in helping to provide safe and high quality patient care. By highlighting shortcomings in patient care, health service providers can learn from past mistakes and take corrective action where necessary. After all complaints are one of the most effective "early warning" systems of possible failings within hospitals and other health services. Ignoring them, as was the case within the Mid-Staffordshire Health Trust, invariably leads to poor practice persisting and, sadly, even lives being lost.  

The theme of today’s conference is ‘Learning from Investigations and Reviews.  I would like to talk to you about some of the recent investigations carried out in my Office.

Learning to Get Better Report (2014) and the Follow-up Report (2018)

In 2013, at the start of my tenure as Irish Ombudsman, I was struck by how few complaints my Office received about the care received in public hospitals. For example, complaints to my Office about all aspects relating to healthcare (and not just care received within a hospital setting) represent approximately 20% of all complaints received. This is very low compared with other jurisdictions such as Northern Ireland (over 60% investigated) and the UK Parliamentary and Health Services Ombudsman (80% of cases investigated). I wanted to know why this was and so I began an "own initiative" investigation. This was the first 'own initiative' investigation undertaken by my Office since it was established over 30 years ago. I published the results of this investigation - a report entitled Learning to Get Better, in May 2015.

The investigation was the most extensive investigation ever carried out by my Office. We surveyed every public hospital, we visited a sample of hospitals (including a maternity hospital and mental health facility), we interviewed front line staff and senior hospital staff and we consulted regulators, medical and nursing schools and health sector and advocacy groups. We asked members of the public to share their experiences of complaining with us (both the good and the bad). In addition, we conducted a small number of focus groups with members of the public and past complainants.  We made a short film which was a very powerful and eloquent piece. 

The investigation discovered that many users of hospital services:

  • were afraid to complain because of possible repercussions for their own or their loved one's treatment,
  • They did not believe anything would change as a result of complaining,
  • They found it difficult to discover how to complain and were not aware of the support available to help them to do so (including the right to come to my Office),
  • They were frustrated at delays, incomplete answers to their complaint and failure to provide proper apologies.

In addition, only a small number of hospital staff interviewed as part of the investigation were aware of changes and/or improvements made as a result of patient feedback or complaints. We found little evidence that hospitals publicised these outcomes even though making these outcomes known can only help to promote public confidence in the value of giving feedback and sharing experiences.

At this point, I should say, that my investigation also highlighted many other good practices in hospitals across the country. For example, in one hospital, I learnt that it is usual for hospital board meetings to begin with a "Patient Story", be it a complaint or indeed a compliment - after all it is worth remembering that feedback is not always negative.

As a result of the investigation, I made a number of recommendations, 36 in all, which were accepted in full by the HSE, and the then Director General fully committed to implement the recommendations. 

Late last year I had the pleasure of launching the Learning to Get Better: Progress Report, which showed the work that had been done in the previous three years on foot of my report.  The initial action plans, which originally focused on the hospital sector have now been extended to, and accepted by all areas within the HSE.

I would like to share some of the actions taken by the HSE on foot of my report.

One of the recommendations was a full review of the ‘Your Service Your Say’  health complaints system. I had asked the HSE and each hospital to put a robust complaints system in place to ensure that it is easy for people to complain, that there is a single, consistent complaint system, that people have access to an independent advocacy service and that the most serious complaints are investigated independently.

  • In November 2017 the HSE launched the revised ‘Your Service Your Say’ Policy,
  • A new HSE Complaints Management System (CMS) is now up and running which allows complaints to be recorded in a standard format for every hospital and CHO thus allowing for the identification of emerging trends,
  • There has been a greater focus on staff training in the handling of complaints which in partnership with my Office, included the development of a suite of e-learning training modules aimed at all HSE staff (clinical and non clinical) including complaints and review officers. I understand that module 3, specifically for clinicians is at an advanced stage of development,
  • The HSE now produces a quarterly Complaints Casebook which contains a selection of anonymised complaints received and addressed during the period.  In this way the learning from complaints is shared across the sector,
  • There is a complaints manager forum that meet quarterly which provides peers support to complaint managers and again enables feedback across the system,
  • I also suggested that learning from complaints could usefully sit alongside other sources of information such as litigation, serious incident or even "near-misses" to ensure that there is a comprehensive approach to learning from mistakes.

Advocacy

One of the areas highlighted in my report was the area of advocacy and I am delighted to see the launch of the new independent patient advocacy service which has been commissioned by the National Patient Safety Office in the Department of Health.  My office has always recognised the need for such a service and I am hopeful that his new service will assist people who have had a negative experience while accessing public health services in Ireland.

A Good Death report (2014)

Every year, 29,000 people die in Ireland and up to 290,000 are newly bereaved. At some point, dying, death and bereavement affects us all. Not everyone will be able to die at home, so the need to improve the experience of dying in hospital for patients and their families is an important consideration.

If something goes wrong with the care provided at the end of a patient’s life, it is clearly too late to put matters right for the person who has been most affected. A poor experience of a loved one’s death in a hospital can leave a lasting negative impact on the family and will often make the bereavement process so much more difficult. It is important to understand that dying with comfort and dignity is a human right. Therefore, compassion, dignity and respect must be part of everyday practice.

Five years ago, I published “A Good Death”.  This report reflected on some of the end of life care complaints that my staff had examined about Irish hospitals. The complaints arose from their bad experiences in public hospitals at the time of a final illness and death of a loved one. All of those people believed that this distress was avoidable. The cases in that report highlighted lapses in standards with regard to communication, a lack of regard for patient autonomy, inability to access specialist palliative care and poor management of complaints.

The purpose of that Report was not to lay blame on particular institutions or professions, but was intended to be a reflective and learning exercise.

Since its publication in 2014, there has been a heightened focus on providing quality care for dying patients in hospital and in residential care settings.

There have been:

  • increases in the range and extent of education and training for staff;
  • improved physical facilities for dying patients and their families; and
  • greater emphasis on the provision of information to patients and their families on end of life.

These achievements are due to the dedication of the staff in the HSE and the Irish Hospice Foundation who have worked continuously to drive improvements across the services. I am particularly pleased to note the increase in the number of End of Life Co-ordinators and End of Life Committees in hospitals nationally. They play a key role in ensuring that Hospice Friendly Hospital practices and protocols are in place for patients who are dying.

One of the key initiatives and drivers of change has been the establishment of the HSE/IHF Joint Oversight Group, chaired by Professor Cillian Twomey. A member of staff from my Office sits on this group. This partnership approach seems to work well and I have no doubt that it will achieve all that it has set out to do.

Our health services come under fire on a daily basis. We seldom hear about the “good outcomes” in our hospitals. I wanted to help address that imbalance and give credit where it is due. This was why earlier this year I launched the A Good Death: This Progress Report which provided us with an opportunity to take stock of the achievements so far. It also helps us to consider the next four years and to highlight the key areas that warrant attention.

 A Good Death report (2014) described how inadequate communication affected patients and their families. In response to this recognised need to provide ongoing training and education for staff, the IHF has developed training workshops for hospital and residential care staff that include:

  • the Final Journeys Workshop;
  • Breaking Bad News Workshop; and
  • The CEOL (Compassionate End of Life) Programme for residential settings. This provides a framework for staff to reflect, review and enhance the end of life care provided in nursing homes and a system for introducing improvements.

In health and social care, patient autonomy involves the person who uses services in making informed decisions about the care, support or treatment that he or she receives. Since the publication of “A Good Death” report, public health campaigns and advocacy groups have highlighted the value of using the Think Ahead form, which includes an Advance Healthcare Directive. The Irish Hospice Foundation also has put in place training programmes for staff and families, as well as a suite of information materials for people with life limiting illness to help them plan for their future. In 2015, the Assisted Decision Making (Capacity) Act (ADMA) was enacted. This legislation promotes the autonomy of the individual in making decisions about their treatment. I understand that the Decision Support Service is developing a governance structure for Advanced Healthcare Directives, but that the service will not be fully operational until 2020. Meanwhile, however, hospitals and care centres will generally comply with the stated wishes and preferences of patients as set out in their Advanced Healthcare Directives.

The Progress Report sets out eight key recommendations which if implemented should ensure that quality end of life care is available for every patient across our hospital services. Much progress has been made in recent years thanks to the determination and hard work of all those involved. We need to ensure high standards are in place throughout all hospitals for the sake of dying patients and their families.

If you have ever had the misfortune of having to make a complaint about a service you received you will appreciate that making a complaint can be a daunting prospect for people generally, but this is particularly true of bereaved families who are grieving the loss of a loved one. An empathetic approach in dealing with the complaint is very important. Delayed, defensive and incomplete responses only serve to heighten the sense of frustration, anger and upset felt by complainants who are recently bereaved.

HIQA Guidance on a Human Rights-based Approach to Care and Support

At this stage I would like to mention that I am aware that HIQA, in conjunction with Safeguarding Ireland, is today launching its Guidance on a Human Rights-Based Approach to Care and Support in the Health and Social Care Setting. My Office was part of the working group for this project, which was part funded by the Irish Human Rights and Equality Authority and I am delighted that the guidance has now come to fruition. 

This guidance is an accessible resource that provides practical examples illustrating a human rights-based approach to support staff across a wide range of services and will be useful for people using services, their families, carers, friends and advocates.

A human rights-based approach to health and social care is about making sure that human rights are protected in practice and embedded in the culture of a service. It is about people being treated with fairness, respect, dignity and equality, having a say over their lives and participating as fully as possible in decisions about their care and support. This is an approach that is very much in line with the values of my Office.

Good complaints management is a key element of public administration. It is essential that complainants have access to an open and responsive complaints system that objectively identifies and acknowledges shortcomings when they occur and readily apologises for them. Complaints provide us with an opportunity to reflect on the way services are provided and to learn from the poor experience of others.

A man recently complained to my office about a fall his elderly aunt had suffered in a private nursing home which resulted in his aunt breaking her hip. The man complained about the circumstances of the fall and what he felt was a delay in seeking medical assistance.  The nursing home conducted an internal review of the incident. It operated an open disclosure policy, met with the family, interviewed all relevant staff, identified key causal and contributory factors (both team and individual), explained what happened and why, made a number of recommendations which were acted upon, apologised unreservedly to the family and reported the matter to HIQA, the Health Information Quality Authority.

Although the family were not happy with what happened to their aunt, and had a number of additional questions, my Office could see very clearly how the nursing home had reacted to the complaint and learned from the complaint.  The review of the incident was very comprehensive. In addition the nursing home provided my Office with its action plan and a progress report on the action plan.

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 the then 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. Apologies, like mistakes, are both simple and complex. Getting the process of the apology right is as important as saying the right thing.

In order to ensure the delivery of a patient centred, learning health service the voice of the patient must be heard. 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.

The question is are we really learning to get better when things go wrong? It is vital that the HSE strives to better listen to service users and their families and to respond to their concerns. Service users need to feel confident to speak up when things go wrong and to know that their concerns are being taken seriously. Likewise, health service staff need to be able to make service users aware of how to complain, provide reassurance that there is nothing to fear from doing so and make sure complaints are properly addressed. Each complaint that is not fully addressed is a missed opportunity for the HSE to improve.

I hear many compliments about the way our health service is delivered, of the many little kindnesses, the highly skilled professionalism and the interventions which save or transform lives. Inevitably, in such a large and complex service, things can go wrong. Learning from mistakes is a key means of ensuring that they are not repeated.