Published March 2006
A Report of the Ombudsman's experience of dealing with complaints against the Public Health Service and some suggestions for improvement.
The year 2004 marked my first full year in office and coincided with, perhaps, the most fundamental reform of the Irish health services since the foundation of the State, the development of a single unified national public health service. I have decided to mark this new development by way of a review of my Office's experience of dealing with complaints in the public health and personal social service sector. Of its nature my Office is primarily concerned with things that go wrong in those services. It is not surprising, therefore, that I am critical of aspects of the service highlighting shortcomings on a regular basis, and will continue to do so in the future. However, I am very keen to present the outcome of this review to the new Health Service Executive (HSE) in a spirit of learning and encouragement. I hope that this will assist the Executive as it begins its journey towards providing a first class, quality, public healthcare system.
I have also approached this report in the context of Quality and Fairness, the National Health Strategy. I share the vision and desire of that Strategy to achieve a health system that supports and empowers the individual to achieve full health potential, that is available, that is fair and is one in which the individual can have trust, and where the views of the individual will be taken into account.
The enactment of the Health Act 2004, is an important landmark in the development of the Office of the Ombudsman. Since 1985 my Office's jurisdiction was limited to the administrative actions of the health boards and those hospitals which came under their direct control. Actions which, in the opinion of the Ombudsman, involve the exercise of clinical judgement are, and will continue to be, excluded from my remit. The new legislation makes provision for the establishment of a statutory complaints procedure in the health service, not only for those services delivered by the Executive but also for those agencies providing services on behalf of the Executive. The net outcome of this development will be that the major hospitals in the Dublin area, the so called Public Voluntary Hospitals, will come within my jurisdiction, as will other similar hospitals in the rest of the country, together with institutions, nation-wide, providing services on behalf of the HSE to the intellectually disabled.
My remit is also being extended by provisions contained in Part 3 of the Disability Act 2005. I will have jurisdiction to deal with complaints about actions relating to access to public buildings and services, and also in relation to sectoral plans drawn up by a number of key Government Departments, including the Department of the Tánaiste Health and Children. This legislation also has specific implications for health service providers in the area of the assessment of need, service statements and redress.
Many of the above mentioned bodies will be unfamiliar with the operation of my Office, and this report is also directed to them as they prepare for the introduction of the new statutory procedure and, in turn, scrutiny by my Office. There will be occasions when my Office will be at odds with these bodies, it will be critical of their actions and it will highlight shortcomings. This will be at the heart of my relationship with them and is something which derives from the very nature of my Office. I accept that many of these bodies will be unfamiliar with how my Office operates and that there may be a certain element of tension as they consider this new form of accountability.
My Annual Reports detail the myriad ways in which my Office has impacted on the lives of ordinary individuals who have had cause to complain about our health and personal social services; families seeking answers from hospitals about the care of their loved ones (particularly where death has occurred), older people seeking affordable care to which they have an entitlement, parents seeking allowances for their seriously disabled children, querying the lack of health services for their children, or applying for medical cards or health related personal social services. The devastating impact of such shortcomings in the health services has been brought home to everyone through the ongoing nursing home debacle, which emanated from a long running failure to acknowledge the illegality of actions which raised charges on patients in public nursing homes and other institutions.
Of no less importance is the role of my Office in helping those same service providers to improve their services, by pointing out mistakes and unfair practices and by guiding them towards a better way of delivering public health care.
A point often made to me by complainants is that the service providers should learn from their mistakes, so as to ensure that other people do not experience similar problems.
Over the years my Office has engaged with the agencies in the public health services in developing better quality decision making in the delivery of their services to the public. My staff engaged with the former health boards, and specific professional groups, in seminars and training exercises on the issues which are of importance to me in the examination of complaints, principles of good administration, best practice for public servants, the rights of users of the health service and the management of complaints. The emphasis in all of these interactions was always positive i.e. how to improve the quality of the health service delivered. This educative aspect casts the Ombudsman in the role of a "critical friend" and I look forward to the further development of this role with the new Executive and the other agencies providing public health services.
I now see the opportunity to develop this function further by way of highlighting, in this special report, issues for the attention of the new HSE based on the experience of my Office, developed in the course of the examination of complaints about the health service. My objective in this report is not simply to focus on the failings identified. In order to assert its positive nature I have decided, on this occasion, not to identify the individual agencies in the examples which I use. This is at odds with my usual procedure, which I will maintain in my Annual Reports, as an element of the accountability which is a vital aspect of my work.
The learning that I want to highlight in this Report falls under the following general issues;
In particular, I want to highlight the Statement of Good Practice For The Public Health Service In Dealing With Patients, which I have developed from my Office's experience of dealing with complaints against those hospitals that were administered by the former health boards. The Statement also takes account of the ethical guidelines published by the Medical Council and the Code of Professional Conduct published by An Bord Altranais.
I see this Statement as a code of good practice for the health service in dealing with patients and, together with the Ombudsman Act, I intend to use it as a framework in my examination of complaints relating to public healthcare. I hope that the Statement will be embraced positively by all health agencies, so that it becomes a living reality for all patients.
In the coming months I also intend to take other initiatives to assist health agencies in their examination of complaints. The series of seminars on good complaint-handling, which my Office conducted with great success with the health boards, will be relaunched for the new bodies coming within jurisdiction. I also intend to re-publish some of my Office's existing guidance notes in a format which is customised to the needs of the health services.
These updated guidance notes, together with the Statement of Good Practice For The Public Health Service In Dealing With Patients, published in this report, will form a Code of Good Administrative Practice For The Public Health Service. The Code will constitute a comprehensive framework, in conjunction with customer service protocols developed by individual health service agencies, which the Ombudsman will utilise in the examination of complaints relating to the health services.
Of course, the success of these initiatives is critically dependent on the development of good working relations between my Office, the HSE and the other new bodies coming within remit. In Chapter 7, I describe the challenges which the HSE is facing on this issue, and the need for early action on the development of new liaison arrangements with my Office.
Finally, returning to this Report, I hope it will be of benefit to the HSE and to those agencies providing services on its behalf. I look forward to developing a good working relationship with these agencies and thereby facilitating better outcomes for all the users of the health services in Ireland.
The Office of the Ombudsman was established under the Ombudsman Act, 1980. The Ombudsman is an independent and non-partisan office holder who oversees public administration, which includes not only the public health service, but also the Civil Service and Local Authorities. The Office deals with specific complaints from the public about administrative injustice and maladministration. It has the power to investigate, report upon, and make recommendations about individual cases and administrative procedures and it seeks solutions to problems by a process of investigation and conciliation. The Ombudsman's authority and influence derive from the fact that she is appointed by the President and reports to the Oireachtas. In dealing with complaints the Office seeks to gather all information relevant to a complaint, including, if necessary, the appropriate files from the body concerned. The Ombudsman ensures that she hears both sides to a dispute. If, in the course of a preliminary examination, she considers the complaint to be justified, she may request the body to review the disputed decision. If warranted, she may initiate an investigation and may make an appropriate recommendation for redress. The Ombudsman is conscious at all times of the need to be impartial, objective and to observe the principles of natural justice.
The core function of the Office in relation to the public health and personal social services is to protect the individuals who avail of those services from unfair, unsound and unjust actions on the part of those who are entrusted to deliver those same services. The Office seeks to ensure that individuals availing of the public health services are treated with dignity, respect and sensitivity, and that complaints from individuals or their families are handled in a proper, fair and impartial manner.
The term maladministration is not used in the Ombudsman Act, 1980. In many ways to define the term would be to limit it. Basically it means "when things go wrong". The Act, however, clearly lists certain actions or inactions, which if they adversely affect someone, may be considered as maladministration.
The list includes actions that are:
(i) taken without proper authority,
(ii) taken on irrelevant grounds,
(iii) the result of negligence or carelessness,
(iv) based on erroneous or incomplete information,
(v) improperly discriminatory,
(vi) based on an undesirable administrative practice, or
(vii) otherwise contrary to fair or sound administration.
The following examples put flesh on these rather abstract criteria by reference to actual cases. They illustrate what happens when things go wrong and identify shortcomings of a very serious nature in a range of health service agencies. The Ombudsman will expect that the new Executive will consider the learning outlined in these examples and the lessons to be learned from future complaints on a systemic basis. The Ombudsman sees this as a fundamental element in the quality of management in the Irish public health system, and one which she will continue to monitor.
The classic example of a body acting without proper authority was the decision by the Department of Health and Children and the former health boards (the Boards) to take the income of children into account when assessing the means of their elderly parents seeking a nursing home subvention. The relevant legislation did not make adult children legally liable for parents' hospital or nursing home costs. Neither was there any indication to suggest that any such liability was contemplated by the Oireachtas. The Regulations, which the Boards relied upon, could not impose a liability on adult children which was not explicitly provided for in the primary legislation. Consequently, the practice of determining, and assessing, a level of contribution which an adult son or daughter should be capable of making towards a parent's nursing home costs was improper.
The Ombudsman drew the foregoing to the attention of the Boards and the Department of Health and Children on numerous occasions, culminating in the provision being repealed and thousands of people receiving rebates of amounts collected without proper authority. These were in the main individuals who were not in a position to organise themselves either to take legal action or for political lobbying.
The lesson from this debacle, and the similar debacle arising from the imposition of illegal charges on residents in public nursing homes, and in other institutions, is that rights of individuals availing of the public health services should not be put aside for the sake of administrative convenience or to bolster funding requirements within the service.
The question of which grounds are relevant or irrelevant in any particular decision will vary depending on the individual circumstances of the case under consideration.
The Ombudsman received a complaint about the raising of charges under the Institutional Assistance Regulations, 1954 on a patient in a public nursing home. On examination it transpired that the assessment of charges should have been raised under the Health (Charges for In-Patient Services) Regulations, 1996. As the patient was a medical card holder with a dependent, he was not liable for any charges under these latter Regulations. In the course of the examination an undercurrent was identified in the reluctance of the Board to consider this aspect, which might have been due to the feeling that the patient's family was not looking after him properly e.g. in relation to changes of clothing, footwear, hairdressing etc. However, the question of any value judgement in this context was a consideration that was irrelevant to the decision in relation to the patient's entitlement to subvention. The Board subsequently accepted the case put forward by the Ombudsman and agreed to refund all the charges paid by the patient from the date he had been admitted to the nursing home.
The lesson from this complaint is the vital importance that decisions must be based solely on a consideration of what is relevant to the issue at hand and that factors that are irrelevant, and which have no bearing on the issue, are not taken into account or are allowed to influence the decision.
The Ombudsman Act does not contain any definition of the term "improperly discriminatory". At its most basic it means treating people in similar circumstances, equally; that comparable situations must not be treated differently; and that different situations must not be treated in the same way unless such treatment is objectively justified.
The Ombudsman received a complaint from a representative of a support group for parents with autistic children in relation to Domiciliary Care Allowance entitlement. When the complaint was examined it was found that different practices operated within different areas of the Board in relation to the payment of the Allowance. Some members of the support group were awarded the allowance from the date of application. However, other members, living in another area, were awarded the allowance from the date of eligibility, which in some cases was considerably prior to the date of application. In the course of the examination it transpired that the children in the former group had prior involvement with health professionals within the Board in relation to their condition before making the application. However, the parents had not been advised of their possible entitlement to the allowance.
The Ombudsman considered that it was reasonable to expect in cases of this nature, where there had been prior involvement with the Board's professional staff, that the possible entitlement to the Allowance should have been brought to the attention of the parents. This principle had been accepted by all of the Boards on a previous occasion in relation to claims for retrospective payment of the Allowance. In the light of this the Board reviewed all of the applications at issue with arrears paid where appropriate.
Many administrative decisions involve choice between one group or category of persons and another. Such choice of its nature reflects an element of discrimination, but does not, of itself, constitute improper discrimination. It is the element of invidiousness which leads to a discrimination becoming improper. This element occurs if the discrimination bears no reasonable relationship to the difference between the group or category of persons under consideration.
The purpose of medical and nursing records is to provide accurate, current, comprehensive and concise information concerning the condition and care of a patient in addition to recording associated observations by nursing and medical staff; to provide a record of any problems that arise and take the appropriate action in response to them; to provide evidence of the medical and nursing care required including intervention by nursing or medical staff; to record the chronology of events and the reasons for decisions made; to support standard setting, quality assessment and an audit trail of the care and treatment administered; and to provide a baseline record against which improvement or deterioration may be judged.
If medical and nursing records are defective, the continuity of a patient's care may be adversely affected by way of communications failures between medical and nursing staff leading to an increased risk of medication or other treatment being duplicated or omitted; a failure to focus attention on early signs of deviation in a patient's condition; and a failure to place on record significant observations and conclusions.
In one particular complaint received by the Ombudsman the family of a man, who died unexpectedly in a General Hospital within two days of admittance, could get no answers as to what had happened to him during those two days. In the course of the examination, a serious gap was identified in the relevant records which made it difficult to establish precisely what happened during the time at issue. The absence of detail in the medical notes following an examination of the patient raised the question as to how any doctor, who was subsequently called to examine the patient, could quickly apprise himself or herself of the patient's condition, in particular where a previous, but unrecorded, medical examination was significant in terms of diagnosis or treatment. The patient's condition had deteriorated rapidly, but the absence of medical notes made it difficult to readily assess the rate of deterioration over the period at issue. The failure to adequately record details of a particular examination on the medical notes could only be described as a stark failure in the standards of medical note record keeping that are expected of medical staff following their contact with patients. It also contrasted with the particular doctor's own expectation that he could update himself on the patient's condition by reading the previous medical notes on the patient's file.
There were also critical omissions in the relevant nursing notes. This was important as there was significant nursing intervention with the patient at the material time. In particular, an observation that the patient's leg had become extremely cold and was wrapped in a blanket reflected a significant change in the condition of the patient. The recording, and timing, of a significant nursing intervention such as wrapping a leg in a blanket because of its coldness and the reporting of this action to the doctor on duty is necessary to ensure that subsequent nursing and / or medical intervention takes account of significant earlier events.
The lesson from this complaint is that the creation and maintenance of medical and nursing records is an essential and integral part of the care that a patient receives from medical and nursing staff. Inadequate and inappropriate record-keeping concerning the care of patients may have a serious impact on the care and treatment a patient receives. Modern and effective organisations appreciate the importance of knowledge management as it is now known. Quick access to records and the information contained in them is now recognised as enhancing efficiencies and productivity. Proper use of technology will enhance these benefits..
It is inconceivable that any health professional would deliberately place a patient at risk. However, elements of carelessness or negligence can occur which may well have that effect. In one complaint a family noticed that tablets had been left on their father's bedside locker. They were subsequently advised by a Ward Clerk (a non medical person) that as the tablets were on his locker then they were for him. A Ward Clerk should never impart such advice, but should have referred the family to the nursing staff. The patient should have been supervised by a nurse, who has a professional responsibility to ensure that medication has been taken. In the same case a Consultant had requested that the patient's fluid intake was to be restricted and that input and output were to be recorded. While the Fluid Chart indicated that the direction had been complied with, the family was adamant that no fluid restriction sign had been placed over their father's bed. The family was also adamant that neither they, nor their father, were made aware of this restriction. Such an oversight could have resulted in possible serious adverse consequences for the patient given the propensity of visitors to bring liquid refreshments when visiting a patient.
The lesson from this complaint is that medical professionals should accept that they are accountable for their own carelessness in the course of their practice. Extraneous factors can never fully relieve them of accountability for actions taken and judgements made. Given the importance of their role in healthcare they are required not only to provide an explanation or rationale for such carelessness to their patients, but also to themselves, their peers and to society in general.
The concept of undesirable administrative practice is constantly changing. Good administrative practice develops naturally alongside that which it gauges, the ideal relationship between the individual and the administration at the time and the place in question.
A complaint involving the admission of a seriously ill student to an A&E Department is a case in point. On admission she was asked to complete a form confirming her VHI membership and placed in a semi-private ward. It subsequently emerged that her VHI membership did not cover the accommodation provided as the standard 26 week waiting period applicable to new members had not expired. She was sent an invoice for in excess of €2,500. While she acknowledged that she signed the form she was in considerable distress and pain at the time. The Ombudsman considered that the process, whereby a seriously ill patient could be held responsible for the completion of a form under such circumstances, to be inherently unreasonable. Following discussion on the matter, the Health Board agreed to waive the charges in the particular circumstances of the case. The Ombudsman subsequently wrote to all of the other Boards outlining this issue and received very positive responses with new procedures being implemented which should obviate such problems in the future.
The lesson from this complaint is that while it is important to have procedures in place to cover operational issues they should not be so rigid or inflexible so as to cause inequity or disallow the consideration of individual circumstances. Furthermore, it is important to undertake regular reviews of such procedures so as to ensure that they are being implemented fairly and in line with best practice.
What constitutes "sound administration"?
In one particular complaint the Ombudsman had to take issue with a Health Board in relation to the maintenance of its record system. It was clear that the medical records in relation to the individual complainant could not be traced. Arising from an inspection of the relevant Medical Records Section it was evident that there was no central record of files which had been removed from the Section, their present location or the amount of time they had been outstanding from the Section. In addition, there was no register of missing files maintained and, as a consequence, when a file which had been temporarily mislaid was returned, there was nothing to alert the seeker of that file to its return, nor was there scope for an audit of other sections of the Hospital for missing files. There was no written code of practice covering the health records function. The Ombudsman would consider that any such code would include policies covering security, privacy and confidentiality of patient information (regardless of the medium on which it is stored), filing and retrieval of records, retention of records, principles of record organisation and management, patient access to records etc. In addition the indications were that the staff responsible for the health records system at the hospital did not receive any formal training in this capacity. There was no written job description for the function of the manager with professional responsibility for hospital records, or any co-ordination of the medical records service function between the Board's hospitals to exploit best practice.
The lesson from this complaint is that the administration of any element of the health service does not stand in isolation but rather is a cog in the overall promotion of good medical care, enabling the HSE to operate more efficiently and enhancing the confidence of the public in the service. In short, all elements of the HSE must constantly strive to ensure that, in all aspects, it operates to the highest standards of quality.
A patient is not just someone who is sick. He/she is first and foremost a person with rights and duties and the past quarter of a century has seen the emergence and rapid spread in Europe of the concept of "patients’ rights". In this context there is evidence that, increasingly, shared principles are being adopted in a number of countries which seem to be independent of the characteristics of a given country's health system.
Amongst current EU Member States to have adopted legislation on patient rights are: Finland (1992), The Netherlands (1994), Greece, Hungary, Lithuania, Latvia, Portugal (1997), Denmark (1998), Belgium, Estonia and France (2002) and Cyprus (2005).
At the international level, prominent examples of documents about patients’ rights include: the Declaration of March 1994 on the promotion of patients' rights in Europe which emerged from an initiative of the Worlds Health Organisation; the Council of Europe's 1997 Convention on Human Rights and Biomedicine. Despite its name, this Convention also deals with patients rights in general; and the "European Charter of Patients’ Rights", drafted under the auspices of an Italian-based NGO called the Active Citizenship Network.
These rights cover the entire aspect of patient care and treatment; Human Rights and Values, Information, Consent, Confidentiality and Privacy, Care and Treatment, Patient Safety and Application. As such they are not dissimilar to the concepts of Trust, Dignity, Information, Communication, Confidentiality and Competence which are encompassed in the ethical guidelines established by the Medical Council for doctors practicing in Ireland. Although long established these guidelines are dynamic, and acknowledged by the Council to be a continuous process in relation to their application to new situations. The rights are also not dissimilar to the provisions of the Code of Professional Conduct established by An Bord Altranais for nurses practicing in Ireland, the purpose of which is to provide a framework upon which nurses can base their professional decision making, promotion of high standards and acceptance of responsibilities.
In addressing this issue the Ombudsman makes a distinction between social and individual rights. Social rights in health care relate to the societal obligation undertaken, or otherwise enforced by Government and other public or private bodies, to make reasonable provision of health care for the whole population. Social rights are dependent on political, social, cultural and economic factors. They are enjoyed collectively and are relative to the level of development of society; they are also in a large measure subject to political priorities for development in our society.
By contrast, individual rights in patient care are more readily expressed in absolute terms and, when made operational, can be enforceable on behalf of an individual patient. It is not the intention of the Ombudsman to create new rights, but to distill those elements from the current thinking as outlined above, and adapt them in a statement of good practice for the health service in dealing with patients. It is the Ombudsman's intention to utilise this as a framework in the future examination of complaints in public healthcare. This Statement is outlined in point 8. The Ombudsman wants the public health service providers to be under no illusion but that she intends to see that the operation of this Statement becomes a living reality for patients.
The problem of adverse events in healthcare is not new. The past decade has witnessed a stream of publications in leading medical journals documenting serious shortcomings in relation to the safety of patients. A major study in Harvard University found that 4% of patients suffer some kind of harm in hospital in the United States; 70% of the adverse events resulted in short-lived disability, but 14% of the incidents lead to death. A report by the Institute of Medicine estimated that "medical errors" cause between 44,000 and 98,000 deaths annually in hospitals in the USA - more than car accidents, breast cancer or AIDS. The UK Department of Health, in its 2000 report, "An Organisation with a Memory", estimated that adverse events occur in around 10% of hospital admissions or about 850,000 adverse events a year. The Quality in Australian Health Care Study (QAHCS), released in 1995, found an adverse-event rate of 16.6% among hospital patients. The Hospitals for Europe's Working Party on Quality Care in Hospitals estimated, in 2000, that every tenth patient in hospitals in Europe suffers from preventable harm and adverse effects related to his or her care. Studies in New Zealand and Canada have also suggested relatively high rates of adverse events at around 10%. Moreover, while errors may be more easily detected in hospitals, they afflict every health care setting: day-surgery and outpatient clinics, retail pharmacies, nursing homes, as well as home care.
There are no comparable studies in relation to Irish public healthcare, but should we expect things to be any better or worse than in those other countries? Is it possible that there may well be a serious problem in the Irish healthcare system which is not directly evident? In a paper presented in 2002 at a conference of the Irish Hospital Consultants Association, a speaker extrapolated the American experience into the Irish acute hospital setting. Her extrapolation indicated that some 937 deaths could occur annually as a result of preventable clinical error, and that death due to preventable clinical errors could exceed the number attributable to breast cancer, then the sixth leading cause of death in Ireland. This implied that, in 2002, more people would die as a result of preventable clinical error (937) than from Breast Cancer (602). If this extrapolation could be proven then this would truly be an appalling vista.
Traditionally, medical errors have been considered performance problems that can be addressed by counseling, retraining, re-educating, and restricting practice. Blame is placed on the individual without consideration of the factors contributing to the error e.g. medications may have similar names or packaging, which can lead to the misreading of a label, they may come in multiple strengths and concentrations and are often dispensed in combination with other medications. These factors can present a higher risk if a caregiver is rushed, tired, distracted, or under pressure during an urgent or emergency situation. Environmental and situation factors, such as poor lighting, noise, or interruptions, can contribute to errors at the "sharp end" where healthcare staff provide care and interact with patients.
Should unsafe practice be blame-free and punishment free? The answer is no. However, a just culture should not be confused with one in which there is no accountability. Medical professionals must be accountable for any deliberate actions that may result in patient injury, and those who are reckless or choose to violate rules must be held accountable for these actions.
The Ombudsman is impressed by the following Statement of Principle enunciated by the National Patient Safety Foundation, an organisation established by the American Medical Association, and she has used it as the framework for the statement of rights enunciated in the Code of Good Administrative Practice, which will guide her in the examination of complaints in this area.
"When a health care injury occurs, the patient and the family or representative are entitled to a prompt explanation as to how the injury occurred, together with its anticipated short and long-term effects. When an error contributes to the injury, the patient and the family or representative should receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients."
Of particular importance is the right that each individual has to expect that health care staff who report existing risks to their superiors and/or peers will be protected from possible adverse consequences. A blame-free, nonpunitive culture encourages individuals to report errors and truly learn from their mistakes. It also supports organisations in their efforts to better understand those errors and make improvements. A just environment assumes that staff at the sharp end of care are concerned about patient safety, but are working within complex systems and in situations that potentially contribute to errors.
A person's medical records are amongst the most sensitive of personal records and great care should be taken to ensure the safe holding of such records. Apart from their sensitive nature, there is also the very practical consideration that they can be of considerable clinical value in relation to the ongoing care of a patient. Their primary purpose is to document the assessments underlying the progress of the patient's care and so contribute to the quality of that care. As months or years may elapse between treatments or illnesses, and staff may have moved on, the records should serve to reconstruct events at a later date without recourse to memory. Poor record keeping can lead a patient's care being adversely affected through;
an increased risk of medication or other treatment being duplicated or omitted, communication problems between staff, both nursing and medical, a failure to focus attention on early signs of change in a patient's condition, and a failure to place on record significant observations and conclusions.
They can also be of great importance in cases alleging medical negligence, or other such litigation, and they may be of value to the family of a patient after he or she has died, provided, of course, that their release is justified in any particular case.
It is the experience of this Office, however, that when we have had occasion to examine patient files we have often found them to be unsatisfactory as a record of the various elements of a period of hospitalisation. International research shows that Ireland is not unique in this situation. Reports in the UK reveal a lack of structure, disorganisation, illegibility, absences of problems or diagnoses. Similar problems were revealed in Australia. In Spain 15% of records reviewed were so illegible as to be rendered meaningless. It is beyond comprehension that caring professions can be so lax in this regard. Such practice could only be described as being akin to a ( no doubt unintentional ) level of disrespect and disregard for the patient.
The retention and efficient management of patients' records should be a key responsibility. In this context the Ombudsman would expect that such records would be legible, intelligible, complete, specific, contemporaneous, signed and dated. Abbreviations should be universally understandable and not open to misinterpretation. They should be written with care (a slip of the pen can easily change the meaning of an abbreviation); that makes life easier for all hospital personnel using the records, for the hospital administration in dealing with any complaint and, ultimately, for the Ombudsman if she has reason to include such records in the examination of a complaint. In addition certain abbreviations are unacceptable (e.g. coded expressions of exasperation, invective or sarcasm).
Deficiencies in those standards were given concrete reality in a particular case dealt with by the Ombudsman, in which the care and treatment afforded to a patient in the days prior to his unexpected death were under consideration. In that investigation the Ombudsman found a paucity of records covering critical treatment junctures, a stark failure to meet the standards of medical record keeping expected of medical staff following their contact with the patient and an absence of relevant entries on the nursing notes during a period of significant nursing intervention. The paucity of the records made it difficult to establish precisely what happened during the period in question. The absence of medical note entries following examinations raised the question as to how any doctor, who was subsequently called to examine the patient, could quickly apprise himself or herself of the patient's condition, in particular where a previous, but unrecorded, medical examination was significant in terms of diagnosis or treatment. The Ombudsman recommended that the hospital review its procedures to ensure (i) that entries on the nursing records created by nursing staff accurately reflect the contacts made with medical staff for the purposes of patient review and the reason that the contact was made; (ii) that all significant observations on a patient's condition that are made to members of the medical team by the nursing staff are recorded on the nursing notes. Furthermore, the Ombudsman recommended that the responsible health board take action to ensure that all the hospitals under its control meet the standards outlined in the recommendation. The Board accepted these recommendations in full by way of :
(i) The development of a programme of nurse education relating to best practice in the maintenance of nursing notes, followed by a chart review and audit of nursing documentation to determine the effect of the programme, and generally to monitor documentation.
(ii) The development of a new module in the induction programme for non consultant (Junior) doctors, concentrating on best practice for medical notes.
Good communications are an integral part of quality healthcare, not alone between patients and medical professionals but also between medical professionals themselves. The Ombudsman is aware of the impetus within the health service towards providing an integrated care pathway for patients on their journey through the system. At the heart of this process is the delivery of the service though teamwork. Communication between health professionals is essential in order to ensure continuity of care and effective treatment for patients. Consequently communication between primary care, secondary care and social and voluntary services, between doctors nurses and other health professionals, should be seen not as a chain, but as a communication net within which any one member may need to communicate with any other. Good management requires that all members of the communication net are as aware as they need to be of who is doing what. An adequate standard of continuing medical care can be achieved only if every member, both medical and non-medical, understands his or her role.
Deficiencies in the communications practices of staff in acute hospitals have been identified in a recent survey of patients in acute hospitals, conducted by the Irish Society for Quality and Safety in Healthcare. The Survey found that approximately one in ten patients were not informed of their condition or treatment in a way that they understood and, at times, were given little opportunity to discuss these matters with members of their healthcare team. One in four respondents reported that they had questions that they would like to have asked members of their healthcare team, but did not, whilst the same number reported that staff discussed medical matters at their bedside whilst ignoring them.
Failures in communications between healthcare professionals and their colleagues, and between professionals and carers, are the source of many complaints. Common problems include the provision of conflicting information, poor record keeping and a lack of involvement in care plans. The benefits of good communications for patients include a better relationship with the professional, higher rates of compliance with treatments and a heightened sense of empowerment in making decisions about their own health.
The benefits for the professionals include a reduction in the incidence of clinical error, being better able to cope with difficult emotional situations, less likely to be the subject of complaint and increased job satisfaction. However, simply recognising this need is not enough; appropriate and effective training should be made available in order that healthcare staff are enabled to develop and refine these skills.
Patients, in general, are vulnerable while in hospital. They may be disoriented, they may be frightened, they may be dependent on others to assist with basic functions for the first time in their adult lives. In other words they have had to surrender control to the medical system whose language they may not understand and that makes them impatient and perhaps a little less receptive than normal. Their relatives may also be on edge and will be resisting their loss of control over the welfare of their loved one. At the same time health professionals are working with many constraints on their priorities and energy; they are also operating in an environment which is familiar to them in terms of its procedures and language. Medical and nursing staff may have their sensitivities blunted to some extent by having to deal with thousands of patients. However, what is routine to them is unique to the patient.
In such conditions there is a particular need to periodically review the manner in which sensitive information is communicated to patients and their families. It is important for all health professionals to appreciate the patient's perspective, to make all exchanges as sensitive, meaningful and humane as possible and to understand that effective communication means more than simply saying something to somebody. The Ombudsman would wish to see a special emphasis placed on the development of improved communication skills as one means of reducing complaints in the sector.
Things can and do go wrong in every organisation. There is nobody, including the Ombudsman, who can say that nothing ever went wrong in their office, surgery, clinic, ward or operating theatre. Everybody makes mistakes. However, few people can easily accept their own mistakes. This is probably more the case in medicine than in most other occupations, because errors can have such serious consequences. The critical question for individuals is how they react when such mistakes are made and things go wrong. Conversely, the critical question for the new Executive is how it views the culture surrounding the resolution of such errors. The crucial element in this equation is the concept of culture.
Culture manifests what is important, valued and accepted in an organisation. It is not easily changed nor is it susceptible to change merely by a pronouncement, command or the declaration of a new vision. At its most basic it can be reduced to the observation the ways things are done around here. Complaints are an inevitable consequence of errors, consequently, an understanding of the way things are done around here is a fundamental first step to developing proper and effective complaint handling procedures.
Most people instinctively regard complaints as unpleasant because they can be a very personal comment on performance. In the hospital context once the word complaint is used there is always the danger of a personal and usually negative reaction. Doctors articulate their sense of fear and hurt, concern about their reputation, distress at the lack of understanding of their action and motives, and their vulnerability. Worry, surprise, annoyance, anger, disappointment, anxiety and distress are among the most common emotions experienced. Clearly, there may be a fear that complaints will have a significant and lasting impact on those to whom blame is attributed. The challenge to the practitioner's expertise is likely to be construed as greater than the content of the particular complaint, resulting in an almost symbolic resistance to such challenge. Indeed, the intensity and duration of the emotional aftermath does not seem to relate to the size of the error or the seriousness of the complaint, but rather to the ability of the individual doctor to put it into perspective. Responses can, and do, exacerbate a complainant's sense of grievance by appearing defensive, using technical language, commenting on the failure of complainants' attempts to manage illness, casting doubt on the complainants' account by labeling them a 'bad patient' and arguing that dissatisfaction is a symptom of the illness being treated.
The experience of the Ombudsman has been, in general, that complaint handling in hospitals has been very much dependent on the goodwill and co-operation of medical staff. With certain exceptions, the Ombudsman has rarely found that health professionals, particularly doctors and consultants, engage wholeheartedly with patients' complaints. This, when allied to a reluctance by patients to complain, usually because they are very dependent on the system, makes for a very unsatisfactory situation. Complaint handling is invariably seen by medical staff as very much a matter for the administrators, even though the kernel of the complaint might well involve particular doctors or consultants.
This may be because it is felt that the examination of complaints; interferes with other (more important) work, causes delay, can reflect badly on the individual performance of colleagues, arise because of the actions of "cranks", is made solely for the purpose of seeking compensation.
However, it is essential that they view the handling of complaints and patient safety as an integral part of clinical governance and risk management. Clinical governance is about using information so as to manage processes in a way which will ensure the effectiveness and safety of clinical outcomes. Information may come from clinical audit, adverse incident reporting, risk management and complaints procedures. This can lead to the systemic identification, treatment and evaluation of risks, incidents and near misses with consequent learning from the lessons observed.
A key indicator in any assessment of the quality of our health service is the way it reacts to the needs of its clients, patients and service recipients. The Executive needs to be aware, and open, to the views of these clients. One of the more important avenues through which these views can be brought into focus is through effective complaints handling mechanisms which are accessible, consistent and provide remedies which are fair. Yet in the survey of patients in acute hospitals referred to in the chapter on Communications, the Irish Society for Quality and Safety in Healthcare found that almost 75% of those surveyed were unaware of a complaints procedure, whilst almost 20% considered that they had grounds to express dissatisfaction with some element of their stay in hospital. Of those who did complain over 40% were dissatisfied with the outcome, whilst a further 31% were only somewhat satisfied. There is much for the Executive to consider in these responses.
Complaints procedures provide an opportunity to put things right for the patients, clients and their families. But they have an equally important role to play in improving services. Complaints from patients, clients and their families can provide a useful additional means of monitoring the quality of health services. Constructive comments and suggestions also provide a helpful insight into existing problems and offer new ideas which can be used to improve these services and provide an opportunity to establish a positive relationship with the complainant and to develop an understanding of their needs.
If a dismissive or defensive approach is adopted in examining a complaint an opportunity for a constructive outcome can be lost, and an issue can escalate from what might have been a minor situation into something more serious and intractable. It is the experience of the Ombudsman that people who make complaints are usually not motivated by prejudice or malice and are not generally seeking financial compensation. What they do tend to look for is a sincere apology or explanation and an assurance that the matter giving rise to the complaint will not re-occur. When a complaint is seen to be ignored, or is handled inadequately, the situation can rapidly deteriorate and lessen the prospects of a resolution.
The Health Act 2004, provides for the establishment of a statutory framework for these complaints procedures. Under this statutory framework, the Health Service Executive will be required to establish procedures for dealing with complaints about the services it provides or about those of other agencies that provide services on behalf of the HSE. During 2005 consultation on the development of a National Complaints Handling Framework took place. In the course of the year the Department of Tánaiste Health and Children began drafting regulations which will give a statutory basis for the handling of complaints. The Regulations have not been published to date. However, I understand that the initial emphasis will be to seek a resolution of the complaint at local level, but with access to independent review if the complainant is dissatisfied with the outcome of the local examination of the complaint. Following this review, if the complainant is still dissatisfied, he/she will have access to the Office of the Ombudsman or the Office of the Ombudsman for Children where appropriate.
It is the Ombudsman's experience that complaints are best dealt with through local resolution where the emphasis should be on achieving quick effective resolutions to the satisfaction of all concerned. In trying to reach local resolutions the Ombudsman has always considered that it is important for service providers to try to view complaints from the point of view of the service recipient. The concerns of the complainant should be understood and possible options for the resolution of the complaint should be considered as soon as possible, even if all that can be done is to give an explanation or apology for any misunderstanding. It is important, therefore, to adopt a constructive attitude towards complaints. They should be dealt with in a positive manner, lessons should be learned and changes made to systems or procedures where this is considered necessary. Complaint handling systems should be strongly supported by management and reviewed and adjusted, where necessary, on a regular basis. They should be well resourced, staffed by competent and well-trained and experienced personnel.
In essence good complaints handling procedures should be; well publicised, easy to access, simple to understand, quick, confidential, sensitive to the needs of the complainant and those complained against, effective, providing suitable remedies and properly resourced
The following example of an investigation completed by the Ombudsman illustrates the various issues outlined above. A family complained to the Ombudsman about the response of a general hospital to the following matter.
Their father had been admitted to hospital complaining of severe pain in his lower back and legs. During the following days he was examined by various doctors but he remained in severe pain and discomfort and became increasingly agitated. His family became concerned and distressed and continually sought explanations from both nursing and medical staff as to the cause of their father's pain and discomfort. The family considered that the attitude and response by a particular doctor was very unsatisfactory. They described his attitude and demeanour as dismissive and stated that he refused to give them information on their father's condition and proposed treatment. Eventually, they became so concerned about their father's condition that family members remained with him in the hospital. Their father was subsequently the subject of an emergency transfer to another hospital where he died shortly after his admission as a result of a ruptured aneurysm.
The family were at a loss to understand the standard of medical care he received after having these concerns raised. They were particularly aggrieved that they were not informed of the nature and severity of their father's condition and of the proposed treatment to alleviate it. Despite raising concerns with the nursing and medical staff on a number of occasions, the family continued to be aggrieved that his condition remained untreated until his emergency admission to another hospital.
The investigation by the Ombudsman revealed the following deficiencies in the manner in which the complaint was handled by the hospital;
i) the family were not viewed as human beings but as possible adversaries in future legal proceedings,
ii) the hospital's Complaints Officer referred the family's concerns to the relevant Consultant. He (the Consultant) had earlier referred the family to the Hospital's Complaints Officer, thus initiating a circular approach rather than undertaking to have the family's complaint examined by himself in conjunction with the senior hospital administrators,
iii) a response by the Hospital which left the family somewhat confused as to what precisely had happened to their father, what treatment he received and why his vascular condition was not diagnosed earlier, given the observations the family had made to the nursing and medical staff. The family also had genuine concerns about the way in which their father was transferred to the other hospital, although the Ombudsman was able to reassure them, on the basis of the investigation, that this aspect appeared to have been dealt with properly,
iv) a paucity of records covering critical treatment junctures,
v) a stark failure to meet the standards of medical record keeping expected of medical staff following their contact with patients,
vi) an absence of relevant entries on the nursing notes during a period of significant nursing intervention.
Overall it was clear from the investigation that the family's concerns had not been adequately addressed and the Ombudsman upheld their complaint.
The investigation provided answers to most of the questions raised by the family. Other recommendations centred on procedures in relation to nursing records, medical notes, complaint handling with particular reference to the role of the Consultant in dealing with complaints and the importance of good communications procedures in responding to the concerns of complainants, and most importantly the delivery of a personal apology to the family.
The case identified a particular issue for joint consideration by the management of the Health Board, the Hospital and the medical staff viz. the need for greater clarification in the respective roles and relationships of junior and senior medical staff. In particular, the Ombudsman recommended that consideration should be given to an administrative protocol outlining the circumstances in which a junior member of a medical team should consult with his or her Consultant when a patient's condition gives cause for concern, and the corresponding obligation on Consultants to be accessible for such consultation. The outcome of these recommendations included;
i) the delivery of the personal apology,
ii) the establishment of a new management structure that would include Consultant medical staff and so incorporate the role of the Consultant medical staff into the complaints procedure,
iii) the establishment of a new programme of nurse education in relation to best practice in the maintenance of nursing notes,
iv) the establishment of a chart review and audit of nursing documentation to determine effectiveness of the programme and generally to monitor documentation,
v) the inclusion of a new module in the NCHD induction programme to address the protocol for medical notes (other acute hospitals within the Board were requested to develop similar best practice in relation to these initiatives),
vi) the development of a new complaints procedure and an administrative protocol relating to the respective roles and relationship of junior and senior medical staff.
It is very important to note that the family in this case did not pursue their complaint in a vindictive way or with a view to litigation. In essence, all they were seeking were clear answers to their questions about their late father's treatment, appropriate apologies for the shortcomings they perceived and assurances that lessons would be learned for the benefit of future patients and their relatives. The Ombudsman tried to provide this for them, and the outcome of the case is a very good example of how an effective complaints process, embedded in the proper culture, could have enabled the particular Hospital to provide appropriate redress for the family in a non adversarial manner, whilst at the same time effecting quality improvements in the service which would benefit other users and help to prevent similar problems occurring in the future.
The Ombudsman's hope for the new HSE framework for handling complaints is that it will meet these essential requirements, and that it will become an established feature in the landscape of quality customer service and complaint handling. The Ombudsman looks forward to the completion of the framework for the handling of complaints and its application on a national basis throughout the health service. The Ombudsman acknowledges that the perfect system will not be easily achieved and that the system will be the subject of on-going review and change over the next few years as the system evolves. The experience of the UK, where a single complaints system was introduced in 1996, is interesting and relevant. In the years since 1996 the National Health Service (NHS) complaints procedure has been evaluated and revised. However, in an in-depth review of the system, published in 2005, by Ms Ann Abraham Parliamentary Commissioner and Health Service Ombudsman, she identified key weaknesses which may have resonance for the proposals being considered for the HSE and are therefore of relevance.
In her report she commented that:
"NHS bodies need to be responsive to complaints and value the feedback they provide. To do so they need competent, trained and motivated staff using robust local procedures."
She went on to say that:
"dealing with complaints should not be a stand alone activity. The lessons from them must feed into improvements in the service delivered to patients."
The above comments echo the sentiments of the Ombudsman on the HSE complaint handling proposals. The Office has always been very keen to heighten the awareness of the public of the value of having accessible and effective complaint handling procedures in operation. The Ombudsman's Guide to Internal Complaints Systems - Settling Complaints - and the Ombudsman's guide to the provision of redress, an essential ingredient in effective complaint handling - Getting it Wrong and Putting it Right - will both be included in the consolidated Code of Good Administrative Practice which, as referred to in her introduction to this Report, the Ombudsman intends to publish in the near future.
Over the years successive Ombudsmen and Chief Executive Officers of the health boards invested considerable energy in establishing a good working relationship between the Office and their respective boards. This was done primarily to promote the interests of complainants who, having failed to secure redress at health board level, brought their case to the Ombudsman.
This positive working relationship facilitated the regular review of liaison arrangements, the functions of liaison officers and the quality and timeliness of reports being furnished to the Ombudsman. It also facilitated the examination of many procedural issues arising from the Office's experience in examining specific complaints e.g. payment of Disabled Persons Maintenance Allowance from age 16 years, backdating of Domiciliary Care Allowance payments based on prior health professional involvement with the applicants, complaints relating to childcare issues and the raising and recovery of non-statutory charges. Over time, there were joint discussions aimed at ensuring greater consistency across all health boards e.g. the development of internal complaint handling/appeal procedures and, generally, agreeing to implement, or take account of, requests/recommendations of the Ombudsman in relation to one board without the need to replicate the investigation process in other boards.
The decision to disband the various boards, and to rationalise the operation and administration of the health service will obviously lead to major change in the manner in which such healthcare is planned and delivered. Certainly, insofar as the Office of the Ombudsman is concerned, the departure of the Chief Executive Officers who were a valuable contact point for this Office, and who were quite visibly accountable for the delivery of health services within defined geographical boundaries, will require a new focus on accountability within the newly restructured service.
While there are clearly many advantages to the new structure - and principal among these are the benefits accruing in time from a single unified and consistent approach to health service delivery - it must be recognised that the new structure will pose many problems too.
Some of these problems will be short-term in nature arising from the departure of personnel with long years of experience in the health service and the arrival of new staff who are in the process of becoming familiar with their new responsibilities.
However, looking to the longer term challenges, it is important that the new staffing structures and reporting arrangements are sufficiently simple so as to ensure that the Health Service Executive (HSE) is responsive to client needs at local level.
One of the fundamental principles of good complaint handling is that complaints should be resolved quickly and as closely as possible to the point of service delivery. This underlines the need for managers with clear lines of responsibility and delegated powers and, in turn, clearly defined lines of accountability. When complaints are made to the Ombudsman it would lead to greater efficiency if local managers have the authority, within certain parameters determined by the HSE, to decide the outcome of these cases with this Office. This "subsidiarity" will undoubtedly pose challenges for the HSE as it endeavours to bring about a single unified health service. However, if the HSE is to embrace a client-centred approach to delivery of services, it is vital that complaints are resolved locally and, in the main, complaints referred by this Office are also resolved locally. The experience of this Office throughout 2005 would indicate that this is an area that requires urgent attention by the HSE. Beyond that, this Office would also welcome the establishment of a forum, similar to that which existed with the health boards, to discuss issues arising from the examination of individual complaints.
Following the presentation of this Report to the HSE, the Ombudsman is hopeful that it will be possible to meet with senior management of the HSE to discuss the development of new liaison arrangements with her Office and indeed, to elaborate on the other issues covered in this Report.
Everyone has the right to be respected as a human being.
Everyone has the right to have his/her physical and mental integrity respected.
Everyone has the right to the security of his or her person.
Everyone has the right to have his/her privacy respected.
Everyone has the right to have his/her moral and cultural values and religious and philosophical convictions respected.
Every patient has the right to information about the available health services.
Every patient has the right to be fully informed about their health status, including the medical facts about their condition; about the proposed medical procedures, together with the potential risks and benefits of each procedure; about alternatives to the proposed procedures, including the effect of non-treatment; and about the diagnosis, prognosis and progress of treatment.
Information should be withheld from patients only exceptionally, when there is good reason to believe that this information would, without any expectation of obvious positive effects, cause them serious harm.
Information must be communicated to the patient in a manner appropriate to the latter's capacity for understanding, minimising the use of unfamiliar technical terminology. If the patient does not speak a common language, some form of interpreting should be available.
Every patient has the right not to be informed about aspects of their condition and prognosis, at their explicit request.
Every patient has the right to choose who, if anyone, should be informed on their behalf.
Every patient has the right to be informed of the identity and professional status of the individuals taking care of them and of any procedures and guidelines which would bear on their stay and care.
Every patient has the right to be able to request and be given a written summary of their diagnosis, treatment and care on discharge from a health care establishment.
The informed consent of the patient is a prerequisite for any medical intervention.
Every patient has the right to refuse or to halt a medical intervention. The implications of refusing or halting such an intervention must be carefully explained to the patient.
The consent of the patient is required for the preservation and use of all substances of the human body. Consent may be presumed when the substances are to be used in the current course of diagnosis, treatment and care of that patient.
The informed consent of the patient is needed for participation in clinical teaching.
The informed consent of the patient is a prerequisite for participation in scientific research.
All information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind must be kept confidential, even after death.
Confidential information can be disclosed only if the patient gives explicit consent or if the law expressly provides for this. Consent may be presumed where disclosure is to other health care providers involved in the patient's treatment.
All identifiable patient data must be protected. The protection of the data must be appropriate to the manner of their storage. Human substances from which identifiable data can be derived must be likewise protected.
Patients have the right of access to their medical files and technical records and to any other files and records pertaining to their diagnosis, treatment and care and to receive a copy of their own files and records or parts thereof, provided access does not put their health at risk
Intervention may be carried out only in the presence of those persons who are necessary for the intervention unless the patient consents or requests otherwise.
Patients admitted to health care establishments have the right to expect physical facilities which ensure privacy, particularly when health care providers are offering them personal care or carrying out examinations and treatment.
Patients have the right to a quality of care which is marked both by high professional standards and by a humane relationship between the patient and health care providers.
Patients have the right to be treated with dignity in relation to their diagnosis, treatment and care, which should be rendered with respect for their culture and values.
Patients have the right to enjoy support from family, relatives and friends during the course of care and treatment and to receive spiritual support and guidance at all times.
Patients have the right to humane terminal care and to die with dignity.
Each patient has the right to be free from harm caused by failures in service delivery, medical malpractice and errors.
When availing of health services each patient has the right to expect that such services and treatments meet high safety standards.
Each patient has the right to expect that hospitals and health services monitor risk factors on a continuous basis and ensure that systems are in place to ensure optimum quality and safety of the environment of health service delivery to patients and service users.
Each patient has the right to expect that all managers and health professionals accept full responsibility for the safety of all phases and elements of medical treatment within their control.
Each patient has the right to expect that medical professionals minimise the risk of errors by monitoring precedents and receiving continuous training.
Each patient has the right to expect that health care staff who report existing risks to their superiors and/ or peers will be protected from possible adverse consequences.
This last right is of the utmost importance. A blame-free, nonpunitive culture encourages individuals to report errors and truly learn from their mistakes. It also supports organisations in their efforts to better understand those errors and make improvements. A just environment assumes that staff at the sharp end of care are concerned about patient safety but are working within complex systems and in situations that potentially contribute to errors.
Over half of all deaths in Ireland occur in hospitals and it is therefore vital that the experience of an estimated 15,000 people and their relatives should be a matter to be taken into account in consideration of this issue. Such experience could lead the development of the adoption, within the health services, of the concept of a good death; the right of people who are dying in hospitals to a dignified death, pain free as is possible, and in conditions which enhance their dignity and privacy. The concept would also take into account the needs of family members and of other hospital patients; the right of patients and, where appropriate, their families, to be communicated with respect, in facilities which afford full privacy and confidentiality.
If patients cannot avail themselves of the rights outlined above, they should be exercisable by a person designated by the patient for that purpose; where neither a legal representative nor a personal surrogate has been appointed, other measures for representation of those patients should be adopted.
Patients must have access to such information and advice as will enable them to exercise these rights.
Where patients feel that their rights have not been respected they should be enabled to lodge a complaint. The mechanisms at institutional and other levels to facilitate the processes of lodging, mediating and adjudicating complaints should ensure that information relating to complaints procedures is readily available and that, where necessary, assistance and advocacy on behalf of the patient would be made available.
Patients have the right to have their complaints examined and dealt with in a thorough, just, effective and prompt way and to be informed about their outcome.