Complaints learning Division of Surgery, Anaesthetics & Cancer Paula King Head of Nursing for Division of Surgery, Anaesthetics Cancer & Divisional Governance Lead
INTRODUCTION 46 yr FEMALE Admitted for a dental extraction under sedation Patient asked to communicate her pain by squeezing hand Sedation given according to patient’s need Local anaesthetic instilled and block tested before surgeon started At the end of procedure the patient complained that she wasn’t asleep and could “feel everything” Patient moved to recovery for post procedure care Patient self discharged and Datix form completed.
SUMMARY OF COMPLAINT MANAGEMENT OF THIS INCIDENT 14th Jan 2015 patient contacted PALS 15 th Jan 2015 - Anaesthetic CD informed PALS that anaesthetist is in process of writing a report. 17 th February 2015 – incident presented at Anaesthetic Clinical Governance Meeting Complaint being managed via the PALS informal complaint process 22 nd Sept 2015 patient wrote to PALS requesting an update on complaint Formal division complaints process begun 21 st March 2016 Failing: Although discussion and shared learning was facilitated within team in February 2015 following this incident, it is evident that there was an unacceptable lack of communication between PALS and the division in responding to the patient. NB: The division have now re-appraised the complaints process
ACTION PLAN In response to patients letter received 22 nd Sept 15, the Trust responded to the patient on the 8 th April 16. The Trust apologised to the patient for the unacceptable delay in responding and investigating this case. The Trust acknowledged that it was clear that the information provided to the patient prior to the procedure and what it would entail was insufficient. The Trust updated the patient on the actions that have been implemented to prevent this situation reoccurring in the future: Issues agreed with complainant or as Actions agreed in final letter in response to investigation Completed Y/N and identified during investigation Date of Completion Patient having tooth extraction was distress The case was presented to the whole anaesthetic department at a Yes during procedure and in pain. Indications Clinical Governance meeting on 27 February 2015 and there was a 27 February 2015 for procedure to stop were ignored. detailed discussion about patient selection, techniques of conscious sedation and how to prevent the same thing happening again. As above A Consultant Anaesthetist was appointed as the lead for sedation Yes techniques February 2015 As above A series of meetings were held between representatives of the Dental Yes Surgery Unit and the anaesthetic department. 22 March 2016 A new guideline was drawn up : “Guidelines for conscious sedation for As above Yes oral and maxillofacial surgeries” February 2015 As above A patient satisfaction audit was developed Yes February 2015
OUTCOME Guidance to anaesthetists, Oro-maxillo facial surgeons and their teams involved in providing good and safe clinical practice for conscious sedation for dental care/oral surgery
OUTCOME
OUTCOME Shared learning
Robust Divisional complaints process
Divisional management of complaints Acknowledgement letter sent to patients/families informing them of investigation and response within 25 days Coordination of investigation, ensuring all relevant parties are informed and information gathered Action plan agreed to prevent reoccurrence of incident Family updated throughout process Investigation response letter sent to family Complaint and action plan presented to division and where relevant cross divisional to ensure shared learning
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