Case studies: cases finalised in conciliation

Advice about Reciprocal Health Agreement between Italy and Australia

Regulation of intensive pulsed light treatment (IPL) equipment and operators

Resolution through acknowledgement of adverse outcome

Improved and integrated care for aged patients

Removal of tooth without adequate explanation of alternative options

Hip dislocation during post operative X-Ray - improved excort procedures

Improved communication an co-ordination between different treating teams

Future treatment plan negotiated through Conciliation

Negotiated settlement through conciliation

 

Advice about Reciprocal Health Agreement between Italy and Australia

The complainant, an Italian visitor to Australia, required emergency hospital treatment for an infection in his left ear. He did not speak English and communicated through family members as interpreters. He was advised by a public hospital to go to a private hospital nearby as the emergency department was very busy and he would be seen more quickly there. He followed that advice and was charged $150 for emergency treatment.
The following day, he was required to pay $1875 before he could be admitted to the private hospital for the administration of intravenous antibiotics. The hospital was asked whether he could have the treatment for free at the public hospital but advised him that because he was a visitor from Italy the cost would be greater. As a result of this advice he paid the money and was admitted to the private hospital. The information given to him was incorrect, since there is a Reciprocal Health Care Agreement between Australia and Italy. Treatment at the public hospital would in fact have been free.
The claimant sought to recover the cost of the hospitalisation and incidental fees, including pathology fees.
Prior to conciliation, the hospital had agreed, as a gesture of goodwill, to refund the sum of $750 plus the emergency fee, and to arrange the bulk billing of the incidental accounts. The patient’s wife was also accommodated free of charge during her husband’s stay. The hospital maintained that it was not entirely responsible for what had occurred, as its staff could not be expected to know about payment arrangements for patients from overseas.
Within conciliation, the hospital agreed to further reduce the complainant’s hospital costs and expenses, and accepted that it was in the interests of overseas visitors that they be correctly informed of the cost of health care.
As a consequence of the complaint, it initiated a process of adding the Australian Governments Reciprocal Health Care Agreements to the standard information provided to admitting staff. Additionally, the Front Office managers will include this information in their internal education.

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Regulation of intensive pulsed light treatment (IPL) equipment and operators

The complainant attended a beauty clinic where she underwent facial hair removal by IPL treatment.
She sustained a burn to her upper lip. She complained that she chose the clinic because she believed the treatment was performed by a doctor when in fact it was not. Further, as she had had similar treatment previously with no ill effects, she believed that there must have been an error on the part of the provider. She also complained that the provider had not taken her injury seriously, she had not been assessed by the doctor at the clinic in a timely way and that she had never received an apology.
In response, the provider advised that the complainant was clearly warned about the small risk of suffering a burn from the treatment, and that she had signed a consent form prior to treatment. It was confirmed that the doctor at the clinic does not carry out IPL treatment. This is performed by a nurse in consultation with the doctor. The machine was used in accordance with normal settings and practice.
In conciliation, it was acknowledged that the complainant had indeed received a burn from the device, but the provider could not explain how this had occurred. The printout from the machine showed that the settings were within normal limits. It was said that there had been 4 or 5 incidents, out of many thousands of cases over a 12 year period, in which minor burns had been sustained, and that this occurs from time to time however cautious the therapist. The provider was unable to say what could be done to eliminate the risk.
An apology was given to the complainant, not only for the burn, but also for the manner in which it was dealt with thereafter.
It became clear in conciliation that there was no regulation of intensive pulsed light equipment in any Australian jurisdiction other than that the requirement that it be registered as a medical device with the Therapeutic Goods Administration. There is also no system to regulate the operators of the equipment, although regulation would be welcomed by this provider.
This matter of public interest was drawn to the attention of the Department of Health and Human Services following the conciliation. I was advised by the Department that the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) had established a working group to develop recommendations for a national approach to the safe use of these devices on humans. These recommendations are now being adapted in Tasmania into a set of draft licence conditions, compliance standards for equipment, and competencies for IPL users which are now reaching the consultation stage. This process should be completed by the end of 2010.

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Resolution through acknowledgement of adverse outcome

The complainant underwent a vaginal hysterectomy, after which she experienced considerable perineal pain. She requested an examination of the area but no adequate assessment of her condition was carried out. Upon discharge from hospital, the complainant discovered the area was red, blistered and weeping and she was diagnosed with a severe burn which had remained undiagnosed and thus untreated for five days. After diagnosis, conservative treatment provided relief, but the burn caused symptoms for some weeks.
The hospital explained that the burn was caused by a disposable diathermy clamp used in surgery, in circumstances where the skin was clearly not sufficiently shielded from the device. There had been two previous instances of less serious burns from the use of the device, which had been neither specifically recorded in the records nor reported. The matter was referred to the hospital’s Serious Incident Panel, but in the meantime the use of the device had been discontinued for reasons unconnected with this complaint.
The surgeon concerned apologised personally to the complainant for the injury and acknowledged that her complaints of pain thereafter were not treated seriously or adequately by the registrar concerned. He undertook to speak to the registrar personally about these deficiencies.
The hospital agreed that the record keeping relating to these adverse events was inadequate. The importance of recording all clinical observations was acknowledged, and was being addressed as part of ongoing staff training.
The hospital offered an ex gratia payment for outstanding medical costs and for pain and suffering, which was accepted by the complainant.

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Improved and integrated care for aged patients

The complainant’s elderly mother, a resident of North West Tasmania, was admitted to hospital suffering from confusion and a urinary infection. The complainant contended that her mother was inappropriately prescribed the anti-psychotic drugs Haloperidol and Risperidone whilst in hospital, and that this caused her condition to worsen and her behaviour to deteriorate to the extent that she was subjected to physical as well as chemical restraint. She complained that hospital staff failed to listen to her concerns about the effects of the medication on her mother.
The patient was eventually transferred to a specialist psycho-geriatric unit in the south of the State, where her debilitating symptoms were attributed to neuroleptic-induced Parkinsonianism. Psychotropic medication was ceased at this stage, and she was eventually discharged home.
The hospital acknowledged the agitation and suffering of the patient and the fact that delirium is invariably more severe in a hospital environment than at home. It was noted that there was no alternative placement available, and that the hospital had provided a high standard of care in difficult circumstances. The hospital asserted that it had consulted regularly with the complainant about the care of her mother.
In conciliation, a report was obtained from a senior specialist in aged care. The specialist advised that the patient’s condition was probably contributed to by some of the medications used to try to manage the patient’s behaviour, and that her outcome would have been better, and her hospitalisation probably shorter, had she been treated in a specialist unit from the outset, rather than in a general hospital environment. The specialist commented that the best management of delirium is in a specialised delirium ward, which no acute Tasmanian hospital possesses. A higher staff-to-patient ratio could provide an environment in which patients are safe to roam without chemical or physical restraint. It was noted that the hospital in this complaint lacks backup from specialised geriatric or psycho-geriatric services.
As a result of the complaint, it was recommended that the systemic problems identified in the expert report, particularly the lack of a specialist unit or ward in the north west of the State be addressed, and that education programs for practitioners involved in the management of dementia patients be introduced.
The hospital responded by holding a planning day involving all stakeholders, to address the issues raised in the report with a view to providing improved and integrated care for aged patients. The key initiatives from the planning
day have now been published, and introduced into the hospital’s strategic plan. A major outcome has been the identification of a hospital precinct specifically suited to the needs of patients with dementia or delirium.

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Removal of tooth without adequate explanation of alternative options

A young woman who underwent dental treatment through the government dental system complained that her dentist extracted a painful front tooth without discussing with her alternatives such as root canal treatment, and without referral for prosthetics. She was left with an embarrassing gap in her front teeth for more than two months.
The dentist responded that it was his practice to discuss all options for treatment with patients, that he would not remove a tooth without fully informed consent and that her consent was noted in the records. He advised that she was made aware that there would be a gap in her front teeth, possibly for some time until a denture could be made. He said he would have advised the patient that complex treatment is normally not available under the government system and she would probably need to attend a private dentist. Unfortunately he had no notes of any such discussions, since some of the practice records had been accidentally destroyed.
An independent dental opinion was obtained to the effect that it was unnecessary to remove the tooth as an emergency procedure, even if it was recommended that ultimately extraction was the best course of action. It would have been better to recommend an emergency pulp removal, which could have been provided under the government service on the day. The complainant could then have been referred back to the DHHS Clinic to allow further consideration of all options, including her capacity to fund other treatment. If the tooth was then to be extracted, it would be usual to provide a temporary partial denture, to be fitted at the time of subsequent extraction whilst a permanent replacement of the tooth was planned.
After consideration of this opinion, the dentist offered, and the complainant accepted, a written apology and an ex-gratia payment for expenses and the embarrassment caused.

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Hip dislocation during post operative X-Ray – improved escort procedures

The complainant’s hip dislocated during a routine X-ray five days after a total hip replacement. This resulted in a second hip replacement operation and a prolonged recovery. The complainant believed the dislocation occurred when his bed was lowered for the X-ray. He was also concerned that during the X-ray he had been required to position himself in ways that caused him a great deal of pain.
The X-ray provider acknowledged that the dislocation occurred during the time the complainant was having his X-ray, but believed it occurred spontaneously as opposed to being attributable to any negligence on the part of their staff. They apologised to the complainant, and acknowledged that some positioning for X-Rays did cause discomfort and that this should have been explained to him better at the time.
The provider acknowledged that when inpatients present for post-operative X-rays there is sometimes a lack of knowledge of their current level of rehabilitation on the ward. In an attempt to remedy this, a Nurse Escort Policy has been developed requiring the “hospital of origin” to provide an appropriate nurse escort for inpatients.
The policy extends to a wide range of “special needs patients” identified in the policy. An ex gratia payment was made to the complainant upon receipt of advice about the impact upon him of the dislocation.

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Improved communication and co-ordination between different treating teams

The complainant presented to A&E with an injury to his leg following an accident with an angle grinder. He was initially reviewed by an intern, who advised him that he would be admitted to hospital. He was then reviewed by the surgical registrar, who debrided and dressed the wound and sent him home with an appointment in three days.
The complainant believed that the registrar removed more flesh than was necessary when debriding the wound, and that this resulted in there being insufficient flesh for the wound to be stitched and therefore the need to proceed with “secondary healing”.
The surgical clinic was closed for the next three weeks, and the complainant was provided with advice as to how to manage the wound in the meantime. He returned to the clinic concerned that the wound was not healing as it should. He was reviewed in A&E and told that he had a bone infection and would need a plate inserted, but this was not correct.
He was admitted to an orthopaedic ward. Over the next six days, he was referred alternately from plastics to orthopaedics and back. Ultimately plastics took over his management and he underwent further debridement and a skin graft.
The complainant was concerned about the treatment provided to him at hospital, both upon his initial presentation, on review and on his subsequent admission. He was also concerned that he had been unable to resolve his issues with the hospital’s internal complaints processes and lodged a complaint with the OHCC.
In its response to the complaint, the hospital apologised for the events that had transpired, and offered to meet with him in conciliation. Within that process, the hospital acknowledged that poor communication had resulted in the complainant’s journey being less than optimal, but expressed the view that too much flesh had not been removed and that the eventual outcome had been acceptable.
The hospital advised that a great deal of work was being undertaken within the hospital to improve communication, both in training junior doctors to communicate well with their patients and in ensuring adequate communication between different disciplines (ie plastics and orthopaedics).
The hospital commented that one of the most important things for junior doctors to know is when to call for assistance, and not to provide advice that they are not qualified to give, and advised that as a consequence of this complaint doctors in A&E have been instructed not to provide advice outside their area of expertise.
The hospital acknowledged that the complainant had been switched between orthopaedics and plastics and that his complaint had highlighted the need for the two disciplines to work more closely together in managing certain patients. The hospital advised that as a consequence of the complaint the two disciplines now meet on a regular basis and review the management of all patients presenting with limb injuries to ensure improved management and communication.

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Future treatment plan negotiated through Conciliation

The complainant was an inpatient at a public hospital following a stellate ganglion block procedure. He developed a pneumothorax and surgical emphysema. The complainant claimed that he was left at times in severe and chronic pain and despite his protests, little if anything was done to alleviate this. He also claimed to have been denied his normal medications and that this left him stressed and anxious. He indicated a great reluctance to return to the hospital as a consequence.
The complaint was referred to conciliation. Representatives from the hospital attended, acknowledged that the complainant had suffered pain and provided an apology. It was also agreed that a concept plan be presented to the complainant for his agreement. This plan would outline a rehabilitation program to treat him holistically and deal with his reliance on strong pain killers and the psychological consequences of his treatment. Counselling was also offered.
The complainant accepted the apology and the offer of a concept plan and subsequent treatments.
The conciliation was successful.

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Negotiated settlement through conciliation

A mother lodged a complaint on behalf of her infant daughter. She claimed that following the child’s premature birth at 36 weeks:

  • the child’s tongue tie was not appropriately diagnosed, assessed or treated and as a consequence, she was unable to successfully breastfeed; and
  • the child’s undeveloped hip dysplasia was not appropriately diagnosed, assessed or treated, and as a consequence she would be required to be in a harness for up to 14 months, as opposed to 12 weeks if she had been diagnosed sooner.

The mother sought an explanation, apology, change in policy and procedure, and compensation because of the costs associated with treating the condition.
Within conciliation, the hospital acknowledged there had been a delay in diagnosing these conditions and agreed to make an ex gratia payment towards the expenses incurred by the complainant as a consequence.

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