Why multiple jeopardy is wrong

Despite having observed at first hand the effects of patient complaint procedures against doctors for several years now, I have been surprised by the extent of doctors’ unhappiness and despair at what they see as a vindictive and unfair process.

The number of patient complaints against doctors has risen significantly in recent years – with complaints against GPs doubling between 2007 and 2012. Our study has shown that complaint processes are associated with huge distress for doctors, and probably damages patient care.

Last year, we published a report, which found that doctors who had experienced complaint investigations suffered high levels of depression, anxiety and even suicidal thoughts. Furthermore, most doctors reported practicing defensively because of their concerns about complaints, with many revealing that they avoided carrying out procedures or seeing “high risk” patients.

In the current study, which has just been published in the journal BMJ Open, we analysed qualitative data from the second part of the survey, where 100 doctors who had been involved in a complaint procedure answered open-ended questions, and were free to write what they wished.

What they chose to write was frankly alarming. When asked about their experience of the complaints procedure, nearly half of the doctors felt negative feelings towards the complainant or complaint. Comments included: “I still find it very hard that a patient’s family could be so vindictive and unpleasant.” Many doctors described feeling impotent and helpless, whilst similar numbers described emotional distress, for example, “I cry, can’t sleep and contemplate suicide and certainly not being a doctor anymore.” While another added simply: “My life was ruined.”

When asked about the process they went through to investigate the complaint, they reported: “Makes you feel worthless even when you know you’ve done the best you can” and  “It seemed as if the patient is presumed to be right, and the doctor is presumed wrong, unless you can prove otherwise.”
Of significance to policy makers, one said: “I am fairly sure that this results in me practising poorer medicine.” In general, doctors did not see complaints procedures as a learning experience.

The problem here seems to be that doctors lack confidence in the complaints process, which they think unfairly stigmatises them and assumes guilt. To add to the problem, many doctors are suspended as a matter of course when a complaint is made, before any decision has been taken. This leads to them being isolated from their colleagues and peers, leaving them with no support structure. The fact is that doctors are often exonerated after a long and stressful process that may seem to have no end. Of the 100 doctors included in the analysis of the survey, the final outcome of the complaint investigation was known for 80 doctors. Sixty-seven were exonerated, two subject to disciplinary action, one was suspended from practice and 10 were subject to an on-going investigation. The wide picture shows the same pattern. The General Medical Council regulates doctors in the UK and can stop or limit their rights to practise. In 2013 there were more than 8,500 complaints about doctors to the GMC, of which just over 3,000 went on to be investigated. Of these 8,500 only 80 doctors were suspended or erased from the medical register. Apart from those referred to the GMC, many more complaints are investigated through hospitals’ or clinics’ internal enquiries.

We would like the whole process to be made more systematic and transparent, and there should be mandatory timescales for all sides so doctors know how long the process is going to take. We want to see an end to ‘multiple jeopardy’ or “death by a thousand arrows” whereby a doctor may be cleared by a Trust and/or the NHS Ombudsman, only to be taken through a further process over the same incident.

We feel a doctor should only be suspended from practice if there is clear danger to patients if that individual remains in post. It should not be a blanket policy and in the event of a complaint there should be a mentoring system to support those involved and doctors must not be isolated from their peers. When a complaint is evaluated it would seem reasonable that for doctors actions to be judged by peers with no connection to the event. In the case of the GMC, this could be achieved by introducing a form of “jury service” within the profession.

Doctors need to expect that complaints will and indeed should happen, but they should also expect to be treated fairly and the consequences should be proportionate. The formalising of complaints processes means that communication between medical staff and patients and their relatives is often hindered and positions become rapidly polarised. There is, of course, a balance to be struck, however, neither patients nor colleagues should not be able to make demonstrably vexatious complaints without limit or consequences. In the majority of cases, the process should be about learning lessons, not simply attaching blame. It should not be governed by fear, which it clearly is currently. When doctors feel impotent, emotionally distressed and afraid, they are not going to be able to perform at their best. Around 10 per cent of the doctors in our study said that they were thinking of leaving medicine altogether because of this issue – a disaster when you consider the investment in training and the need we have for qualified health professionals. If we add on the potential damage to patients and cost of defensive medical practice, the response of doctors to the current culture represents a significant public health problem.

I don’t accept that doctors should merely ‘toughen up’ and accept that current complaints procedures in the NHS are “part of life”. In my opinion, doctors tend to be emotionally resilient, but even they are finding it hard to cope with a system that can be divisive, isolating and emotionally damaging. The Berwick report stated that fear is toxic to patient safety, our study suggests that fear is endemic in the event of a complaint investigation. This has to change if we are going to learn when things go wrong and ensure adverse events are not repeated.