PI Brief Update

Why relatives are being branded as troublesome - Dr Mark Burgin

24/10/24. Dr Mark Burgin discusses how raising complaints can lead to the relatives being excluded from the ongoing care and how a clinical negligence lawyer can provide support.

All health professionals make mistakes, official figures are 800k in the NHS per year (about 4 per doctor per year) however the true figure is much higher. Observation of doctors suggests that they make about one mistake a day. Although most are addressed at the time or cause no harm many are missed until the relative points them out.

Health care professionals who have good communication skills and are free of burnout will generally put the problem right straightaway. They may apologise or offer an explanation however this is rarely necessary. The relatives want to believe that their loved one is getting good care and a smile or reassurance is enough.

A proportion of health care staff are burned out and take any complaint personally. This is more likely to occur if the department is dysfunctional and poorly lead. Even then the staff often deal with the complaint in an appropriate way, building trust in the care that is being delivered. Rarely there will be a perfect storm where the relative’s behaviour, the staff’s stress and problems in the department will combine and cause a problem.

There is a temptation for experts to consider these problems as evidence that the relatives are being unfairly punished. There are two sides to every story and despite the lack of good documentation it is clear that staff face abuse on an everyday basis. The investigation of the mistakes must not bias the expert’s opinions.

Unacceptable Behaviours

There is a long list of behaviours that can trigger a response and are said to be against the rules. The rules actually apply only to a limited number of behaviours – physical, verbal aggression and hate speech. The actual behaviours can include not looking at the person talking, referring to the staff by sex or colour, crying, talking over the staff member and so on. These are then described as ‘hostile and aggressive’.

Discussion with relatives suggests that the real ‘unacceptable behaviour’ was the complaint. They will often describe having a reasonable discussion with the staff member but as soon as they ask why something has not been done the conversation is terminated. A senior member of staff asks the relative to ‘have a chat’ in a private room. They are then told off for their ‘hostile and aggressive’ behaviours.

When a lawyer requests documentation of the alleged behaviours and the discussion it may not exist or be very brief. The relative will confirm that no contemporaneous records were made and the notes are inconsistent with the events. No formal monitoring of these events occurs so the department will continue to proudly announce that they have not had any complaints.

Dealing with behaviour problems

The number of exclusions, processes against relatives and telling offs that a department makes is heavily dependent on the staff. Some have excellent mediation and communication skills and others are mentally unwell and are triggered by the relative’s behaviour. Logically the staff are there for the patient and the relatives should be part of the solution not a part of the problem.

The responses of staff to poor behaviours are generally more tolerant that they should be. Relatives that are aggressive, swearing and intoxicated are rarely removed as quickly as other people might wish. The staff are reluctant to have even clearly disruptive people removed. The response to complaints can be less appropriate.

Often a person making a complaint uses a louder voice or with more pressure of speech than a normal person. They may be standing but often they are sitting and the staff member is standing. The staff member (who might have been a few minutes before dealing with a shouting person) appears to get upset and they do not know what to say.

Department functions

Complaints are inherently challenging because they request action from the staff member. Often this means speaking to another member of staff who can action the request. In dysfunctional departments the person asking the other will get told off for asking and must return to explain to the relative. Even when the senior staff member speaks to the relative, they may struggle to use appropriate communication skills.

The relative will be dealt with according to usual procedures which can be a little one-size-fits-all. Their behaviour will be categorised and the department will follow the protocols which may be unwritten. There is rarely any reflection in the department due to pressure of work and lack of records. The key concern is to get everyone back to work and remove the cause of the issues.

Lawyers can find challenging any decisions almost impossible the reasoning is largely added after the event. The decisions are made emotionally rather than logically and complaints generate higher emotional responses than other behaviours. Without a recording of the conversation the staff will deny any statement from the relatives.

Conclusions

There are problems on both sides with relative’s behaviour and the staff’s responses often less than ideal. Relatives have always got upset and sometimes stepped over the boundaries of acceptable behaviour. The staff have always been under pressure and struggling to manage the demands of relatives and patients.

Increasing rates of burnout in staff particularly A and E means the ability of staff to cope with troublesome relatives is getting worse. Increasing mental health problems in society generally and less tolerance of emotional distress is causing more troublesome relatives. These changes mean that there are more unsatisfactory interactions but healthcare leaders have largely been inactive.

There are several things that should happen to improve the current situation. The first is to log each time a relative gets a warning, second to include whether the relative was making a complaint, third make leaders responsible for reducing the number of exclusions, fourth provide support to staff affected by interactions, fifth provide training in dealing with complaints and finally consider a list of the complaints for common themes.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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