Health complaint outcomes

Examples of the types of complaints we have resolved are:

Diagnostic services improved after complaint

A man complained that his wife was unable to access the necessary diagnostic services in to treat her condition at a hospital. Following the Commission’s enquiries the hospital audited their service and as a result employed a new manager that initiated service changes including:

  • standardising terminology used to categorise the urgency of referrals and developed timeframes to reflect appropriate wait-times for each category;
  • began daily audits to ensure wait-times were met and staffing, or delivery of essential material, can be adjusted in response to demand; and
  • changed staffing including employing more staff.

As a result service availability has increased from three to five days a week and the recommended timeframes for each categorisation of urgency are being met with much improved frequency. The man was satisfied that access to the service was improved and the case was closed.

ACT cancer treatment investigation

A man complained that following a cancer diagnosis he was assessed as unsuitable for treatment and referred to palliative care services.

He sought a second opinion in another state, a different clinical decision was reached and he has since undergone successful treatment.

The man complained about the assessment and clinical decision reached in the ACT and sought the Commission’s assistance in relation to costs associated with seeking treatment interstate. The Commission successfully sought payment for his interstate travel costs. Its investigation of the man’s management found that the decision to decline active treatment resulted from a communication breakdown in his treating team.

Improved community-based nursing

The Commission was alerted to vulnerable patients in the community being exposed to possible inappropriate nursing practices.

The Commissioner initiated a consideration into the oversight of staff working in this environment with a focus on reporting and supervision of community nurses and their adherence to the Health Records Act that regulates their work. The Commission was provided with a variety of material including a Clinical Management Standard Operating Procedure (SOP) that revealed gaps in formal oversight of nursing practice, inadequate supports for nurses and inadequate education.

The Commission recommended changes to the SOP including:

  • scheduling regular meetings to ensure oversight of practice and provide support;
  • formal handover processes to ensure continuity of care even when carers change; and
  • a clinical management framework for all clients identified as vulnerable and with complex and long-term needs.

The Commissioner was satisfied the revised SOP improved oversight of nurses and the continuity of management provided to community-based clients.

Conciliation improves discharge planning

A woman complained to the Commission that her husband was discharged from cancer treatment at a hospital without sufficient support or coordination of ongoing care. She claimed the health provider’s management and care of her husband’s treatment contributed to a poorer quality of life in the time he had remaining with his family.

The complaint was resolved through Commission conciliation with the health provider agreeing to change its discharge planning practice, communication with patients and their families and outpatient appointments management. The health provider acknowledged and apologised to the complainant for their experience and provided financial compensation for costs relating to the complaint.

Communication key To informed consent

A woman complained to the Commission that she experienced extreme pain and tissue damage as a result of incorrect procedures performed by a junior health practitioner during post-operative radiation treatment.

She alleged she did not provide fully-informed consent for the procedure and raised concerns about her privacy during the procedure.
The Commission sought statements from the relevant practitioners and jointly considered the matter with the Nursing and Midwifery Board.
The matter was resolved through conciliation with the health service agreeing to change its communication practices with patients about the procedure, including telling them who would perform it, and changes to ensure patients privacy.

Inadequate dental treatment

A complainant contacted the Commission about experiencing adverse effects after root canal treatment and being charged additional fees he had not been made aware of. A notification was made to the Australian Health Practitioner Regulation Agency and after an investigation regulatory action taken against the dentist. The Commission conciliation and the complaint was resolved with an offer of refund for the treatment and an undertaking by the dentist to change the practice’s communications about fees.

Delay in booking a surgical procedure

The Commission received a complaint from a man who stated that he was seen at a public hospital outpatient clinic, and was assessed as requiring a surgical procedure. After seven months without hearing from the hospital, the man contacted the relevant unit, and was informed that he was not on the waiting list. The administrative staff advised the man that they could see that he had been assessed, and that he required the procedure, but they were unable to locate his referral. He was reassured that they would solve the problem.

This phone conversation was then repeated, on a monthly basis, for several months, with the man remaining unsuccessful in his attempts to secure a place on the waiting list. After almost a year, the man contacted the Commission. On receipt of the complaint, the hospital was able to establish that the man’s referral had been lost. The hospital reissued the referral, backdated to his original appointment so he was not disadvantaged by the administrative error.

The man was satisfied with the outcome, but the Commissioner was concerned that this situation could recur without systemic changes being implemented. She therefore suggested that the hospital advise patients to expect a letter confirming placement on the waiting list, and that if this does not occur, the patient should contact the relevant unit. She further recommended that the booking process be reviewed, to ensure that actions taken by administrative staff in response to contact from the patient, be logged and followed up.

Treatment in emergency department

A man made a complaint about the circumstances of his mother’s death after she had presented to hospital following a fall. The man alleged the hospital discharged his mother on the same day as the fall without diagnosing a fracture, and encouraged his mother to keep moving and see her GP for review. His mother was subsequently found unresponsive and she was taken to hospital where she died the following day. The man was seeking an explanation about the circumstances relating to his mother’s death, a review of procedures or further training, and an apology.

The Commission invited the hospital to respond to the concerns raised by the man. The hospital acknowledged that a fracture had been diagnosed however the woman’s treating doctor was not aware that the x-ray had been reviewed by a radiologist and a report was available prior to discharge.

The treating doctor made a provisional diagnosis of musculoskeletal injury based on physical assessment and review of the x-ray films. The hospital considered that the woman was appropriately assessed as being able to mobilise and was suitable for discharge with pain relief and planned review with the GP. The man disputed aspects of the hospital response particularly in relation to suitability for discharge. The matter was referred to conciliation where the matter was able to be resolved.

Regulatory action taken regarding a nurse

A woman complained that while her son was being treated in hospital for an infection, his IV dislodged resulting in an injury. The woman complained that the IV site wasn’t checked often enough, and that the injury was not managed appropriately. The woman said that a nurse who was responsible for her son’s treatment for an extended period of time did not check his IV site despite her raising concerns about it.

The Commission sought responses from the hospital and the nurse and reviewed clinical records and relevant policy and procedure documents. The Commission identified that while there was no relevant guideline to inform the nurse’s immediate management following the injury, she did not follow the relevant hospital procedure by failing to check the cannula site prior to administering antibiotics.

Following joint consideration with the Nursing and Midwifery Board, relevant regulatory action was taken against the nurse.

Falls in an emergency department

A daughter made a complaint against a hospital on behalf of her mother. She reported her mother attended an emergency department where she fell twice when she was taken to the bathroom by a nurse in a wheelchair. The daughter reported the two falls resulted in her mother breaking her arm and her hip.

The complaint resolved with an agreement that the hospital would cover the costs of home physiotherapy sessions and provide other necessary equipment.

Billing practices

A man contacted the Commission to raise concerns of billing practices by a dental prosthetist. The man said he was not provided with a quote prior to the treatment being performed. After the appointment, he was given a business card with the amount owing hand written on it and directions to go to a particular bank shopfront to deposit the money directly into the practitioner’s account. After writing a letter to the practitioner, the man was sent a proper invoice.

After receiving a response from the practitioner including the clinical records, the matter was jointly considered by the Commission and AHPRA. Regulatory action was taken against the prosthetist. The Commission then facilitated settlement of the complaint and a partial reimbursement was received by the complainant.

Inappropriate prescription of antibiotics

The Commission received a complaint from a man who had taken his unwell child to the GP. The GP identified the child likely had a viral illness, requested a sample be collected for pathology, and recommended simple management which included pain relief and oral fluids. The child did not improve, and two days later the child was again brought to the same GP. The pathology results were not yet available, but the GP decided to prescribe antibiotics without waiting for the results.

The child’s condition deteriorated, and he was taken to hospital. His family was advised that the antibiotics were inappropriate for his condition and may in fact have worsened the child’s symptoms.

On receipt of the complaint the GP acknowledged his error. He advised that it was not his usual practice to prescribe antibiotics without first having pathology results to inform his management. The GP advised that he was aware of a significant bacterial infection in the community at the time, which is why he prescribed antibiotics in this instance.

The family accepted the response received from the GP. The Australian Health Practitioner Regulation Agency (AHPRA) was notified, and the complaint was jointly considered by the Commissioner and the Medical Board. The decision reached was to take no further action against the GP.