Apologising after a medical or surgical mishap

No doctor goes into work in the morning intending to harm a patient; however, medical errors do and always will occur, occasionally with devastating consequences.

Statutory duties of candour now require clinicians to provide a factual explanation and apologise after a notifiable incident. Following the well-publicised Bawa-Garba case many doctors have become concerned that an apology, especially a written apology admitting fault, could place the clinician in an unfavourable position in subsequent disciplinary or criminal proceedings. For example, a doctor whose error had unfortunately led to a patient’s death might find their apology admitted for evidence in a charge of gross negligence manslaughter.

Saying sorry for a medical error is a doctor’s ethical and professional duty. A proper apology can demonstrate respect and empathy to patients and their family, lessen distress and reduce the risk of subsequent legal action. Conversely, failure to apologise, or an evasive partial apology, may increase the psychological distress and exacerbate a dispute.

Most apologies for medical mishaps are delivered before all the facts behind how an event occurred are fully understood. Speculation regarding causation should always be avoided as these are often unhelpful to all those concerned. The guidance from the Medical Protection Society is helpful in this respect and clearly recommends that clinicians in this unenviable situation should state: ‘I am so sorry that this happened to you’, rather than ‘I am so sorry that this happened to you, and it was my fault because…’.

What are your views? Have you ever been in a situation when you have found it necessary to apologise, or admit fault, to a patient?

Comments (10) Add yours ↓
  1. Christian Brown Urologist

    It is inevitable that this type of situation will happen to anyone reading this article, it has happened to me. Advice can vary but fundamentally patients and their families want information and an explanation, not always blame or money. Often patients just want to understand how the event took place and that it won’t happen to anyone else.

    It’s important to document everything that is said for future reference and explain that the situation will be explored via a formal process within the hospital (Serious Incident Review or Route Course Analysis) and a report will be shared with the family.

    I think it’s ok to say you are sorry and most importantly that you will do your best to fix the problem, involve other specialists if required and offer a transfer of care to another colleague if the patient wants it. The worst thing to do is avoid the patient and hide the issue and not get involved.

    August 8, 2019 Reply
  2. Robyn Webber Consultant urologist

    I would echo Christian’s comments. It is very important to speak to the patient and/or their family as soon as possible. Communicate clearly and take as much ownership of the situation as circumstances (and your hospital managers) will allow. It may feel painful and uncomfortable for you at the time, but if you avoid the patient you may well be storing up problems for yourself for later on. Many patients just want honesty and an explanation, and it is better coming directly from you. And again, as Christian says, document everything (clearly and legibly).

    August 8, 2019 Reply
  3. Christian Barnick Consultant Obstetrician and Gynaecologist

    As medicine has become ever more complex we as doctors cannot be expected to know everything. Sometimes we may also underperform. These issues affect all specialties and create a situation of ‘necessary fallibility’ where it simply isn’t possible to always get everything right. As a result we have all faced situations where there has been a suboptimal outcome and we have to say sorry.
    Normally these events can be mitigated by good systems, communication and team work.
    Saying sorry is not an admission of individual fault and should not be seen as such by either the patient or the doctor. We as doctors have to be honest and open and both parties must understand that when errors occur it is rare that individuals are to blame. More often than not there is a fault in the system and it is this that must be addressed if we are to make progress.

    So, when things go wrong I would suggest we say sorry and that we then reflect not just on how we might have done things differently but also on how the system that we work in could be improved to better support us and help us to avoid similar outcomes.

    August 8, 2019 Reply
  4. Declan Murphy Urologist

    I do agree that expressing remorse is very important. A sincere apology goes a long way.

    August 8, 2019 Reply
  5. Eoin Dinneen Urology Researcher

    As the blog points out, part of the rub here is that it’s a balancing act. The details of each instance will vary and may influence the ‘type’ of apology or the kind of interaction between the medical practitioner and the patient who suffered the mishap. Details that input into this interaction may include; severity of mishap, likelihood of investigation/further action, whether this could have been avoided by different/better practice rather than bad luck, relationship and rapport between doctor-patient, and clinician estimation on the likelihood of complaint, personality type of the clinician. In my view, honesty and sincere, face-to-face apology (where appropriate) will always be of value to all involved. Wouldn’t you want the same?

    August 9, 2019 Reply
  6. Roger Kirby Professor of Urology

    Many very wise comments indeed! Many thanks one and all. I would just particularly reiterate Christian’s phrase “do your best to fix the problem, involve other specialists if required and offer a transfer of care to another colleague if the patient wants it“. In addition don’t be embarrassed to ask for help, and importantly don’t beat yourself up about a mistake or complication. In surgery such difficulties“go with the territory” and happen to us all. Don’t be reluctant or afraid to talk to others about your mishap – bottling up your remorse can result in you becoming the “second victim” – and can consequently impact negatively upon your family and friends. Resilience is all about facing up to these difficult issues, dealing with them, and getting on with your work.

    August 9, 2019 Reply
  7. Natasha Robinson Past President, Patient Safety Section, Royal Society of Medicine

    NHSResolution says ‘Saying sorry: is always the right thing to do; is not an admission of liability; acknowledges that something could have gone better; is the first step to learning from what happened and preventing it recurring.’

    I agree, and believe that this applies whether there has been a recognised significant complication such as a wound dehiscence, or an obvious error such as a retained item, and everything in between. There will always be the risk that a patient assumes a complication to be your ‘fault’, and may wish to take the matter further, but this will be reduced by a genuinely sincere and sympathetic explanation of the facts, and a promise to learn, which is what most patients want, and too few get.

    But it isn’t easy, and we shouldn’t pretend it is. I have known senior and very expert doctors who have found it almost impossible to carry on after a bad outcome, and I would endorse the comments about talking to others and sharing the burden if you possibly can. Take advantage of the wisdom of colleagues. If you suffer in silence then those around you will suffer too, and that includes your patients.

    August 10, 2019 Reply
  8. Peter Rimington Consultant urologist

    I guess the point is we must as doctors assume the attitude best expressed by Natasha Robinson rather than Frank Sinatra in his epochal song, I did it my way!
    There are accidents, mistakes and complications. Some are inexplicable and these puzzle both patient and doctors for expended periods as we run through the “ how on earth… “ scenarios. Mistakes have numerous causes and these need to be carefully considered by the medical team and lessons learnt and widely aired. Complications need to be analysed and audited to ensure the frequency of these events is not outside the accepted norm.
    In every case the patient must be considered an ally and a full clear precise explanation given with an atomic drawings if need be so that they gain insight into what can go wrong and what did actually happen. My urgent advice from this would be to explain and apologise that the desired perfect outcome did not materialise. But do not say or write, I made a mistake. Say I did what I considered to be the correct thing st the time. The difference is that when the reports are read in the coroners court journalists are present. Journalists who, with respect, have no respect for the doctors serving their community, will use this single play of words to label the doctor inept, incompetent or overconfident. The resulting headlines reissued via platforms of social media will haunt you all the days of your life.
    Apologise and mean it. Ensure you do everything you can to enable repair of the damage. Keep in touch with the patient and family if you can. If you are a good doctor who cares for the patient, this will be recognised.

    August 13, 2019 Reply
  9. Michael Kirby Professor

    This is a great rule
    SAY sorry as soon as possible, trying to hide or run away from genuine errors is a recipe for disaster and highly like to end up with a formal complaint in my experience.
    A clear explanation of what went wrong and why is the way to defuse the situation.

    August 13, 2019 Reply
  10. Jenny Vaughan Consultant Neurologist

    Agree with so many of the comments on here but want to say that sometimes whatever you, when things go wrong you may find yourself in the centre of a very worrying investigation. The important thing here is to take very early advice from your defence organisation. Obviously we now must take account of the Duty of Candour but even there it is wise to ensure you have checked any admissions before they are formalised. Doctors can find themselves in a difficult position when admissions were made when they were not under any form of charge. Be aware that any admission is disclosable but try not to let this prevent you from honest conversations with your patients.

    September 1, 2019 Reply

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