Mr Ian Thurgood
Director
Complaint Assessment Branch
Health Care Complaints Commission
Locked Mail Bag 18
Strawberry Hills NSW 2012
12 April 2010
Dear Mr Thurgood,
Thank you for your response to my complaint in which I act as an advocate for the late Ms B P. On the basis of the information provided in your response I wish to request a review of the decision the Commission has taken for not proceeding.
I must confess that I remain appalled at the way in which the SSWAHS has dealt with this serious complaint and the way in which it dealt with the original complaint made by Ms B P in 2007.
In respect of my complaint lodged with the Commission in November 2009 I made the following statement:
“In late 2007 or early 2008 the person affected and named above was a client of the Bowral Community Mental Health Service. She was being treated by a psychiatrist at the Browne Street Community Mental Health Service with whom she had elected to be treated while she remained residing in her home at Bundanoon. She had formed a good therapeutic relationship with that doctor who, nevertheless, requested care coordination and support be offered to the patient by the local Bowral Mental Health Service.”
In your response you note that I reported that Ms B P had reported her concerns about the alleged professional misconduct by Mrs T K, her assigned care coordinator in late 2007. I recall making a record of Ms P’s exchanges of text messages with me and placing a transcript of the messages in her file, at that time held at the Bowral Community Health Centre. I am unable to confirm the exact dates and the exact content of those text messages because I do not have access to her clinical file. I do note that I did enter the complaint in the NSW Health incident reporting system (IMMS) which would have made it available to the SSWAHS Area Executive and the Area Mental Health Service. A record of the incident and its subsequent management would be available on the electronic history of the incident held by the SSWAHS and NSW Health.
I suggest that if the Commission gained access to the clinical file of Ms BP and of the IMMS report of the alleged incident of professional misconduct they would have a better understanding and timeframe of the events associated with the original complaint made by Ms BP.
Mr Thurgood, there are some issues with the SSWAHS response which, singly and collectively, cause me great concern.
When the issue of the alleged professional misconduct was first raised by Ms B P and lodged with the electronic incident monitoring system, Mrs T K was still employed by SSWAHS. I can confirm that she was asked by me to withdraw from her role as care coordinator to Ms B P as a result of my receiving the texted information which was recorded in the clinical notes. Mrs T K was advised that this was due to a complaint received although she was not informed of the substance of the complaint. She was, however, informed that the complaint would be investigated. Subsequently, Mrs T K resigned from her position in April 2008 and commenced working for the Southern Highlands Division of General Practice, providing clinical services as a registered nurse and psychologist to the present day.
I believe the complaint made by Ms B P to the General Manager’s Unit of Bowral District Hospital on 13 August 2008 was, in part, due to the reluctance of Ms B P to continue to be care coordinated by the Bowral Mental Health Service. The fact that she may have again raised the matter of the earlier allegation of professional misconduct would be, to a reasonable person, indicative that she was not satisfied of the actions of the SSWAHS Executive in general, and of Mr Scott Fanker of the SSWAHS Area Mental Health Service in respect of her earlier complaint.
There was a meeting scheduled by the General Manager of the Bowral District Hospital in late 2007 in response of her earlier complaint. This would suggest that Ms B P’s complaint was seen as having some urgency and there was an attempt then to deal with it before Mrs T K resigned in April 2008. It does not surprise me that Ms B P postponed that meeting due to the fact that she was both emotionally and physically unwell and that she had the support of her treating psychiatrist Dr Kim Nguyen of the Browne Street Mental Health Service in Campbelltown.
With the subsequent diagnosis of the inoperable large cell lung cancer in late 20 08 or early 2009 it could be reasonably assumed that Ms B P would be less preoccupied with the complaint originally made in 2007 and the apparent lack of diligence on the part of Mr Fanker and of SSWAHS and the Area Mental Health Service to deal with the issue of an alleged serious professional misconduct made against Mrs T K.
Mr Thurgood, you note in your response that there was an emailed response to my letter to Ms B P in November 2009. You report her statement about her inoperable cancer and that she had other things to occupy her mind than pursuing the complaint. The email also indicated that her mental state was more stable and that she had been living at her home in Bundanoon since the diagnosis was made. She also makes a pointed statement about her perception of Mr Scott Fanker of the SSWAHS Area Mental Health Service and his actions and attitude to her complaint. A reasonable person could suggest that with her diminished confidence in the processes of complaint resolution in SSWAHS she would be unlikely to take up any offer made by Mr Fanker.
Finally, I find it extraordinary that SSWAHS, with its access to Ms B P’s clinical record and the electronic incident monitoring system could not respond to the Commission’s request for a response in a period of four months, but could only do so a short time after they knew of Ms B P’s death in early February in Bowral District Hospital. A reasonable person would have some difficulty in seeing any serious intent on the part of SSWAHS to deal in a timely way, with diligence and transparency with the Commission’s request for a response and for bringing some appropriate resolution to Ms B P’s first complaint in late 2007.
In summary then, I wish to make the following observations as the basis for my request for a review:
Ø It may be appropriate for the Commission to question why the SSWAHS was unable to respond any earlier than after the death of Ms B P when they appeared to have ready access to the limited information and facts that they appear to have provided to the Commission.
Ø The Commission may wish to ask the SSWAHS Area Mental Health Service why they did not use the services of their Patient Advocate, Mrs Gillian Holt, to visit Ms Pickersgill at her home or to gain further information about the complaint of 2007 and 2008. Mrs Holt lives in the Southern Highlands, is a Carer of a person with a mental illness and has regularly worked with people with a mental illness. This option of interviewing Ms B P does not appear to have been considered by SSWAHS even up to the time of Ms B P’s death in February 2010.
Ø The Commission may wish to consider whether or not SSWAHS attempted to use Ms B P’s treating psychiatrist, Dr Kim Nguyen, a SSWAHS employee who was a person of confidence to Ms B P during her treatment between 2007 and 2009 and possibly to 2010, in order to elicit an understanding of the complaint made by Ms B P.
Ø The Commission may wish to ask SSWAHS why they did not report the alleged professional misconduct of Mrs T K to the Nurse’s and Midwive’s Registration Board and to the Psychologist’s Registration Board as required by the reporting requirements of NSW Health Code of Conduct (9.1).
Ø The Commission may wish to ask the SSWAHS why Mr Scott Fanker and the SSWAHS did not show fairness in dealing with Ms B P’s complaint of 2007/2008 consistently, promptly, transparently and fairly as required by the NSW Code of Conduct (6.1).
Ø The Commission may wish to ask Mr Scott Fanker (SSWAHS)whether his decision and/or professional behaviour to Ms B P was lawful; is in line with the policies of SSWAHS; and whether his decision or behaviour can be justified in terms of public interest and whether it could withstand public examination (NSW Health Code of Conduct 1.1.1; 1.1.2; 1.1.6).
Yours sincerely,
Kevin O’Neill
Socrates reports this information for the information of all who might be concerned about the way in which this Area Health Service treats complaints by the consumers of their health services. You be the judge!