Pre-amble:

• Introduce yourself and your role:
• Check for support: “Would you like anyone to be with you for this conversation?”
• Assess understanding: “Can you tell me what you already know about what’s happened so far?”
  
  

Tell them of adverse event:

• “As part of [patient’s name]’s care, there has been a complication. I want to tell you about what happened and explain how we’re making sure [he/she/they] remain safe.”

Allow their response:

• Apologise 
• Acknowledge distress
  • “I’m really sorry for what’s happened. I can see this has been very upsetting for you.”
• Get their version of events first:
  • “Tell me what happened from your perspective.”
  • “Can you tell me about your concerns?”
    

Discussion of the Event:

• PAST – Factual Account of Events:
  • Provide a clear, concise, and honest summary.
  • “With any procedure, there is always a risk involved. We always weigh those risks against the need for the intervention. Unfortunately, your mother suffered a rare event.”
    
    
• PRESENT – Current Situation:
  • “Right now, the situation is [X], and we are treating it with [current management].”
    
    
• FUTURE – Next Steps and Error Management:
  • Multi-factorial
  • Incident report + investigation
  • Improvements 
  • Feedback to complainant (written, timeframe)

• “We will undertake a full investigation into what happened.”
• “I agree, this is a serious error. We will investigate all aspects of this"
  
• “We know that errors almost never occur because of one person. They usually result from a series of breakdowns within the system or the safety processes we have in place.”
• “We will complete an incident report, and there will be a formal review process to identify what can be improved.”
• “You will receive written feedback once the investigation is completed, and we will give you a timeframe for that.”
• “I’d like to put you in touch with our Patient Liaison Officer. If you would like to make a formal complaint, I will fully support you in doing that.”

ADMIN QUESTION ON ADVERSE EVENTS

Categories of adverse events - REACT:

• R – Rights: consent, confidentiality breaches
• E – Environment: poor conditions (e.g. cold, no food, overcrowded, inadequate facilities)
• A – Access: long waits, perceived inequity in care
• C – Communication: poor explanations, lack of empathy, perceived rudeness
• T – Treatment: clinical errors or perceived suboptimal care

Contributors to Adverse Events:

• System Factors
  • Overcrowding
  • Access block
  • Poor processes
  • Inadequate supervision
  • Absence of clear guidelines or protocols
    
    
• Process Factors:
  • Excessive workload
  • Inefficient communication pathways
  • Inadequate escalation procedures
    
    
• Individual Factors:
  • Clinical skill gaps
  • Poor communication or documentation
  • Hazardous attitudes (e.g. overconfidence, fatigue, reluctance to seek help)