What are investigations all about? An investigator's perspective
Over the years the process of investigating a complaint has changed considerably, but, fundamentally, investigating a complaint is about resolving the issues, not finding someone “guilty” or “not guilty”. Sometimes bringing about resolution is not easy.
Recently I completed an investigation of a complaint by the family of a much-loved mother against the rest home that cared for her. The family’s complaint covered a number of issues about the care Mother received, but my main concern was the possibility that she might have been abused. Mother was found to have a fractured femur, which led to amputation. She subsequently died from complications following the surgery. There was no evidence of how the fracture had occurred, and the family was convinced that Mother had been dropped and the incident not reported.
As part of this investigation, I obtained expert advice and, in particular, an explanation of the differences between pathological and acute fractures. I hoped Mother’s family would be comforted by our expert’s explanation of pathological fractures and our finding that there was no evidence that Mother had been abused by those caring for her. Unfortunately, our expert’s explanation provided little comfort. The family claimed that they had known we would come to such a conclusion because it had taken us five months to decide to investigate and because doctors always stick together anyway. In this case, it may have been helpful for the family to have taken up the Commissioner’s offer of the option of mediation – to have talked through their concerns with staff from the rest home who had been involved in Mother’s care, with a view to sharing with them their feelings about what had happened. The investigation eventually closed with the rest home being found to have breached the Code in relation to shortcomings in its communication with the family.
Investigations are about telling people’s stories, albeit tragic stories. As investigators, we have to be very careful not to cultivate unrealistic expectations that we subsequently cannot fulfil. Many complainants put their lives on hold during an investigation, and it is not unusual to commence an investigation of events that occurred one or more years beforehand. Many providers probably put their lives on hold also, once an investigation commences.
How do we handle this challenge? There are no magic answers. However, I make a point of listening to my colleagues, talking the investigation process through with complainants, clarifying information obtained from providers, and encouraging the parties to contact me with any questions. I think it is also helpful for everyone going through an investigation – be it consumer, complainant or provider – to have one person in the organisation to contact and consult.
Investigations are about impartiality. Where possible we obtain information from all the parties, and clarify conflicting information by talking, listening, reading medical records, consulting professional standards and obtaining the advice of relevant experts. We plan, consult and explore ideas with our colleagues, including, when appropriate, with legal advisors. The information is considered and analysed to determine whether the facts suggest that there has been a breach of the Code.
We then write the ‘story’ of the case to go to the Commissioner for his opinion. We consider how best to present the information: do the facts suggest Breach/No breach/No further action/Mediation? Would the parties be better served if the Commissioner’s opinion is by letter or in a report? Is there any educational value in the case? How should the report be given to the complainants – will it be suitable to send it by post or should we arrange for a third party to be there? If it is a breach report, is the employer also culpable, and should the case be referred to the Director of Proceedings for consideration of formal disciplinary charges?
Regardless of whether or not the outcome is a breach finding, it is important that the investigation uncovers what occurred, and why, so that the people involved – and other health and disability services providers in the community – can learn from the events.