Why clinical claims occur and how to avoid them

In this article, Dr Karen Power examines some of the common features seen in the SCA’s portfolio of clinical claims.

Learning from adverse outcomes in health and social care is critical to advancing a culture of patient safety and reducing the likelihood of future harm to service users. The SCA is uniquely positioned to analyse claims at national level and to share that learning.

What type of adverse incidents results in claims?

Clinical claims frequently arise due to diagnostic error (delayed, missed or misdiagnosis) often leading to delayed or incorrect treatment, or as a result of a range of adverse outcomes related to treatment or therapeutic intervention (Table 1).

Table 1: Examples of incidents resulting in claims

Examples of claims related to diagnostic error	Examples of claims related to therapeutic interventions
Missed diagnosis or delayed diagnosis e.g. of cancer, of lesions on imaging, of fractures, of appendicitis, of abdominal aortic aneurysm	Complications of surgery e.g. damage to nerves or vessels, damage to adjacent organs, venous thromboembolism
Misdiagnosis e.g. the misdiagnosis of severe infections such as meningitis or endocarditis as viral infections	Retained foreign objects e.g. retained swabs/sponges during surgery
Related to delivery e.g. incorrect CTG interpretation	Medication error e.g. administration of a contraindicated medication
	Delayed treatment e.g. delayed referral to specialist services
	Related to delivery e.g. incidents resulting in hypoxic ischaemic encephalopathy, shoulder dystocia, sphincter injury

Examples of claims related to diagnostic error

Examples of claims related to therapeutic interventions

Missed diagnosis or delayed diagnosis

e.g. of cancer, of lesions on imaging, of fractures, of appendicitis, of abdominal aortic aneurysm

Complications of surgery

e.g. damage to nerves or vessels, damage to adjacent organs, venous thromboembolism

Misdiagnosis

e.g. the misdiagnosis of severe infections such as meningitis or endocarditis as viral infections

Retained foreign objects

e.g. retained swabs/sponges during surgery

Related to delivery

e.g. incorrect CTG interpretation

Medication error

e.g. administration of a contraindicated medication

Delayed treatment

e.g. delayed referral to specialist services

Related to delivery

e.g. incidents resulting in hypoxic ischaemic encephalopathy, shoulder dystocia, sphincter injury

Although all procedures carry the risk of complications, claims may arise if there is an allegation that technique was sub-standard, if the plaintiff alleges they were not made aware of the potential complication, or if there is insufficient documented evidence of consent.

Why do clinical claims occur?

As well as knowing what results in claims, it is just as important to understand why they occur, i.e., what factors lead to the adverse outcome, which results in a claim. Some of the common factors resulting in claims are presented in Table 2. Claims rarely arise due to one single error; more usually several factors can contribute.

Table 2: Common factors contributing to claims

Common factors contributing to claims
Communication	Substandard/omitted consent Unsigned, illegible or absent entries in the healthcare record Inadequate or substandard communication between colleagues and with service users Inadequate communication between teams and services when transferring care
Monitoring	Failure to recognise a deteriorating service user or the seriousness of a service user’s condition Failure to act on abnormal findings or to escalate as appropriate
Diagnostic tests	Delayed performance of diagnostic tests or investigations Failure to follow-up on diagnostic tests
Therapeutic interventions	Delay in initiating treatment Inappropriate deviation from good practice/clinical guidelines Inadequate training for, or familiarity with, an intervention

Lessons for patient safety?

Get communication right

All healthcare staff should consider enhancing their communication skills through training.
Consent should include discussing with the service user the risks, benefits and alternatives of treatments and interventions and documenting those discussions
Clear and comprehensive documentation enables effective communication between professionals and significantly enhances the chances of being able to successfully defend a claim.
Particular attention should be paid to communication when care is being transferred between teams and services. The use of communication tools such as ISBAR /ISBAR3 and huddles should be considered.
All staff should be aware local escalation processes and protocols and be empowered to use them.

Match skills and competence to the task at hand

Those undertaking diagnostic or therapeutic procedures should have the knowledge/skills and competency suitable to the task and be aware of good practice/clinical guidelines.
Junior staff should be supervised appropriately and empowered to call for assistance when necessary.

Follow up and action test results

Those ordering tests should check the result and ensure that the appropriate follow-up action is undertaken. Don’t assume someone else will check the result of a test you’ve ordered.

Build a culture of learning and transparency

Report incidents accurately and promptly to the National Incident Management System (NIMS)
Undertake appropriate reviews and upload them to NIMS
Complete and record Open Disclosure in accordance with the HSE’s Open Disclosure policy

References available on request

Clinical Risk Insights

View more articles from the latest edition of Clinical Risk Insights by the State Claims Agency.