International Journal for Quality in Health Care Advance Access published January 29, 2016

International Journal for Quality in Health Care, 2016, 1–6

doi: 10.1093/intqhc/mzw003
Article

Article

Patient complaints about hospital services:

applying a complaint taxonomy to analyse
and respond to complaints
REEMA HARRISON1, MERRILYN WALTON1, JUDITH HEALY2,
JENNIFER SMITH-MERRY3, and COLETTA HOBBS1
1
School of Public Health, University of Sydney, Edward Ford Building, Sydney, NSW 2006, Australia, 2Research School
of Pacific and Asian Studies, Australian National University, Canberra, Australian Capital Territory 0200, Australia, and
3
Faculty of Health Sciences, University of Sydney, Edward Ford Building, Sydney, NSW 2006, Australia
Address reprint requests to: Reema Harrison, Room 314, Edward Ford Building, University of Sydney, Sydney, NSW 2006,
Australia. Tel: +61-2-9036-7826; E-mail: reema.harrison@sydney.edu.au
Accepted 1 January 2016

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Abstract
Objective: To explore the applicability of a patient complaint taxonomy to data on serious complaint
cases.
Design: Qualitative descriptive study.
Setting: Complaints made to the New South Wales (NSW) Health Care Complaints Commission,
Australia between 2005 and 2010.
Participants: All 138 cases of serious complaints by patients about public hospitals and other health
facilities investigated in the 5-year period.
Main Outcome Measure: A thematic analysis of the complaints was conducted to identify particular
complaint issues and the Reader et al. (Patient complaints in healthcare systems: a systematic review
and coding taxonomy. BMJ Qual Saf 2014;23:678–89.) patient complaint taxonomy was then used to
classify these issues into categories and sub-categories.
Results: The 138 investigated cases revealed 223 complaint issues. Complaint issues were distribu-
ted into the three domains of the patient complaint taxonomy: clinical, management and relation-
ships. Complaint issue most commonly related to delayed diagnosis, misdiagnosis, medication
errors, inadequate examinations, inadequate/nil treatment and quality of care including nursing care.
Conclusions: The types of complaints from patients about their healthcare investigated by the NSW
Commission were similar to those received by other patient complaint entities in Australia and
worldwide. The application of a standard taxonomy to large numbers of complaints cases from dif-
ferent sources would enable the creation of aggregated data. Such data would have better statistical
capacity to identify common safety and quality healthcare problems and so point to important areas
for improvement. Some conceptual challenges in devising and using a taxonomy must be
addressed, such as inherent problems in ensuring coding consistency, and giving greater weight
to patient concerns about their treatment.

Key words: patient complaint, patient safety, quality of health care, patient satisfaction, classification

© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved 1
2 Harrison et al.
Introduction
Complaints from patients and/or their carers are important indicators
of problems in a healthcare system [1]. The patient perspective is im-
portant because users of health services may have a different view of
problems to those reported by health professionals in the adverse in-
cident reporting systems that are now routine practice in many coun-
tries [2, 3]. Complaints from patients often relate to safety and service
quality problems in their care [4–6], as well as concerns about
treatment and poor communication with health professionals [3].
Complaints by patients therefore provide a distinctive, large and ex-
panding pool of data. For example, in 2013–14 the National Health
Service (NHS) for England received over 175 000 written complaints
from patients; the equivalent of 479.1 complaints per day [7]. Patient
complaints to the independent health ombudsmen/complaints com-
missioners in the eight states and territories of Australia have increased
annually with 4767 written complaints received in 2013 [8, 9].
In a strong safety culture, patient complaints are recorded and sys-
tematically analysed; they enable healthcare organizations to identify
weaknesses in the way services are delivered and so point to areas that
call for improvement and perhaps extra resources [1]. Inadequate
complaint management by service providers has led to high profile in-
vestigations, such as the Mid-Staffordshire NHS Foundation Trust
Public Inquiry in England, and the New South Wales (NSW) Minister-
ial Inquiry into unregulated cosmetic surgery in Australia [1, 10, 11].
In such cases, the failure to listen to patient concerns and then to im-
plement reforms led to major quality and safety failures [12].
Whilst mechanisms for managing and responding to health
complaints by patients are now part of the regulatory landscape
in most countries, complaints are categorized differently in different
health systems and different countries, making it difficult to make com-
parisons and draw conclusions. Complaint categorization also varies
within countries. For example, healthcare complaints commissions in
the eight Australian states and territories vary in their classification
of complaint types, which hinders the development of a national policy
approach [13]. An accepted taxonomy applied nationally and inter-
nationally to categorize and analyse complaints would help make health
services more accountable to patients, and also would offer a patient-
centred strategy for improving the safety and quality of healthcare.
A taxonomy enables the ‘categorization of . . . information using
standardized sets of concepts with agreed definitions, preferred terms,
and the relationships between them based on an explicit domain
ontology. It is designed to facilitate the description, comparison,
measurement, monitoring, analysis and interpretation of information’
[14] Applying a standardized taxonomy to patient complaints has the
potential to identify consistent problems arising in care [6]. This re-
quires aggregated data that offer sufficient statistical power to explore
problems and trends and so inform policy and practice. This analytic
approach is widely used in adverse event reporting systems based on
reports made by health service staff but is not routinely used in analys-
ing complaints made by patients [15–17]. The WHO International
Classification for Patient Safety demonstrates the value of an agree-
ment on key patient safety terms as a method for collecting and aggre-
gating data in order to compare findings, identify priorities and
develop wide-reaching patient safety solutions [15, 18–20].
While various complaint taxonomies exist, they have not been
externally validated and routinely used in the analysis of patient
complaints [6, 21]. The recently published taxonomy by Reader
et al. [6, 21] is useful because it is based on a systematic review
of the complaints literature. This taxonomy categorizes patient com-
plaints into three conceptual domains: (i) safety and quality of clinical
care, (ii) management of healthcare organizations and (iii) problems in
staff–patient relationships [6]. Within each domain are categories and
sub-categories for particular complaint types; there are 7 categories
and 26 sub-categories in total. The present study applies this tax-
onomy to explore the nature of serious complaints investigated in
NSW from 2005 to 2010, describes the resulting recommendations,
comments on the applicability of this taxonomy to NSW data.
Methods
Ethical approval
The Human Research Ethics Committee at the University of Sydney
granted ethics approval. Western Sydney Local Health District
(LHD) also approved this study as part of a larger multi-site project.
Data source
The NSW Health Care Complaints Commission (HCCC) provided
the authors with de-identified details of 138 serious complaints
made by public hospital patients (61% of all complaints including
those that were not classified as serious) investigated between January
2005 and June 2010 (5.5 years) as part of a larger project funded by
the Australian Research Council exploring patient complaints, Com-
mission recommendations and their implementation. Data included
details of the nature of the complaint, the hospital or service type re-
lating to the complaint, the complaint summary, and the recommen-
dations arising from the investigation. The NSW HCCC is obliged
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under its legislation to formally investigate serious complaints, defined
as ‘complaints that may require notification to external bodies such as
insurers or regulatory bodies’ [22].
Analysis
The Reader et al. taxonomy, being based on a systematic literature re-
view, was selected as a potential viable framework to analyse patient
complaints. Complaint cases were provided to the team by the HCCC
as brief passages describing the issues raised. Passages varied in length
but were no more than 150 words. The Reader et al. [6] taxonomy was
used as a guide for labelling each issue and its sub-category. One pa-
tient safety researcher with a background in Health Psychology (R.H.)
and understanding of the context of the field read each complaint case
alongside the Reader et al. framework and applied a basic content
analysis adapted from the six-step approach identified by Zhang
and Wildemuth [23]. The unit of analysis was the complaint cases pro-
vided by the HCCC and analysis involved identifying and grouping
the one or more complaint issues arising in each case based on a cod-
ing scheme derived from the complaint issues included in the existing
taxonomy [23]. The researcher remained vigilant throughout the cod-
ing process to any complaint issues not included in the taxonomy.
Each complaint case and the labels applied were logged in an MS
Excel file as a way to manage the coding process. In order to check
coding validity (whether a category appeared to measure what it is
supposed to measure), and coder reliability (the extent to which assess-
ment was consistent), a second researcher (J.S.M.) coded 10% of the
complaint cases (14 cases), which included 35 complaint issues and
found substantial agreement (κ = 0.92) [23].
Results
The HCCC data covered 138 serious complaint investigations for
the 5-year period. From these anonymized case data records, 223
Patient complaints about hospital services
complaint issues were identified; a mean of 1.62 complaint issues
per case. These complaints involved 67 public hospitals (including a
small number of day facilities). As these 138 cases involved serious com-
plaints, the outcomes of the events leading to the complaint were substan-
tial and included: death (38%), death from suicide (3%), life-threatening
harm (12%), permanent serious harm (4%) and non-permanent serious
harm (15%). The remainder of cases also were serious matters but the
records lacked detail about patient outcome (28%).
Table 1 sets out the typology with its three tiers of domains, cat-
egories, sub-categories and the complaint issues used by Reader
et al. Complaint issues were assigned into the three domains: clinical
(68%), management (19%) and relationships (13%). Most complaint
issues were associated with the categories of Quality (n = 86) and
Safety (n = 66), and with the sub-categories of ‘Quality Care’ (n = 39),
‘Delays’ (n = 26) and ‘Skills and Conduct’ (n = 26). Substantial num-
bers of complaint issues were also identified in relation to the sub-
categories of ‘Treatment’ (n − 22), ‘Examinations’ (n = 22) or ‘Error
in Diagnosis’ (n = 21).
On closer inspection of complaint issues, a substantial proportion
(35%) could be described as problems relating to patients’ treatment.
The 22 complaint issues (9.8%) under the ‘Treatment’ subcategory
therefore under-represent the number that could be classified in this
category. Based on the types of complaints classified as ‘treatment is-
sues’ by the NSW HCCC, complaint issues considered as related to
treatment are marked by asterisk in Table 1. Treatment issues include
delayed diagnosis, misdiagnosis, medication errors, inadequate/nil ex-
aminations, lack of treatment and neglect.
The HCCC made 453 recommendations calling for systemic im-
provements to hospital services arising from their investigations into
these 138 serious cases, classified under 7 headings: (i) develop or im-
plement guidelines or policies; (ii) education, training and/or counsel-
ling, (iii) review guidelines, policies and protocols, (iv) audit services,
(v) improve physical or administrative environment, (vi) define roles
and responsibilities and (vii) provide information to patients about
the risks and benefits of conditions or services. In most cases more
than one recommendation was made in relation to a case (on average
3.3 recommendations per case). The HCCC made recommendations
for each complaint case rather than for the specific complaint issues
within each; therefore, it was not possible to study the link between
type of recommendation and complaint issues or category.
Discussion
Our study results indicate that patient complaints in NSW did fit into
the three domains proposed in the Reader et al. taxonomy: clinical,
managerial and relationships (interpersonal). The application of a
complaint taxonomy therefore was useful for classifying complaints
data and highlighting problem areas. But a major shortcoming of
this taxonomy relates to validity of measurement: in particular,
many issues associated with clinical treatment were dispersed across
the domains.
While Reader et al. report that ‘treatment (16.6%) was a common
complaint issue, this category accounted for a much higher proportion
in the NSW data [6]. Our analysis showed that clinical complaints re-
lating to treatment, such as delayed diagnosis, misdiagnosis, medica-
tion errors and poor examinations accounted for 35% of complaint
issues, which is consonant with findings from other Australian com-
plaint entities. For example, Walton et al. [13] reported ‘treatment is-
sues’ as the most common cause of complaint across Australian
healthcare complaints commissions. Annual reports of the HCCC
also reveal treatment complaints remain the most significant [24].
3
For example, Taylor et al. [25] identified nearly 33% of emergency de-
partment complaints as treatment-related.
While Reader et al. report that ‘communication’ (13.7%) also was
a common complaint issue, our study finding was that only 10% of
issues related to communication [6]. This differs from the substantial
literature that reports major problems in staff–patient relationships
and in communications between staff and with patients [25–27].
A large literature on complaints asserts that patients are unhappy
with service quality issues, such as poor coordination of care, staff at-
titudes and behaviour [1, 25, 28]. Taylor et al. [25] identified nearly
32% of emergency department complaints as communication issues.
Analyses of patient complaints in Singapore and Sweden also report
the top causes of patient grievances as staff–patient communication,
rude and aggressive behaviour or feeling ignored [26, 27]. The con-
flicting findings may reflect the taxonomy used to categorize com-
plaints in each of the studies, but also be due to the focus on serious
complaints only in our study. In addition, recent review findings indi-
cate that the perceived impact of health professionals’ interpersonal
behaviours on the quality of patient care may be dependent on pa-
tients’ backgrounds, needs, demands and preferences [29].
While a coding taxonomy enables better measurement, the appli-
cation of a rigid set of labels to complex and nuanced complaint cases
may not accurately capture the full spectrum of issues. Our analysis
revealed that many complaint issues were inter-related, demonstrating
the multi-faceted nature of complaints and the complexity associated
with their coding and analysis [9]. For example, complaint cases may
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be recorded variously; some records detailed a number of issues while
others noted only the main issue. Therefore, it is likely that many com-
plaint issues were not captured in this analysis of HCCC data.
The communication and interpersonal issues present particular
coding difficulties in relation to validity and reliability as many pro-
blems arising in care contain a communication element. Several exam-
ples when applying the Reader et al. [6] taxonomy demonstrate such
coding ambiguities. The labels ‘Communication delay’, ‘Delay in ad-
mission’ or ‘Delay in treatment,’ could be applied interchangeably, de-
pending on the recorded description and sequence of events. Once an
issue is labelled as a delay in admission or treatment, it could be
classed in the domain of either ‘Management’ or ‘Relationship’.
Such labelling issues may go some way to explaining the low propor-
tion of ‘Relationship’ complaints in our analysis.
Such examples also raise the lack of temporal distinction between
prior causal factors and a complaint event in the Reader et al. tax-
onomy. For example, a complaint issue may be classified as an adverse
event in the shape of a ‘medication error’ or it may be classified as the
prior ‘inadequate communication’ that led to the event occurring.
Multiple coding may enable complaint issues to be coded to more
than one category in the taxonomy. A problem is that coding multiple
complaint issues for every complaint case, rather than identifying a
‘primary’ issue, may reduce the clarity of the information produced
from a taxonomy.
Broad subcategories and labels that are subjective, such as ‘inad-
equate treatment’ or ‘inadequate communication’, are also problemat-
ic and could be recorded and coded inconsistently. However, the
challenge of subjectivity in applying a taxonomy is not unique to com-
plaints data, but is also a challenge for the classification of patient
safety incidents and the use of taxonomies generally [30].
Implications
Notwithstanding patient safety initiatives, complaints by patients
about their treatment remain frequent [24]. The routine collection
4 Harrison et al.

Table 1 Categorization of complaint issue using the Reader et al. [6] taxonomy

Domain Category Subcategory Complaint issue No. of issues Total

a
Clinical (n = 152, 68% Safety (66) Error in diagnosis Diagnostic procedures 1 21
of total complaint issues) Misdiagnosisa 11
Missed diagnosisa 7
Triagea 2
Medication errors Medication errors 13 16
Prescribing 3
Safety incidents Equipment failure 3 3
Skills and conduct Incompetencea 1 26
Inexperienced staff 3
Negligencea 1
Poor clinical leadership 4
Poor staff team working 6
Technical skills 5
Unprofessional conduct 3
Unqualified staff’a 1
Unsuitable staff 2
Quality (86) Examinations Failure to investigatea 11 22
Poor investigationa 11
Patient journey Poor future planning 3 3
Quality care Absence of due care 4 39
Care quality 19
Care/treatmenta 4
Nursing care 11
Health service care 1
Treatment Inadequate/inappropriate treatmenta 5 22

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Management (n = 43, 19%
of total complaint issues)
Relationships (n = 28, 13%
of total complaint issues)
Total
Institutional issues (13) Bureaucracy
Environment
Service issues
Staffing
Timing and access (30) Delays
Patient discharge
Communication (24) Communication breakdown
Incorrect information
Patient-staff dialogue
Humaneness/caring (4) Respect, dignity and caring
Patient rights (4) Consent
Incorrect treatmenta 4
Non-performance of treatmenta 12
Poor treatment plana 1
Grievance handling 1 1
Accommodation 1 1
Medical records 9 10
Transport 1
Staffing 1 1
Delay in admissiona 1 26
Delay in diagnosisa 15
Delay in ED admissiona 1
Delay in treatmenta 7
Timelinessa 1
Waiting time 1
Patient discharge 4 4
Communication delay 3 10
Lack of communication 4
Poor conversation skills 1
Inadequate communication 2
Inaccurate information 1 2
Conflicting information 1
Decision sharing 1 8
Doctor–patient 1
relationship 1
Insufficient participation 5
Not listening
Neglecta 1 4
Respect and caring 3
Problems in consent 4 4
223

a
Treatment issue.

of standardized data using common terminology is the cornerstone of healthcare complaints managers and policy makers to recognize pat-
learning and change following health system failure [31]. Using a stan- terns of complaints and therefore develop targeted recommendations
dardized taxonomy to categorize and analyse healthcare complaints is and interventions. Importantly, this approach is more likely to identify
therefore important for improving care quality. A taxonomy enables and address the systems issues that often underpin related quality and
Patient complaints about hospital services
safety-related problems [32]. Any analysis of recommendations would
need more database detail, but a better complaints taxonomy is likely
to facilitate decisions about and analysis of recommendations.
The taxonomy was well-suited in its application to these serious
complaints data as many of these types of complaint were linked to
safety concerns. The clinical, managerial and relationship domains
were therefore relevant and appropriate. However, the taxonomy
did not enable enough specificity in the categorization of the many
treatment issues identified in our data. Table 1 shows there were 20
types of issues associated with ‘treatment’ currently scattered across
the typology. One solution to this problem may be to elevate the
‘Treatment’ sub-category to a category or to a domain. The taxonomy
currently does not capture the broad spectrum of complaint issues that
go beyond safety concerns. This presents a particular problem for ap-
plying the taxonomy to general complaints data rather than serious
complaints. Complaints are not submitted on standardized forms;
they are submitted verbally, in writing and often via a series of com-
munications with the healthcare provider. The vast array of formats in
which complaints are received creates further challenges for coding
complaints in a way that can facilitate system learning. The collection
and analysis of adverse events in many countries now requires health
professionals to complete a standardized incident reporting form to fa-
cilitate the categorization of incidents [33, 34]. A similar approach in the
capture of complaints data may create more comparable data that will
facilitate system learning. Such an approach however would require the
provision of support from healthcare providers to patients and carers
wishing to make a complaint and raises the issue of resource.
In the present study, we focus only on serious complaints, which is
likely to have influenced the complaints categories most commonly
identified. Complaint coding taxonomies may benefit from taking
into account the severity of the event given the divergent nature of pa-
tient complaints that include problems experienced from the quality of
food provision to the handling of serious adverse events. Countries
such as the UK and Australia apply risk matrices that provide a process
by which to categorize the severity of an adverse event based on its
outcome and likelihood of occurrence [35, 36]. A similar strategy
may be valuable in the context of complaints coding.
Limitations
Our findings must be considered in the context of the study limita-
tions. Serious patient complaints investigated by the HCCC only
represent a small proportion of patient complaints arising in health-
care. Most patients make no complaint even if they are not happy
about the health care they received, while others may complain direct-
ly to the hospitals. Engaging with health professionals and patients
should produce a better fit between complaints and a complaints tax-
onomy. Methodological limitations must also be acknowledged. The
taxonomy was assessed for reviewer/coder reliability in only a small
number of cases. The further development of a taxonomy calls for a
larger test of its validity and reliability.
Conclusion
Despite significant investment in improving safety and quality in
health care, patients continue to complain about the health services
that they receive. The routine collection of standardized data for pa-
tient complaints using common terminology would be a big step for-
ward to facilitate the use of valuable data to improve patient safety and
care quality. Refinements to current taxonomies are required to
address the challenges of nuanced and complex complaints data.
5
We suggest such a taxonomy assign more prominence to ‘treatment’
complaints as a first step.
Acknowledgements
The authors thank the New South Wales Heath Care Complaints Commission
for providing the data for this analysis.
Funding
This study was funded by an Australian Research Council (ARC) Discovery
Grant DP1093048: “Resolving patients’ complaints about hospitals: responsive
regulation by health ombudsmen.”
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