Introduction

Mental ill health is prevalent across countries and cultures. However, people with mental ill health often experience discrimination and stigma, as well as violation of their human rights. Previous studies within the research project Human Rights and Patient Complains, where patient complaints about healthcare services were illuminated, identified a need for further research within the area of mental healthcare (Råberus et al. 2019; Sundler et al. 2020). Therefore, the present study was conducted with a focus on patient complaints about mental healthcare, in both hospital and primary healthcare settings, including outpatient and inpatient mental healthcare.

Background

Mental health may be the most neglected aspect of health in both developed and developing countries (Ngui et al. 2010) and the proportion of adults and children with untreated mental ill health and lack of access to care remains high (Kohn et al. 2018). Worldwide, mental healthcare systems differ, particularly between low-, middle-, or high-income countries (Kirmayer & Pedersen 2014; Wainberg et al. 2017). In Sweden, where this study was conducted, the treatment gap is considered relatively low, although the prevalence of mental health problems is high. In 2018, 17% of the Swedish adult population reported mental ill health. A large proportion reported experiencing anxiety (17%), of which 7% reported severe anxiety (The Public Health Agency of Sweden 2019). The Swedish healthcare system aims to ensure equal access to healthcare services for all, as regulated by the Health and Medical Service Act (SFS; 2017:30). The healthcare system is largely tax funded and decentralized. The central government has the overall responsibility for principles and guidelines, while the responsibility for healthcare services lies within each of the Sweden’s 21 regions. Although some healthcare facilities are privately managed, they too are publicly funded. However, access to healthcare is not equal in Sweden, as differences can be seen between urban and rural areas. Challenges related to funding, quality, and efficiency of healthcare services, including shortages of staff, similar to many other welfare states, have been identified.

Mental health and well-being are essential aspects of the right to health. The highest attainable standard of health is a fundamental part of the United Nations Conventions of Human Rights. There is a legal obligation on member states to ensure access to acceptable and affordable mental healthcare services of good quality. Lack of or inadequate treatment and care for patients with mental ill health can result in unmet healthcare needs (Sundler et al. 2020), even in countries such as Sweden, which has a well-developed universal healthcare system. Inequality in the delivery of healthcare services or denial of dignity and autonomy impact on the quality of care. Feelings of powerlessness or neglect due to inadequate or disrespectful communication causes patient suffering (Berglund et al. 2012). Patients’ experience of not being listened to results in mistrust of healthcare services (Wiklund-Gustin 2013). The experiences of healthcare professionals describe that patients with mental ill health may be particularly vulnerable, which can limit their ability to express health concerns (Karesi et al. 2019). Mental health issues are associated with challenges such as stigma, misconceptions, and discrimination, as well as ethical concerns related to inequalities and human rights. An ethical perspective on mental healthcare with respect for individuals and empowerment of all people is called for (Ngui et al. 2010).

Patient complaints can be helpful for healthcare organizations. Formal patient complaints are a valuable source of information for quality improvement and for future development of healthcare services (Thi Thu Ha et al. 2015), as they provide feedback on problems experienced by patients. Healthcare services wanting to improve their practices can be guided by such complaints. However, while necessary to add information to traditional quality and safety reporting systems within healthcare organizations, formal patient complaints are reported to be relatively rare (Gallagher & Mazor 2015; Leape 2002), (Leape 2002). Quality and safety concerns are driving forces behind complaints about healthcare services.

In previous research, patient complaints reported on inadequate medical care, long waiting times, lack of information and communication, and unprofessional attitudes (Bouwman et al. 2016; Catron et al. 2016; Jangland et al. 2009; van Mook et al. 2012). A study on patient complaints about mental healthcare in Finland reported similar areas of patient complaints (Kuosmanen et al. 2008). Despite the dearth of studies on patient complaints in mental healthcare, there are some studies describing experiences from patients with mental ill health in other areas of healthcare (Grandizio et al. 2021; Kuosmanen et al. 2008; Råberus et al. 2019; Sundler et al. 2020). Literature on patient complaints has focused on the number of complaints, areas for complaints and reasons for making a complaint. Further studies are necessary to deepen the understanding of meanings and experiences from patient’s perspectives, particularly related to mental healthcare.

In Sweden, patients and/or relatives who are not satisfied with the healthcare provided can make formal patient complaints. The right to complain is guaranteed by law, and complaints typically pertain to treatment, diagnosis or medication, or the attitudes or actions undertaken by healthcare professionals. When a patient or relative has a complaint, the first recommendation is to contact the healthcare provider in question. Alternatively, a complaint can be made to one of the Patients’ Advisory Committees (PAC) available in each region. The 2017 Health Care Complaints Act (SFS 2017:372) aims to clarify the responsibility of healthcare organizations and PACs and to support the rights of patients and relatives wishing to make complaints. The PACs have no disciplinary role but can assist patients and their relatives with information and advice and ensure that complaints are addressed by the healthcare service in question.

Little is known about formal patient complaints about mental healthcare and patients’ own views. Although key areas of healthcare service delivery in previous research on formal patient complaints has been reported, a pressing need for in-depth knowledge on patient-reported problems related to mental healthcare remains. More knowledge on patient complaints and patients’ experiences of deficits in mental healthcare is needed.

Aim

The aim of this study was to explore the nature and meaning of formal patient complaints about mental healthcare services in one region of Sweden.

Methods

In this study, we used a descriptive design with a qualitative approach. A combination of a purposeful and systematic random sample of 106 formal patient complaints made by patients with mental ill health or their relatives was analysed with a thematic analysis approach based on descriptive phenomenology (Sundler et al. 2019). The COREQ guidelines for publication of qualitative research was used.

Setting and sample

A sample of 106 patient complaints from a total of 297 complaints made over a 6-month period in 2017 on publicly funded mental in- and outpatient healthcare services in Region Västra Götaland, Sweden, serves as the base for this study. Patients and/or relatives in the relevant region originally made the complaints. The patient complaints were made anonymous when handed out from the PACs’ reporting system to the researchers, and no names or other personal information on individual complaints was obtained. The number of complaints was chosen to get a suitable sample with data saturation within the scope of this study and to allow for a qualitative in-depth thematic analysis.

The region served approximately 15 000 inpatient and 650 000 outpatient mental healthcare visits in 2017. The region operates 17 hospitals and 121 healthcare centres which provide healthcare and medical treatment for over 1.7 million people. Some of the healthcare settings included were provided by subcontracted private healthcare facilities. In relation to the total amount of healthcare services provided in the region, the volume of formal patient complaints can be considered quite few. Yet, it reflects complaints statistics on a national level.

The inclusion criteria were patient complaints about primary healthcare services and psychiatric care made from January to June in 2017. These two settings/groups were identified as purposeful with help from the head of the PAC. A systematic random sample was collated from all patient complaints by the head of the PAC. The sample was reviewed for skewedness to check that patient demographics such as age and gender distribution were comparable and representative at a national level for patients seeking help for mental healthcare. When there were more than 40 complaints from either of the two groups of primary healthcare services and psychiatric care, a sampling strategy was chosen to get rich data material with sufficient descriptions from all groups for the in-depth qualitative analysis. Sampling strategies were discussed among researchers and the head of the PAC until consensus was reached about how to best get appropriate data. See Table 1 for the sample and selection from the two groups. The complaints were either made as a written complaint by the patient or a relative, or documented in a written report following a telephone call by an administrator at the region’s patients’ advisory committee (PAC).

Table 1. Overview of the sample of formal patient complaints from primary healthcare services and psychiatric care Number of complaints Included Systematic random sample strategies Primary healthcare services Complaints written by the patient or the relative 9 9 All complaints included Complaints written by an official at the PAC 33 33 All complaints included Psychiatric care Complaints written by the patient or the relative 74 32 Systematic random sample every 2nd day Complaints written by an official at the PAC 181 32 Systematic random sample every 5th day Total number of complaints 297 106 PAC, Patients’ Advisory Committees.

The patients were predominantly female (67%). A majority of the patients (58%) were aged between 20 and 49 years. In 16% of the complaints, patient’s age was not stated. For the distribution of sex and age, see Figure 1.

Age and sex of the patients in the complaints. Age was not stated in 17 complaints.

Data analysis

Data, in the form of complaints in text, were analysed qualitatively to understand and explore the nature of the complaints and meanings. The analysis was inductive and aimed to understand and describe what the complaints were about and the meaning these events have had for patients’ health and care. The analysis followed the approach for thematic analyses based on descriptive phenomenology (Sundler et al. 2019). The descriptive phenomenology used focuses on lived experiences and was grounded in the writings of Husserl and Merleau-Ponty. From this viewpoint, the lifeworld forms the ontological and epistemological foundation when understanding meanings. From this foundation, methodological principals for thematic analysis guides the researcher in text analyses to organize and structure the content in meaningful themes.

The analyses began with a thorough reading and rereading of all text in the complaints until the researchers understood the meanings embedded in the narratives. Meaningful units of text were identified and highlighted. Notes and short descriptive sentences were developed to give meanings preliminary names and content. As the analysis progressed, meanings that were related to each other were compared to identify differences and similarities. Meanings related to each other were organized into patterns. Similarities and differences between meanings were compared and contrasted. Patterns emerged that successively developed into themes. The developing themes were analysed and discussed among the researchers. Themes were compared with the original text material several times to reach trustworthiness in the data. The developed themes were then organized into a descriptive result. The analysis was mainly performed by two of the researchers, and thereafter discussed and validated among all researchers on how meanings were understood and whether meanings and themes were related to the aim and original data. Quotes presented in the findings exemplify complaints made by patients and/or relatives. The number given to each quote corresponds to an anonymous code each complaint received.

Ethical considerations

The Regional Ethics Committee in Gothenburg approved this study (DNo. 951-15). The study complies with the principles declared in The Declaration of Helsinki.

Results The findings reveal challenges with access to mental healthcare and to competent professionals. Experiences from patients with unmet needs and difficulties as well as problems related to lack of continuity and follow-up of care and treatment were described. Patients and relatives reported experiences of being ignored or not taken seriously. The findings are described based on four themes: Lack of access to mental healthcare services and specialist treatment Problems related to unmet needs and difficulties with healthcare staff Insufficient care and treatment and lack of continuity in care Experiences of not been taken seriously or feeling abused Lack of access to mental healthcare services and specialist treatment

Patient complaints described problems regarding access to mental healthcare. The problems reported were related to mental healthcare both within and outside hospital services. Mental ill health affects patient’s everyday lives, causing suffering for patients over a long period. Suffering increased when not getting the healthcare they needed. For instance, patients’ criticized long waiting times for getting a psychiatric consultation, they lacked renewed medical prescriptions when needed, or did not get medical or mental health support when needed. Problems with lack of access to healthcare for persons diagnosed with anxiety, depression, or other mental ill health conditions were described. Patients with neuropsychiatric disorders or addictions were represented in the reporting group.

A patient diagnosed with mental ill health had been treated with medications for several years and now needed additional therapeutic support made the following complaint:

‘But there are problems with getting a psychiatric or psychological consultation, I was told.’ (97)

When the help needed was not forthcoming, the patient’s relatives helped the patient to pay for a private alternative while waiting. At the time of the complaint, several months later, the patient was still waiting for a response from mental healthcare services. Complaints reported on lack of access to specialist treatment from mental healthcare. Situations were described when patients found it troublesome to get access to care when needed and the complaints illustrate how it may not be reasonable to face long waiting times when in urgent need of help.

There were a number of complaints reported about limited access to specialist treatment from mental healthcare in different healthcare settings. A patient reports:

‘I criticise how they run the unit. They have no psychologist or any specialist in this area, only temporarily staff.’ (102)

The patient who made this complaint had been diagnosed with bipolar disorder and attention deficit hyperactivity disorder but had been without necessary help over the previous 2 years. Previous experiences in another health region had been very different and the patient was troubled by limitations in the mental healthcare offered.

Problems with access to neuropsychiatric investigation and long waiting times for such investigations were also described. Patients were denied an investigation when a neuropsychiatric disorder was suspected, or such an investigation was delayed for a long period, in some cases for several years, or the investigation was never completed. The reasons for such delays were described as related to a lack of specialists in psychiatry. For instance, one complaint involved the patient having to wait for more than 3 years for a neuropsychiatric investigation. While waiting, the patient suffered from periods of depression, anxiety, and stress. Lack of investigation has consequences for the patient's health and daily life, making, for example, contacts with different authorities difficult. The patient described a feeling of not being credible to the authorities when not having any diagnoses. Consequently, the patient’s needs were ignored. Limited access to mental healthcare made life more difficult for patients.

Problems related to unmet needs and difficulties with healthcare staff The complaints reported described patients with mental ill health feeling their needs and difficulties were not acknowledged. They described themselves as suffering from mental ill health and neuropsychiatric disorders, often in combination. Multiple problems often made their needs more complex, such as anxiety or depression in combination with low self-esteem or social ability or phobias. Specific needs were described such as patients having difficulties sitting in a waiting room due to social phobia, difficulties with contact over the phone, or social difficulties with communication and non-verbal communication, or of expressing self-needs. Their experiences point to complex needs when diagnosed with mental ill health in combination with neuropsychiatric disorders. A young adult reported that mental healthcare services repeatedly failed to follow-up and extend prescriptions and sick leave certificates, causing increased anxiety and stress. These failings made everyday life troublesome and caused the patient’s mental ill health to deteriorate:

‘I’m on sick leave for my depression. I also have autism. I need help and support for my long-term well-being.’ (108)

Mental ill health can lead to misunderstanding of the patient’s needs and lead to difficulty such as the physician perceiving the patient to be difficult or violent. A patient described having a social phobia. On arrival at the primary healthcare centre, the patient had to wait in a crowded waiting room. When moved to the examination room, the patient had to wait another 15 min for the physician. During the consultation, they discussed therapy and medications and the physician needed to consult a colleague. This meant the patient was left waiting again and became irritated. The patient described:

‘The physician asked why I was angry. Then I was really upset and asked if it was necessary for me to wait that long. The physician flipped out and started to yell at me, saying that it was his right to have a lunchbreak. I cried during the entire consultation and felt even worse when leaving. Are they really allowed to treat a person with borderline, social phobia and panic disorder like that?’ (45)

This example illustrates how a person struggling with mental ill health and/or neuropsychiatric disorders can have additional needs. Patients with anxiety, phobias, or autism, for example, may not cope with changes, waiting times, or adversities that are considered by others to be harmless. The patients' mental ill health can be adversely affected by unforeseen events, changes, or when medicines are changed, jeopardizing the patient's health and ability to function in the situation.

Insufficient care and treatment and lack of continuity in care

Patient complaints described problems about drug treatments, lack of follow-up, problems with side effects, or treatment problems related to incorrect combinations of drugs. In addition, there were experiences of problems with responsibility and coordination for the care, where the complaints made illustrated lack of or unclear responsibility for specific care, or when lack of continuity of staff affected care negatively.

The complaints emphasize deficiencies in the care and treatment for patients. Such deficiencies were deemed a safety risk in some situations. Patients being cared for by specialist psychiatric care or primary healthcare described situations where new medications were prescribed or that prescribed medications were renewed, without any follow-up. Drug treatment was continued and prescriptions renewed without the patient being re-evaluated:

‘Not even a phone call with a request for the patient's condition was made.’ (96)

Another patient described that the patient’s diabetes was not correctly treated while hospitalized in psychiatric care. During involuntary hospitalization following a suicide attempt, the patient needed help with insulin injections. The patient felt that nursing staff treated them disrespectfully when they did not trust the patient’s ability to self-administer the medication. Nor did they administer in accordance with the prescriptions given from the diabetes clinic. Other areas of insufficient care were serious side effects not being noticed, or medical treatments being too quickly administered or incorrectly interrupted, without any reasonable explanations.

Complaints also related to lack in continuity of care leading to feelings of worry and insecurity. Continuity of care related to the number of, and consequences of, meeting different healthcare professionals. For instance, there were reports on the absence of follow-ups or prescriptions of medications when staff ended their employment and nobody took over responsibility for the patient’s care. Patients emphasized the importance of knowing that someone was in charge of their care. It was also described as stressful when not feeling that there was any continuity among professionals:

‘I have to meet a different physician every time. It’s difficult and takes time to feel confident enough to talk to an unknown person about your mental health problems.’ (104)

Having mental ill health was experienced as stigmatizing. The patients reported that mental ill health was difficult to talk about during consultations. They described how telling someone about one’s mental state was more complicated than telling about other illnesses. Thus, mental ill health seemed to make the patients vulnerable in a different way than other patients. Patients preferred to meet the same or a limited number of healthcare professionals. A patient complained about conflicting advice regarding continued medical treatment during pregnancy from different physicians. Initially she was told to immediately cease with the antidepressant medication she had taken for several years but this advice was changed shortly after:

‘I finally got a reassurance that I could continue to take my medication during pregnancy. All these different messages have created a nagging feeling of worry and anxiety. I don’t know who I can trust.’ (51)

Meeting different professionals led to patients receiving contradictory information, which was stressful. Some of the reports related to lack of collaboration between healthcare professionals, even within the same organization, and between different healthcare organizations.

Experiences of not been taken seriously or feeling abused

A plethora of experiences were described from situations where patients felt they had not been listened to, not been taken seriously, or felt violated. The reports included situations where patients felt mistrusted or questioned, leading to upset feelings and conflicts with professionals. Misunderstandings caused problems, even though neither patient nor professional had any negative intentions.

Healthcare professionals made decisions without involving the patient or relatives. In the following illustration, a patient described feeling left out and not listened to during a care-planning meeting. The agenda for the meeting was already set before the meeting:

‘The physician explained that I had recovered and didn’t need help any more. He removed me from the waiting list for therapy and ended my medication. The decision had been beforehand by the physician. As we never had met before, I presumed we were to have a two-way conversation. However, whatever I asked or referred to, they stated that this was the decision they had made. // Over all the years I been treated in psychiatry I’ve never been treated like that before!’ (92)

In various ways, patients described experiences from situations where decisions about them were taken without their involvement.

Misconceptions occurred when the patients or relatives were not involved in care, leading to increased challenges. The following complaint illustrates an incident of a patient needing an emergency consultation in the home from the mobile psychiatric team. Afterwards, the relative who made the complaint identified that something went very wrong, and questioned how the situation could have been handled in a less degrading way, with less harm to the patient. During the consultation, the mobile team excused themselves saying that the team needed to consult the physician. They returned shortly later, accompanied by the police, as the patient was deemed by the mobile team to be violent. The patient’s relative was shocked when the patient was handcuffed and forcibly carried down the stairs. These actions were experienced as an unnecessary abuse against the patient.

‘Me and my oldest son could have talked to him and he would have followed us calmly down the stairs.’ (98)

The actions made were described as a threat to the patient’s dignity. In a variety of ways, patients and/or relatives described feeling dehumanized. In some cases, patients described a lack of understanding for their individual needs.

Discussion

This study found patient complaints about mental healthcare to be related to lack of access to care or unmet healthcare needs. There were reports on problems related to communication, where patients and/or relatives felt not being listened to or being excluded from decisions. The experiences described exacerbated patient suffering in addition to the mental ill health. Even if the total number of formal patient complaints addressed in the study are few, these may be indicative of a much larger problem. These experiences warrant attention and can be helpful to improve practices.

The significance of professionals’ attitudes and approaches described in the present study has similarly been described by patients admitted to acute psychiatric inpatient wards (Stapleton & Wright 2019). Positive experiences from inpatient care were related to opportunities to be listened to and having control of one’s situation. Negative experiences were related to negative attitudes of professionals. Thus, professionals’ attitudes and approaches either can be supportive and instil trust and confidence, or negative and neglect the patients’ needs and experiences: the latter seems to be a prime source for misconceptions and conflicting situations.

Findings report on situations where patients needs or dignity were ignored or overlooked. This illustrates the vulnerability of patients in interactions with healthcare professionals (Gjengedal et al. 2013). Using a sensitive and open approach to patients or families’ perspectives, healthcare professionals can transform this vulnerability to a strength. Patients are dependent on professionals and may be on a spectrum between wanting to be passive and dependent or wanting autonomy. Consequently, autonomy and vulnerability makes the interaction with patients complex. Upholding dignity in healthcare encounters means balancing patients’ vulnerability, expectations, and needs in relation to treatment and care (Delmar 2013). Findings illustrate challenges related to patients´ dignity and stresses that they want to be taken seriously and treated with respect. Gjengedal et al. (2013) call for professionals to be sensitive to the vulnerability of patients as a key for acting ethically. Similarly, Ngui et al. (2010) point to the need for care based on ethics and with respect for all patients. We recommend that healthcare professionals engage with patients with the sensitivity needed to balance their vulnerability and dignity. This sensitivity will help to empower and support patients with mental ill health, similar to the study by Raphalalani et al. (2021). In addition, our study indicates that families can be seen as a resource for a more person-centred care. In some situations, the family can be the point of connection needed for well-functioning relationships between patients and healthcare professionals.

The findings point to misunderstandings, conflicts, and poor communication being a source for patient complaints. Misunderstandings can cause conflicting and negative experiences, as reported by patients and relatives. Similarly, improved communication and interaction between patients and professionals is important (Van Der Merwe et al. 2013). The importance of communication and collaboration with patients and families should be a consideration in care. Based on experiences of patients suffering from depression, Damsgaard et al. (2021) argue that traditional institutional structures should be challenged and healthcare professionals' empathic competences and their ability to empower and support patients’ require a greater focus and improvement. To avoid unnecessarily suffering from care, patient’s authority and individuality must be acknowledged in accordance with person-centred care (Entwistle & Watt 2013; Håkansson Eklund et al. 2019).

The findings can be discussed in view of the right to health and illustrates the violation of rights of patients suffering from mental ill health. Findings point to problems with access to care and negative experiences from the care delivered. Challenges remain on how to move towards the realization of the right to health and healthcare. The World health organization’s (WHO) right to health states the ‘right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (United Nations Committee on Economic, Social & Cultural Rights 2000). In the move towards a more ethical and humane healthcare mental health inequalities must be addressed. The findings point to problems with unmet mental healthcare needs in a developed, welfare-based country like Sweden. There is a growing interest in the rights of patients with mental ill health, including the rights to be treated with dignity and be able to complain about their care. A previous study points to dignity-related matters being a common reason for the complaints of patients, particularly in involuntary patients with mental ill health (Raphalalani et al. 2021). More work is required to change attitudes and approaches related to dignity, the stigma, and discrimination of patients with mental ill health, and to address unmet mental healthcare needs.

Strengths and limitations

To the authors’ knowledge, this study is one of the first to explore the nature of formal patient complaints about mental healthcare services. A need for future qualitative research studies is vital for a deeper understanding of patients’ experiences (Raphalalani et al. 2021). A strength of this study is the sample, which although small, was still large enough to get suitable responses with richness of meanings for a qualitative in-depth thematic analysis. However, these formal patient complaints are from one region in Sweden and do not represent the whole country, which might be a limitation. A further strength could be that the sample of patient complaints came from different healthcare sectors, for example, both inpatient and outpatient psychiatric healthcare. Although, this study did not focus on differences in complaints from various sectors, it might be interesting to explore in future research.

A qualitative research method was appropriate to the research question. In qualitative studies, the researchers are part of the whole research process; therefore, reflexivity is an important issue, particularly when using thematic analysis grounded in descriptive phenomenology. In this approach, openness is a methodological principle described as a reflective attitude including a constant questioning of the researchers’ preunderstanding (Sundler et al. 2019). The authors were unbiased regarding preconceptions related to professional knowledge of the participants or professionals, and the actual care facilities. Critical and reflective discussions on the meanings and tentative themes were ongoing during the analysis and the writing of findings. Other principles appropriate for the research approach are credibility and transferability (Sundler et al. 2019). Credibility refers to the meaningfulness and the presentation of findings. To ensure this, we have tried to describe the research process transparently so that the reader can form an opinion about the study's credibility. Transferability refers to the study’s relevance and applicability. When interpreting qualitative research findings, context should be considered in relation to transferability to other contexts. Therefore, we attempted to carefully describe the study’s context so that the reader could validate the transferability of the study.

Conclusion

This study reports on patients’ and/or relatives’ complaints about mental health care services in one area of Sweden, which highlight experiences of unmet mental healthcare needs. Based on the findings, we conclude that improved access to specialist services, continuity in care, and treatment based on dignity, are all necessary actions to protect the rights of patients with mental ill health. The vulnerability of patients already in the system is a greater issue than previously realized.

Relevance to Clinical Practice

Patients’ need for mental healthcare may be challenging for healthcare organizations. To further develop mental healthcare services and increase patient satisfaction, the vulnerability of patients should be acknowledged by healthcare professionals and within organizations. The need for improvement in daily actions by healthcare professionals relating to patient dignity, how to look at issues relating to ethics, and then use them in daily interactions with patients, is paramount to the well-being of persons with mental ill health. Challenges remain on how to more fully realize the right to health and healthcare, irrespectively of whether the person with mental ill health is seeking help from primary or specialist mental healthcare.

Funding Information

This work was supported by the Committee for Human Rights, Region Västra Götaland, Sweden and Sparbanksstiftelsen sjuhärad, Sweden.

Ethical Approval

The Regional Ethics Committee in Gothenburg, Sweden, approved this study (DNo. 951-15). The study complies with the principles declared in The Declaration of Helsinki. The data provided by the patient complaints reporting system were anonymous when handed out by the PAC, and no names or other personal information was obtained.

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