Duty of Candour; when things go wrong

Question 1

Define the proffesional duty of candour

Answer 1

Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that healthcare professionals must:

1. tell patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
2. apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
3. offer an appropriate remedy or support to put matters right (if possible)
4. explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested.

Question 2

In what circumstances do I need to apologise to the patient?

Answer 2

This guidance is not intended for circumstances where a patient’s condition gets worse due to the natural progression of their illness. It applies when something goes wrong with a patient’s care, and they suffer harm or distress as a result.

• When you realise that something has gone wrong, and after doing what you can to put matters right, you or someone from the healthcare team must speak to the patient.
• The most appropriate team member will usually be the lead or accountable clinician.

Question 3

When should I speak to the patient or those close to them, and what do I need to say?

Answer 3

You should speak to the patient asap after you realise something has gone wrong with their care. When you speak to them, there should be someone available to support them (for example a friend, relative or professional colleague). You do not have to wait until the outcome of an investigation to speak to the patient, but you should be clear about what has and has not yet been established.

• You should share all you know and believe to be true about what went wrong and why, and what the consequences are likely to be.
• You should explain if anything is still uncertain and you must respond honestly to any questions.
• You should apologise to the patient

Question 4

What if people dont want to know the details?

Answer 4

Patients will normally want to know more about what has gone wrong. But you should give them the option not to be given every detail. If the patient does not want more information, you should try to find out why.

• If after discussion, they don’t change their mind, you should respect their wishes as far as possible,* having explained the potential consequences.
• You must record the fact that the patient does not want this information and make it clear to them that they can change their mind and have more information at any time.

Question 5

Saying sorry - how:

Answer 5

1. Patients expect to be told three things as part of an apology:
   
   • what happened
   • what can be done to deal with any harm caused
   • what will be done to prevent someone else being harmed
2. Apologising to a patient does not mean that you are admitting legal liability for what has happened. This is set out in legislation in parts of the UK and NHS Litigation Authority also advises that saying sorry is the right thing to do. In addition, a fitness to practise panel may view an apology as evidence of insight.
3. When apologising to patients and explaining what has happened, we do not expect you to take personal responsibility for something going wrong that was not your fault (such as system errors or a colleague’s mistake). But the patient has the right to receive an apology from the most appropriate team member, regardless of who or what may be responsible for what has happened.
4. We do not want to encourage a formulaic approach to apologising since an apology has value only if it is genuine. However, when apologising to a patient, you should consider each of the following points.
   
   • You must give patients the information they want or need to know in a way that they can understand.
   • You should speak to patients in a place and at a time when they are best able to understand and retain information.
   • You should give information that the patient may find distressing in a considerate way, respecting their right to privacy and dignity.
   • Patients are likely to find it more meaningful if you offer a personalised apology – for example ‘I am sorry…’ – rather than a general expression of regret about the incident on the organisation’s behalf
   • You should make sure the patient knows who to contact in the healthcare team to ask any further questions or raise concerns. You should also give patients information about independent advocacy, counselling or other support services
   • You should record the details of your apology in the patient’s clinical record. A verbal apology may need to be followed up by a written apology, depending on the patient’s wishes and on your workplace policy

Question 6

Speaking to those close to the patient

Answer 6

1. If something has gone wrong that causes a patient’s death or such severe harm that the patient is unlikely to regain consciousness or capacity, you must be open and honest with those close to the patient. Take time to convey the information in a compassionate way, giving them the opportunity to ask questions at the time and afterwards
2. You must show respect for, and respond sensitively to, the wishes and needs of bereaved people. You must take into account what you know of the patient’s wishes about what should happen after their death, including their views about sharing information. You should be prepared to offer support and assistance to bereaved people – for example by explaining where they can get information about, and help with, administrative and practical tasks following a death; or by involving other members of the team, such as chaplaincy or bereavement care staff.

Question 7

Being open and honest with patients about near misses

Answer 7

1. A ‘near miss’ is an adverse incident that had the potential to result in harm but did not do so. You must use your professional judgement when considering whether to tell patients about near misses. Sometimes there will be information that the patient needs to know or would want to know, and telling the patient about the near miss may even help their recovery.
2. Sometimes failing to be open with a patient about a near miss could damage their trust and confidence in you and the healthcare team. However, in some circumstances, patients may not need to know about an adverse incident that has not caused (and will not cause) them harm, and to speak to them about it may distress or confuse them unnecessarily. If you are not sure whether to talk to a patient about a near miss, seek advice from your healthcare team or a senior colleague

Question 8

Reporting errors

Answer 8

1. When something goes wrong with patient care, it is crucial that it is reported at an early stage so that lessons can be learnt quickly and patients can be protected from harm in the future.
2. Healthcare organisations should have a policy for reporting adverse incidents and near misses, and you must follow your organisation’s policy
3. A number of reporting systems and schemes exist around the UK for reporting adverse incidents and near misses.
   
   • a Adverse and patient safety incidents in England and Wales are reported to the National Reporting and Learning System
   • You must report suspected adverse drug reactions to the UK-wide Yellow Card Scheme run by the MHRA and the Commission on Human Medicines.
   • You must report adverse incidents involving medical devices to the UK-wide MHRA reporting system.
   • Healthcare Improvement Scotland has a national framework,which outlines consistent definitions and a standardised approach to adverse incident management across the NHS in Scotland.
   • The procedure for the management and follow-up of serious adverse incidents in Northern Ireland is set out on the Department of Health, Social Services and Public Safety’s website.
   • In England, GPs and other primary medical services must submit all notifications* directly to the CQC
4. In addition to contributing to these systems, you should comply with any system for reporting adverse incidents that put patient safety at risk in the organisational duty of candour).
5. You must not try to prevent colleagues or former colleagues from raising concerns about patient safety
6. You must take part in regular reviews and audits of the standards and performance of any team you work in, taking steps to resolve any problems. You should also discuss adverse incidents and near misses at your appraisal.

Question 9

Additional duties for doctors, nurses and midwives with management responsibilities and for senior or high-profile clinicians

Answer 9

1. Senior clinicians have a responsibility to set an example and encourage openness and honesty in reporting adverse incidents and near misses.
2. If you have a management role or responsibility, you must make sure that any concerns about the performance of an individual or team are investigated and, if appropriate, addressed quickly and effectively
3. If you are managing or leading a team, you should make sure that systems, including auditing and benchmarking, are in place to monitor, review and improve the quality of the team’s work.
   
   • You must work with others to collect and share information on patient experience and outcomes.
   • You should make sure that teams you manage are appropriately trained in patient safety and supported to openly report adverse incidents.
   • You should make sure that systems or processes are in place so that:
     
     • lessons are learnt from analysing adverse incidents and near misses
     • lessons are shared with the healthcare team
     • concrete action follows on from learning
     • practice is changed where needed