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Duty of candour should also cover 'moderate' harm, says review


The “old days” where clinical errors were not disclosed must give way to an environment that allows staff to be trained and supported in “admitting, reporting and learning fully from mistakes”, according to an independent review for the government.

The review – by Salford Royal Foundation Trust chief executive Sir David Dalton and Royal College of Surgeons of England president Norman Williams – recommended all staff should be trained in how to disclose incidents to patients and their families and apologise “where appropriate”.

If the recommendations of the government-commissioned review are adopted, NHS organisations will also be required to tell patients about all but the most minor patient safety incidents under a new statutory “duty of candour”.

Based on current levels of incident reporting to the National Reporting and Learning System, this would mean trusts owning up to almost 100,000 incidents every year.

“If the NHS embraces this new culture and takes it seriously this could be the basis of a profound change”

David Dalton

Sir David said: “If the NHS embraces this new culture and takes it seriously – thinking about all the things you would need to put in place to make a reality of candour – this could be the basis of a profound change to the ways in which organisations and staff interact with patients.”

David Dalton

David Dalton

The government announced plans for a statutory duty of candour on organisations registered with the Care Quality Commission in its response to the Francis report last year.

Robert Francis QC recommended the duty should only apply in cases of death or serious harm. However, following pressure from patient groups, the government agreed to look again at what the threshold should be.

Sir David and Professor Williams concluded the threshold should also include “moderate harm”. This extends the number of incidents likely to be covered by the duty from 11,000 to 96,000.

Under the proposals, all cases involving death or moderate or severe harm would be classed as “significant” and would sit alongside a “low harm” and “no harm” incidents categories.

The duty of candour is one of the 11 fundamental standards being introduced in the wake of the Francis report.

“It is now up to trust boards and managers to lead by example”

Peter Carter

The Royal College of Nursing said the review had “rightly focussed” on the importance of organisations creating a culture where staff were supported to be open when things go wrong.

RCN chief executive and general secretary Peter Carter said: “Healthcare is inherently risky and sometimes things will go wrong. When this happens patients deserve an open and honest discussion with staff, and to know that lessons will be learnt.”

Peter Carter

He added: “We also support the recommendation that the duty of candour should apply to all cases of ‘significant harm’, and not just cases which result in serious permanent injury or death.

 “This is an important and useful report and it is now up to trust boards and managers to lead by example and ensure their organisation has a culture which is good for staff and good for patients,” he said.

Don Redding, director of policy at the patient group National Voices, welcomed the findings of the review.

“The key advance is that the definition of ‘significant’ should include what are currently classified as incidents of ‘moderate’ harm but which are significant to patients – the original plan was to limit to the duty to fatal cases or those causing the most severe permanent disability,” he said. 

“We also welcome recommendations that staff should have training and support in taking this forward,” he added.

This week marked the first anniversary of the Speak Out Safely campaign, which Nursing Times is running to increase protection for staff who raise concerns.

One of the campaign’s aims is for a duty of candour to be introduced covering both organisations and individuals.


Readers' comments (13)

  • I appreciate that this will formalise the process - but I've been working in the NHS for more than 30 years - and in the early days saw errors covered up - but for the last at least 15 years certainly in my experience if a mistake was made the service user would be informed regardless of the severity (as an organsiational expectation). For example, if a medication was given wrongly but it was a similar group and carried no harm to the receipient - that person would be informed and reassured that they would come to no harm. Isn't this treating people how we would want to be treated ourselves?

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  • we always documented and discussed any error made, no matter how small or large. where is the problem with that? it prevented making mountains out of molehills and leading to any conflict and in most cases any need for complaint or costly staff and the means to process them. as ours was an open and trusting environment it did not put us in a position of stress and cover up where major errors are more often made.

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  • michael stone

    There was a piece in today's Times (page 16) and I am with Peter Walsh on what [it appears - this isn't entirely internally consistent, as reported in the paper] is an 'immunity proposal':

    Hospitals must come clean about their mistakes but patients should not be able to use any admissions in court, a government-ordered review recommends.

    “When things do go wrong, patients and their families want to be told honestly what happened, how it might be corrected and to know that it will not happen to someone else,” said Professor Norman Williams, President of the Royal College of Surgeons and co-author of the report.

    The review says that fear of being sued is discouraging openness, and it could be helpful to minimise the possibility that explanations might be used later to support an admission of negligence.

    Peter Walsh, chief executive of the charity Action against Medical Accidents, who otherwise welcomed the report, said: “It’s misconceived and grossly unfair. You get to know the truth but you can’t do anything with it.”

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  • I understand why the NHS would want to protect itself from litigation - a sigificant amount of money is lost as a result of this. But this immunity proposal can't be right can it - we all get irritated with the industry that touts for trade where the loss is superficial i.e. the cold callers that ask you if you've been in a car accident so they can process your claim. However, where clinical negligence has caused significant and/or lasting loss how could we deny a person the right to seek compensation for that loss by using our acceptance of the role we played in that loss - it just doesn't seem right.

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  • tinkerbell

    Most relatives just want the truth not compensation, especially if their loved one has died.

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  • michael stone

    My position on the immunity issue, now I've got longer to type it up, is that it hinges on the meaning of 'honest mistakes'.

    Everyone can sometimes make a mistake - so provided you don't try to cover it up, you should not be 'punished' provided most other people would feel they were in the 'I couldn't throw the first stone' category: in other words, if the general opinion is 'I'm sorry, but that sort of thing could happen to most of us', I would link coming clean to 'immunity'.

    But you can't have 'coming clean about really awful/wilful unacceptable behaviour' as a route to 'immunity' - that is absurd !

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  • michael stone | 8-Mar-2014 2:15 pm

    now what are you on about?

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  • michael stone

    Anonymous | 8-Mar-2014 4:57 pm

    There was a report about this in the Times (see my post at 7-Mar-2014 2:36 pm) and, although it wasn't entirely clear, it appears that the report might have recommended:

    'Hospitals must come clean about their mistakes but patients should not be able to use any admissions in court, a government-ordered review recommends.'

    Some of us, don't like that !

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  • michael stone | 9-Mar-2014 12:17 pm

    there we go again. you just don't get it!

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  • tinkerbell | 7-Mar-2014 8:28 pm

    Most relatives just want the truth not compensation, especially if their loved one has died.

    I speak from experience.

    You want the truth, you want an apology that is sincere. Getting them is very difficult.

    You don't want compensation it doesn't seem right. The problem is Trusts only seem to respond to financial threats. There should be large financial penalties that a family can direct towards a chosen charity if care was found to be due to negligence in any way.

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