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Nursing staff 'mistakenly believe apology leaves them liable for error'

  • 24 Comments

Senior nurses have been warned that when trying to implement the new legal duty of candour they may face resistance from some staff who fear having to offer an apology to patients when harm has occurred.

The law means clinicians will increasingly be asked by their employers to say “sorry” when a patient safety incident has taken place, but many will resist doing this because they may falsely believe they will be held liable, according to a serious incident investigator at a trust in Sussex.

“There can be awkward silences you feel you have to fill”

Elaine Spencer

However, nurses should be aware that their employer is obliged by the regulator to provide both a written and verbal apology within 10 days of the incident being reported or highlighted, said Elaine Spencer, serious incident investigator at Brighton and Sussex University Hospitals Trust.

 

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Ms Spencer, who was speaking about the duty of candour at an event run by Health Conferences UK and who trialled the new requirements at her trust during the early stages of development, said the 10-day period was “quite a challenge” due to the time required to assess the level and type of harm.

The duty of candour law applies to patient safety incidents that either appear to have, or could in the future, result in death, severe harm, moderate harm or prolonged psychological damage. It does not include “near misses”.

She also warned nurses who may be asked to apologise that although they will be expected to explain fully to patients what has happened, they should be careful to only provide the basic facts initially and wait until after an investigation to provide more details.

Ms Spencer said: “I would say within those 10 days you couldn’t possibly understand what has happened. You may think you know…but you will not know until you’ve investigated it.”

She added: “Within those 10 days we explain what we are going to do…Of course as soon as you tell someone harm has occurred or may occur they want to ask questions and there can be awkward silences you feel you have to fill. I would say don’t. Give the facts you know at that point.”

The statutory duty of candour for organisations was recommended following the Francis Inquiry which investigated care failings at Mid Staffordshire Foundation Trust.

“You both have the same responsibly to be open and transparent”

Elaine Spencer

It was introduced for NHS providers in November 2014 and all other CQC-registered providers in April 2015.

The Francis report also recommended the legislation apply to individual members of staff, but the law stopped short of this and instead professional regulators – including the Nursing and Midwifery Council – were asked to strengthen their guidance on the duty of candour.

Ms Spencer said the new law brought employers into line with nurses’ existing professional responsibility to be open and transparent with patients and removed any potential “tension”.

She said: “Before the legal requirement – there could have potentially been a tension between what you wanted to be open and candid about with patients and what your organisation wanted to say to your patients.

“It’s bringing that together now – you both have the same responsibly to be open and transparent,” she added.

  • 24 Comments

Readers' comments (24)

  • michael stone

    It will be very interesting, to see how this works out in practice.

    I think - but I'm not sure if this will happen universally - that whenever a patient says to a doctor or a nurse something which amounts to 'I'm not sure I'm happy about ... - why did that happen ?', that the clinician should indeed 'Give the facts you know at that point'.

    This is 'a trust issue' at root - and if 'the immediate response to a layman's question 'seems defensive' it doesn't promote trust'. So it needs a combination of 'front-line honesty and openness' combined with the organisation 'not blaming clinicians for unavoidable 'mistakes'' (not an easy phrase to get right - and my language skills, might not be up to it !).

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  • More and more it seems that we are having to have lessons on how to be a human being with a place in society,whats happened !!!!!!! I have no problems saying " Oh,Im sorry that I didnt do XXXX or Im sorry that you feel youve had a rough deal" whats the matter with people ! Im getting more and more worried that the people who have chosen to be nurses are only satisfied when they have someone to hide behind.Its a job that has always carried loads of responsibility but not many seem to want to take responsibility,what a terrible state we are in.I have always thought we should keep our NHS but now I am beginning to wonder !

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  • Healthcare workers need also to be aware of the issues that can arise when they initially perceive something to be entirely their fault, apologise for it (and hence attract blame).... only to find later that there are system failures that have contributed or even caused the situation (e.g. the injection given erroneously because two different vials are almost identical in colour, design and packaging, and therefore easy to mix up.)

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  • Being honest to your patient when a mistake has been done promotes openness. I believe it does not make one less of a health care provider if he or she makes a mistake. The Francis Report makes us all more aware consequences of more harm if we do not own-up to our mistakes. Patients' trust is breached if an unavoidable incident happened and yet as health care provider we don't make efforts to bring this to light. We all make mistakes at some point in our practice yet what we do about it is what matters.

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  • I agree with Julie - apology doesn't mean taking unlimited blame to oneself. For me, it might mean expressing remorse about something I know I have done wrong, or expressing sympathy for someone's suffering. Surely it is possible to say reasonably, in answer to questions 'well, there is only so much that I can say for sure at the moment, but I will come back to you as soon as I know more' - then do it! I disagree that getting rid of NHS would make things better - likely to make things far worse IMHO

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  • IME, the "don't apologise as it is a potential admission of liability" is what we were instructed by trust management, supposedly, so I was told, in the light of guidance from the trust legal department.

    This means that either our management, for whatever reason, were giving inaccurate instructions or the trust legal dept were giving inaccurate advice...

    My first inclination was always to say sorry.

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  • We should all remember that we are not only Healthcare Professionals, but are also patients ourselves at some point in time. We should all offer the patients we treat with no less humanity, sympathy, empathy and caring than we would expect our families or ourselves to receive when placed in their shoes. We all have a responsibility to be as open and honest as the law and our employers allow. Is there a risk of liability with honesty? Possibly so. Is there a tragedy in treating without transperancy? Absolutely so. We should give no less to others than what we expect to recieve ourselves.
    If you were a patient and had an unexpected, unforseeable, or even unavoidable mishap occur while in another's care, would you not want as much explanation as could be offered. It never hurts you or others to sympathize and say "I am sorry for what has occured during your stay in our care, as well as the physical and mental strains you are experiencing as a result. If I can do anything to make you more comfortable in any way, please let me know. I am certain that someone will discuss further with you the occurance you have experienced as soon as they have all the details necessary to provide you a complete explanation and a reasonable plan going forward. Please be patient and know that I am here to help keep you as comfortable as possible in the meantime." To offer such words does not imply knowledge of detail, placement of blame, acknowledgement of fault or anything that might further tarnish the relationship with the patient, but keeps the lines of communication open, offers sympathy on a human level, acknowledges grief and pain and allows for time to investigate and someone to provide proper explanation.

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  • Anonymous | 26-May-2015 3:56 pm said:

    "Healthcare workers need also to be aware of the issues that can arise when they initially perceive something to be entirely their fault, apologise for it (and hence attract blame).... only to find later that there are system failures that have contributed or even caused the situation (e.g. the injection given erroneously because two different vials are almost identical in colour, design and packaging, and therefore easy to mix up.)"
    -------
    Sorry, but that post says a lot about modern nursing attitudes and how accidents occur. When I was a nurse we were taught to meticulously read the prescription sheet, the packet, the vial - even to the extent of saying everything under our breath - then approach the patient saying their name and checking their wristband. You're to blame if you give the wrong drug under these circumstances, not "the system".

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  • Almost every one drives a motor vehicle; if you are involved in a collision you are told not to apologise as this is taken as an admission of fault. Maybe this is why there is a presumption of guilt attached to apologising.
    Anonymous 3:56 pm, sorry but you are very wrong, there can be systemic faults that precipitate errors in all safety/mission critical systems not just health care. The Kegworth air crash is one example, where an experienced pilot switched off the working engine in the erroneous belief it was the one on fire based on a display in the cockpit, as a result the layout of the cockpit was modified. The design of safety critical systems should be such that the potential for errors are minimised, particularly those that could cause serious harm, and the onus is on the manufacturing/designing companies, there are international standards that apply. Quite frankly if pharmaceutical companies insist on putting different medication in similar containers then that is a system fault as it does nothing to reduce the risk of errors occurring irrespective of how meticulous the clinician administering the drugs is.

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  • Anonymous | 26-May-2015 6:52 pm - you're almost making my point for me! Why can't people be more meticulous in actually READING things these days? Like labels on drugs, for example? Is it down to general education?

    You're criticising "Anonymous 3:56" in your post. If you'd bothered to read it properly and check your response, you'd find the person you were taking issue with was me at 6.23 pm.

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