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Openness and honesty when things go wrong: The professional duty of candour

About this guidance

1

All healthcare professionals have a duty of candour – a professional responsibility to be honest with patients1 when things go wrong. This is described in The professional duty of candour, which introduces this guidance and forms part of a joint statement from eight regulators of healthcare professionals in the UK.

1

When we refer to ‘patients’ in this guidance, we also mean people who are in your care.

2

As a doctor, nurse or midwife, you must be open and honest with patients, colleagues and your employers.

3

This guidance complements the joint statement from the healthcare regulators and gives more information about how to follow the principles set out in Good medical practice2 and The Code: Professional standards of practice and behaviour for nurses and midwives.3 Appendix 1 sets out relevant extracts from General Medical Council (GMC) and Nursing and Midwifery Council (NMC) guidance. This guidance applies to all doctors registered with the GMC and all nurses and midwives registered with the NMC across the UK.

2

General Medical Council (2013) Good medical practice (accessed 15 June 2015), paragraphs 24 and 55

3

Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives (accessed 15 June 2015), section 14

4

This guidance is divided into two parts:

  1. Your duty to be open and honest with patients in your care, or those close to them, if something goes wrong. This includes advice on apologising (paragraphs 6 - 21).
  2. Your duty to be open and honest with your organisation, and to encourage a learning culture by reporting adverse incidents that lead to harm, as well as near misses (paragraphs 22 - 28).
6

Patients must be fully informed4 about their care. When discussing care options with patients, you must discuss the risks as well as the benefits of the options.

7

You or an appropriate person6 must give the patient clear, accurate information about the risks of the proposed treatment or care, and the risks of any reasonable alternative options, and check that the patient understands. You should discuss risks7 that occur often, those that are serious even if very unlikely, and those that the patient is likely to think are important.8 

8

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. This guidance also applies in situations where a patient may yet suffer harm or distress as a result of something going wrong with their care.

9

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.9 The most appropriate team member will usually be the lead or accountable clinician.10 If this is not you, then you must follow the guidance in paragraph 5.

10

You should speak to the patient as soon as possible 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.

11

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.11 You should apologise to the patient (see paragraphs 13–19).

12

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.

13

Patients expect to be told three things as part of an apology:

  1. what happened
  2. what can be done to deal with any harm caused
  3. what will be done to prevent someone else being harmed.12 
14

Apologising to a patient does not mean that you are admitting legal liability13 for what has happened. This is set out in legislation in parts of the UK14 and the NHS Litigation Authority also advises that saying sorry is the right thing to do.12 In addition, a fitness to practise panel may view an apology as evidence of insight.15 16 17

15

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 (see paragraph 9), regardless of who or what may be responsible for what has happened.

16

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.

  1. You must give patients the information they want or need to know in a way that they can understand.18 
  2. You should speak to patients in a place and at a time when they are best able to understand and retain information.
  3. You should give information that the patient may find distressing in a considerate way, respecting their right to privacy and dignity.
  4. 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. This doesn’t mean that we expect you to take personal responsibility for system failures or other people’s mistakes (see paragraph 15).
  5. 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 services19 that can give them practical advice and emotional support.
  6. You should record the details of your apology in the patient’s clinical record.20 21 A verbal apology may need to be followed up by a written apology, depending on the patient’s wishes and on your workplace policy.22 
17

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.3  23 Take time to convey the information in a compassionate way, giving them the opportunity to ask questions at the time and afterwards.24 

18

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. 25 26

19

You should make sure, as far as possible, that those close to the patient have been offered appropriate support, and that they have a specific point of contact in case they have concerns or questions at a later date.

20

A ‘near miss’ is an adverse incident that had the potential to result in harm but did not do so.27 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. In these cases, you should talk to the patient about the near miss, following the guidance in paragraphs 10–16.

21

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.

22

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.

23

Healthcare organisations should have a policy for reporting adverse incidents and near misses, and you must follow your organisation’s policy.28 

24

A number of reporting systems and schemes exist around the UK for reporting adverse incidents and near misses.

  1. Adverse and patient safety incidents in England and Wales are reported to the National Reporting and Learning System.29 
  2. You must report suspected adverse drug reactions to the UK-wide Yellow Card Scheme run by the Medicines and Healthcare products Regulatory Agency (MHRA) and the Commission on Human Medicines.30 
  3. You must report adverse incidents involving medical devices to the UK-wide MHRA reporting system.31 
  4. Healthcare Improvement Scotland has a national framework,32 which outlines consistent definitions and a standardised approach to adverse incident management across the NHS in Scotland.
  5. 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.33 
  6. In England, general practitioners and other primary medical services must submit all notifications34 directly to the Care Quality Commission (CQC).
25

In addition to contributing to these systems, you should comply with any system for reporting adverse incidents that put patient safety at risk within your organisation (see paragraphs 32–33 on the organisational duty of candour). If your organisation does not have such a system in place, you should speak to your manager and – if necessary – raise a concern in line with our guidance.35  

26

Your organisation should support you to report adverse incidents and near misses routinely. If you do not feel supported to report, and in particular if you are discouraged or prevented from reporting,37 you should raise a concern in line with our guidance.35 

27

You must not try to prevent colleagues or former colleagues from raising concerns about patient safety.38 If you are in a management role, you must make sure that individuals who raise concerns are protected from unfair criticism or action, including any detriment or dismissal.37 

28

You must take part in regular reviews and audits39 40 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.41 42

5

This guidance is for individuals. We recognise that care is normally provided by multidisciplinary teams, and we don’t expect every team member to take responsibility for reporting adverse incidents and speaking to patients if things go wrong. However, we do expect you to make sure that someone in the team has taken on responsibility for each of these tasks, and we expect you to support them as needed.