Openness and honesty when things go wrong: The professional duty of candour
Appendix 1: Extracts from GMC and NMC guidance that are referenced in this guidance
From Good medical practice
23. To help keep patients safe you must:
a. contribute to confidential inquiries
b. contribute to adverse event recognition
c. report adverse incidents involving medical devices that put or have the potential to put the safety of a patient, or another person, at risk
d. report suspected adverse drug reactions
e. respond to requests from organisations monitoring public health.
When providing information for these purposes you should still respect patients’ confidentiality.
24. You must promote and encourage a culture that allows all staff to raise concerns openly and safely.
55. You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should:
a. put matters right (if that is possible)
b. offer an apology
c. explain fully and promptly what has happened and the likely short-term and long-term effects.
From Raising and acting on concerns about patient safety
13. Wherever possible, you should first raise your concern with your manager or an appropriate officer of the organisation you have a contract with or which employs you – such as the consultant in charge of the team, the clinical or medical director or a practice partner. If your concern is about a partner, it may be appropriate to raise it outside the practice – for example, with the medical director or clinical governance lead responsible for your organisation. If you are a doctor in training, it may be appropriate to raise your concerns with a named person in the deanery – for example, the postgraduate dean or director of postgraduate general practice education.
Doctors with extra responsibilities
21. If you are responsible for clinical governance or have wider management responsibilities in your organisation, you have a duty to help people report their concerns and to enable people to act on concerns that are raised with them.
22. If you have a management role or responsibility, you must make sure that:
a. there are systems and policies in place to allow concerns to be raised and for incidents, concerns and complaints to be investigated promptly and fully
b. you do not try to prevent employees or former employees raising concerns about patient safety – for example, you must not propose or condone contracts or agreements that seek to restrict or remove the contractor’s freedom to disclose information relevant to their concerns
c. clinical staff understand their duty to be open and honest about incidents or complaints with both patients and managers
d. all other staff are encouraged to raise concerns they may have about the safety of patients, including any risks that may be posed by colleagues or teams
e. staff who raise a concern are protected from unfair criticism or action, including any detriment or dismissal.
Also see the raising concerns decision making tool.
From Leadership and management for all doctors
24. Early identification of problems or issues with the performance of individuals, teams or services is essential to help protect patients.
25. 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.
26. You should be familiar with, and use, the clinical governance and risk management structures and processes within the organisations you work for or to which you are contracted. You must also follow the procedure where you work for reporting adverse incidents and near misses. This is because routinely identifying adverse incidents or near misses at an early stage, can allow issues to be tackled, problems to be put right and lessons to be learnt.
27. You must follow the guidance in Good medical practice and Raising and acting on concerns about patient safety when you have reason to believe that systems, policies, procedures or colleagues are, or may be, placing patients at risk of harm.
Doctors with extra responsibilities
28. If you have a management role or responsibility, you must make sure that systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams. These should include systems for conducting audits and considering patient feedback. You must make sure that any such failure is dealt with quickly and effectively.
29. 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 must make sure that teams you manage are appropriately supported and developed and are clear about their objectives.
From: Consent patients and doctors making decisions together
75. In making decisions about the treatment and care of patients who lack capacity, you must:
a. make the care of your patient your first concern
b. treat patients as individuals and respect their dignity
c. support and encourage patients to be involved, as far as they want to and are able, in decisions about their treatment and care
d. treat patients with respect and not discriminate against them.
76. You must also consider:
a. whether the patient’s lack of capacity is temporary or permanent
b. which options for treatment would provide overall clinical benefit for the patient
c. which option, including the option not to treat, would be least restrictive of the patient’s future choices
d. any evidence of the patient’s previously expressed preferences, such as an advance statement or decision
e. the views of anyone the patient asks you to consult, or who has legal authority to make a decision on their behalf, or has been appointed to represent them
f. the views of people close to the patient on the patient’s preferences, feelings, beliefs and values, and whether they consider the proposed treatment to be in the patient’s best interests
g. what you and the rest of the healthcare team know about the patient’s wishes, feelings, beliefs and values.
From Treatment and care towards the end of life: good practice in decision making
84. Death and bereavement affect different people in different ways, and an individual’s response will be influenced by factors such as their beliefs, culture, religion and values. You must show respect for and respond sensitively to the wishes and needs of the bereaved, taking 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 the bereaved, for example, by explaining where they can get information about, and help with, the administrative practicalities following a death; or by involving other members of the team, such as nursing, chaplaincy or bereavement care staff.
From The Code: Professional standards of practice and behaviour for nurses and midwives
You make sure that patient and public safety is protected. You work within the limits of your competence, exercising your professional ‘duty of candour’ and raising concerns immediately whenever you come across situations that put patients or public safety at risk. You take necessary action to deal with any concerns where appropriate.
14. Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place
To achieve this, you must:
14.1. act immediately to put right the situation if someone has suffered actual harm for any reason or an incident has happened which had the potential for harm
14.2. explain fully and promptly what has happened, including the likely effects, and apologise to the person affected and, where appropriate, their advocate, family or carers, and
14.3. document all these events formally and take further action (escalate) if appropriate so they can be dealt with quickly.
16. Act without delay if you believe that there is a risk to patient safety or public protection
To achieve this, you must:
16.1. raise and, if necessary, escalate any concerns you may have about patient or public safety, or the level of care people are receiving in your workplace or any other healthcare setting and use the channels available to you in line with our guidance and your local working practices
16.2. raise your concerns immediately if you are being asked to practise beyond your role, experience and training
16.3. tell someone in authority at the first reasonable opportunity if you experience problems that may prevent you working within the Code or other national standards, taking prompt action to tackle the causes of concern if you can
16.4. acknowledge and act on all concerns raised to you, investigating, escalating or dealing with those concerns where it is appropriate for you to do so
16.5. not obstruct, intimidate, victimise or in any way hinder a colleague, member of staff, person you care for or member of the public who wants to raise a concern, and
16.6. protect anyone you have management responsibility for from any harm, detriment, victimisation or unwarranted treatment after a concern is raised.
For more information, please see Raising concerns: Guidance for nurses and midwives