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

Being open and honest with patients in your care, and those close to them, when things go wrong

Discuss risks before beginning treatment or providing care

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.

4

General Medical Council (2008) Consent: patients and doctors making decisions together (accessed 15 June 2015)

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 

6

General Medical Council (2008) Consent: patients and doctors making decisions together (accessed 15 June 2015), paragraphs 26 - 27

7

General Medical Council (2008) Consent: patients and doctors making decisions together (accessed 15 June 2015), paragraphs 28 - 36

8

The Supreme Court (2015) Judgment: Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland) (accessed 15 June 2015), paragraphs 86–91

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

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.

9

If the patient has died, or is unlikely to regain consciousness or capacity, ‘patient’ in paragraphs 9–16 should be read as ‘those close to the patient’.

10

General Medical Council (2014) Guidance for doctors acting as responsible consultants or clinicians (accessed 18 June 2015)

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

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).

11

General Medical Council (2013) Good medical practice (accessed 15 June 2015), paragraph 11

What if people don't want to know the details?

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.

Saying sorry

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 
12

NHS Litigation Authority Saying Sorry (accessed 15 June 2015)

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

13

‘Legal liability’ here refers to a clinical negligence claim. The NHS Litigation Authority ‘will never withhold cover for a claim because an apology or explanation has been given’.

14

Compensation Act 2006 (England and Wales) (accessed 15 June 2015), section 2

12

NHS Litigation Authority Saying Sorry (accessed 15 June 2015)

16

Nursing and Midwifery Council (2012) Indicative sanctions guidance to panels (accessed 15 June 2015)

17

Nursing and Midwifery Council (2014) Guidance for decision makers on insight, remediation and risk of reoccurrence (accessed 15 June 2015)

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.

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.

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 
18

General Medical Council (2008) Consent: patients and doctors making decisions together (accessed 15 June 2015), paragraphs 21 - 22 

19

For example, you could direct them to Action against Medical Accidents (AvMA), which works across th UK, or to their local Healthwatch group in England, the Patient and Client Council in Northern Ireland, the Patient Advice and Support Service in Scotland or the Community Health Council in Wales. See Patients’ help on the GMC website or When to make a referral on the NMC website for further information.

20

General Medical Council (2013) Good medical practice (accessed 15 June 2015), paragraph 21

21

Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives (accessed 15 June 2015), section 14.3

22

See appendix 2 for detail of the statutory duty of candour for organisations providing healthcare.

Speaking to those close to the patient

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 

3

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

23

General Medical Council (2013) Good medical practice (accessed 15 June 2015), paragraphs 33, 65, 68 

24

If a patient has previously asked you not to share personal information about their condition or treatment with those close to them, you should respect their wishes. While doing so, you must do your best to be considerate, sensitive and responsive to those close to the patient, giving them as much information as you can.

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

25

For information about patient and carer support and advocacy services, counselling and chaplaincy services, and clinical ethics support networks, see the advice and resources listed on the National End of Life Care Programme website and the Northern Health and Social Care Trust website.

26

General Medical Council (2010) Treatment and care towards the end of life: good practice in decision making (accessed 15 June 2015), paragraph 84

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.

Being open and honest with patients about near misses

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.

27

This does not include adverse incidents that may result in harm but have not yet done so – the patient must be told about these events and they must be reported in line with this guidance.

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.