Missed diagnosis


Belinda has baby Anthony on the 27 February. He is born at term and feeds well. 

Two weeks later, Belinda takes him to see Dr Visconti as he is no longer feeding well, he is not gaining weight and he seems jaundiced. 

Dr Visconti examines him and says the jaundice is mild and common with breastfeeding babies. He tells Belinda to come back in a few days if Anthony’s colour doesn’t improve.


Two days later, Belinda brings Anthony in. He’s floppy and won’t feed. Dr Visconti realises Anthony is far more jaundiced than he thought and he should have referred him to Paediatrics. He sends Anthony to children’s A&E for an urgent evaluation. 

In the hospital they find that Anthony has a dangerous concentration of bilirubin in his blood and needs a prolonged admission to hospital. Exposure to this high concentration may have caused long-term damage to Anthony’s brain.

Dr Visconti knows that doctors have a duty to tell patients, or those close to them, when something goes wrong in their care. But he is not sure whether he or the paediatrician should do this. He is also not sure whether he should wait to see whether Anthony experiences any developmental delays, and apologise only if he has come to some harm. 

What the doctor did

Dr Visconti talked with the lead paediatrician. They agree that someone needs to explain to Belinda straightaway that the bilirubin test should have been done earlier, apologise, and tell her what could happen next. While either of them could do this, they decide that the paediatrician should speak to Belinda, as he is more able to explain what the likely outcomes will be for Anthony, and what will happen next in Anthony’s care. 

What the doctor had to consider 

  • When the duty of candour applies. The guidance applies not only when something goes wrong with a patient's care and they suffer harm or distress as a result, but also in situations where the patient may yet suffer harm or distress as a result of something going wrong. In other words, the duty of candour applies even if no harm is immediately apparent. (paragraph 8). 
  • When is the right time to speak to the patient? The right time to speak to the patient is the point at which you realise that a mistake’s been made is the trigger for the duty of candour to come into effect, not the point at which harm or distress is apparent (paragraphs 8 and 9).  
  • When you should apologise? You should apologise when you realise that something has gone wrong, after doing what you can to put matters right.
  • Who should apologise?  The most appropriate person to apologise will usually be the lead or accountable clinician. This is because that person will usually have an ongoing relationship with the patient, and will be in the best position to know the details of what went wrong and what the effects are likely to be. The important thing is to consider the patient’s needs. If they have suffered harm or distress because of something going wrong, they have a right to expect an apology and explanation.
  • It doesn’t necessarily have to be the person who is responsible for the adverse incident who apologises for it, much of the time it won’t be clear who or what is responsible (paragraphs 9-11).

  • Saying ‘I am sorry’ doesn’t mean taking personal responsibility for someone else’s mistakes. But it is likely to be more meaningful to the patient than a general expression of regret (paragraph 16d).