Appendix 1: Extracts from GMC and NMC standards and guidance that are referenced in this document
From Good medical practice
45. You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you must follow our guidance on Openness and honesty when things go wrong: the professional duty of candour, and you should:
a. put matters right, if possible
b. apologise (apologising does not, of itself, mean that you are admitting legal liability for what’s happened)
c. explain fully and promptly what has happened and the likely short-term and long-term effects
d. report the incident in line with your organisation’s policy so it can be reviewed or investigated as appropriate – and lessons can be learnt and patients protected from harm in the future.
73. 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 (including software, diagnostic tests, and digital tools) that put the safety of a patient or another person at risk, or have the potential to do so
d. contribute to incident reviews and/or investigations
e. report suspected adverse drug reactions
f. respond to requests from organisations monitoring public health.
When providing information for these purposes you must follow our guidance on Confidentiality: good practice in handling patient information.
76. If you have a formal leadership or management role, you must take active steps to create an environment in which people can talk about errors and concerns safely. This includes making sure that any concerns raised with you are dealt with promptly and adequately, in line with your workplace policy and our more detailed guidance on Raising and acting on concerns about patient safety.
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 medical professional in training, it may be appropriate to raise your concerns with a named person in your training organisation.
Medical professionals 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
24. Early identification of problems or issues with the performance of individuals, teams or services is essential to help protect patients.
All medical professionals
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.
Medical professionals 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 Decision making and consent
87. We use the term ‘overall benefit’ to describe the ethical basis on which decisions are made about treatment and care for adult patients who lack capacity to decide for themselves. This involves weighing up the risks of harm and potential benefits for the individual patient of each of the available options, including the option of taking no action. The concept of overall benefit is consistent with the legal requirements to consider whether treatment ‘benefits’ a patient (Scotland), or is in the patient’s ‘best interests’ (England, Wales and Northern Ireland).
88. If you are the person with lead responsibility for the patient’s treatment and care, before concluding that it is your responsibility to decide which option(s) would be of overall benefit to a patient who lacks capacity, you should take reasonable steps to find out:
- whether there’s evidence of the patient’s previously expressed values and preferences that may be legally binding, such as an advance statement or decision
- whether someone else has the legal authority to make the decision on the patient’s behalf or has been appointed to represent them. *[or in Scotland if someone is applying to be granted such authority (see s49 Adults with Incapacity (Scotland) Act 2000)]
89. If there is no evidence of a legally binding advance refusal of treatment, and no one has legal authority to make this decision for them, if you are the person with lead responsibility for the patient’s treatment and care, then you responsible for deciding what would be of overall benefit to your patient.5
In doing this you must:
- consult with those close to the patient and other members of the healthcare team, take account of their views about what the patient would want, and aim to reach agreement with them
- consider which option aligns most closely with the patient’s needs, preferences, values and priorities
- consider which option would be the least restrictive of the patient’s future options.
90. If a proposed option for treatment or care will restrict a patient’s right to personal freedom, you must consider whether you need legal authorisation to proceed with it in the circumstances.
91. You should allow enough time, if possible, for discussions with those who have an interest in the patient’s welfare, and you should aim to reach agreement about how to proceed.
Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates (accessed 17 January 2022), section 4.2
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, midwives and nursing associates
Preserve safety
You make sure that patient and public safety is not affected. 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
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 health and care 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
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
From Future Nurse: Standards of proficiency for registered nurses (NMC, 2018)
Section 1.3: understand and apply the principles of courage, transparency and the professional duty of candour, recognising and reporting any situations, behaviours or errors that could result in poor care outcomes.
From Standards of proficiency for midwives (NMC, 2019)
Section 1.19 - understand and apply the principles of courage, integrity, transparency, and the professional duty of candour, recognising and reporting any situations, behaviours, or errors that could result in sub-standard care, dysfunctional attitudes and behaviour, ineffective team working, or adverse outcomes.
From Standards of proficiency for registered nursing associates (NMC, 2018)
Section 1.3 - understand the importance of courage and transparency and apply the Duty of Candour, recognising and reporting any situations, behaviours or errors that could result in poor care outcomes.
