Health Care Risk Insights: Complying With the Duty of Candour

As a health care provider, you have a responsibility to be honest with patients or the people acting lawfully on their behalf—particularly when something unexpected or potentially harmful happens during their care or treatment. This obligation is known as the duty of candour and the Care Quality Commission (CQC) developed detailed guidance to help you fulfil that commitment.

Duty of Candour Overview and Requirements

The duty of candour affects any UK organisation that is regulated by the CQC, and applies to any registered person—a domiciliary care provider, care home operator, nurse, health care volunteer, GP, surgeon, etc—performing an activity on a patient. As a health care provider, if a ‘notifiable incident’ occurs during a patient’s care or treatment, you are obligated to comply with the regulations outlined by the duty of candour.

A notifiable incident is any unexpected incident that causes unintended physical or mental harm to patients while they are receiving care or treatment. The CQC has described the four following unintended consequences of care as notifiable incidents:

  1. Death: Immediate or resulting from the incident
  2. Severe harm: A permanent lessening of bodily, sensory, motor, physiologic or intellectual functions—including removal of the wrong limb or organ as well as brain damage
  3. Moderate harm: Significant but not permanent harm that requires a moderate increase in treatment, such as an unplanned return to surgery
  4. Prolonged psychological harm: Psychological harm that was experienced, or is likely to be experienced, for a continuous period of at least 28 days

If a patient were to experience any of these four types of notifiable incidents, you would be obligated to do the following:

  • Tell the patient, or the person acting lawfully on his or her behalf, as soon as reasonably possible, that an incident has occurred. This should involve providing a detailed account of how the incident occurred.
  • Apologise to the patient for the incident. While an apology should express sorrow or regret, it should not admit nor imply fault or liability for the error.
  • Offer an appropriate remedy or support—surgery, therapy, etc—in order to correct the incident.
  • Explain to the patient, or the person acting lawfully on his or her behalf, both the short- and long-term effects of what has happened.

In addition to being forward and honest with patients, you must provide a written account of both the incident and your notification for your organisation’s records.

Breach of Duty

In order to comply with the duty of candour, all health care organisations must register with the CQC. During the registration assessment, the CQC will observe the facility, staff and culture to determine whether the health care organisation can provide safe, effective, caring, responsive and well-led service. In addition to the inspection, the CQC will conduct an ‘interview’, during which the CQC representative will ask questions about the quality of care and what procedures will be put into practice by the staff to achieve that standard.

If you or any of your colleagues are found guilty of non-compliance, you could be charged with a criminal offence—which could result in a fine for both the guilty party and your organisation. The CQC may also refuse or revoke the health care organisation’s registration.

Yet, the CQC is unable to monitor every organisation full time in order to detect a breach of duty. It is therefore important that you understand your responsibility to be forward and honest with your colleagues, patients and relevant organisations in the event of a notifiable incident.         

Guidance to Implement the Duty of Candour

Developing an open and honest culture between health care providers and patients is fundamental to providing adequate quality of care. To help establish that culture within your health care practice, consider adopting these four procedures:

  1. Provide regular training for all health care staff and volunteers on what constitutes a notifiable incident and what steps should be taken to address the issue.
  2. Offer health care staff training on how to properly apologise without implying or admitting liability.
  3. Draft a notification letter template to streamline the record-keeping process.
  4. Develop procedural documents which outline the organisation’s commitment to exemplifying the characteristics of candour.

Narrative Examples for General Practice

To clearly and effectively illustrate the kind of scenarios in which the duty of candour would be relevant, consider these two examples:

  1. While treating a patient for pneumonia, the GP identified a ‘suspicious lung lesion’ on an X-ray which would require a follow-up. Upon discharging the patient, the GP carried out the appropriate investigations of the lesion—the results of which were normal. However, the practice failed to follow normal processes for relaying the results to the patient and he was not informed for more than one month. Consequently, the patient spent several weeks in a state of extreme distress, concerned about the possibility of cancer, and he developed symptoms of anxiety and depression which lasted more than 28 days. (This example illustrates a notifiable incident resulting from prolonged psychological harm, as the practice failed to communicate the results of the test on the lesion in a timely manner.)
  2. A patient has been prescribed to take 10 milligrams of morphine sulphate twice a day for chronic back pain. However, the prescription is incorrectly written down as 100 milligrams. The patient’s wife, unaware of the error, gives her husband the incorrect dosage. The next day, the patient is unresponsive and is rushed to the hospital where he goes into cardiac arrest and dies. (This example illustrates a notifiable incident resulting from death, as the prescription was incorrectly written down.) 

Always Remember Your Professional Duty

Honesty, especially if an error was made which could be potentially harmful, is paramount when communicating with patients or the people acting lawfully on their behalf. Neglecting that duty not only reflects poorly upon you, as a health care provider, but on the organisation that you represent as well. Honour your duty of candour and contact Business Insurance Service to ensure that you and your organisation remain compliant.

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