F174 Response Accepted

Candour about harm

Recommendation

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be informed of the incident, given full disclosure of the surrounding circumstances and be offered an appropriate level of support, whether or not the patient or representative has asked for this information.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
- The Department of Health and Social Care and NHS England stated in April 2025 that the statutory Duty of Candour and the Patient Safety Incident Response Framework (PSIRF) address requirements for disclosure (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- A review of the statutory duty of candour in November 2024 reported that many respondents viewed the duty as a "tick-box exercise" (DHSC - Duty of Candour Review, November 2024).
- An academic review in February 2023 stated that structural changes including the duty of candour were largely delivered (Academic Review - Ten Years After Francis, February 2023).
Sources
DHSC and NHS England implementation update provided to the Thirlwall Inquiry (April 2025)
Academic Review - Ten Years After Francis (February 2023)
How was this evidence gathered?
Evidence searched by Gemini (Google) on 30 Jun 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.legislation.gov.uk, hansard.parliament.uk
This recommendation applies across many organisations. The evidence above reflects central policy activity; adoption in individual organisations may vary.
Jurisdiction
England
Response
Accepted
Accepted Department of Health and Social Care
19 Nov 2013

The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf

Read Full Response
Note: Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Progress Timeline
Official Report
01 Apr 2025

DHSC and NHS England implementation update provided to the Thirlwall Inquiry (April 2025). This is the government's own account of progress, submitted to the inquiry. Reviewed extent of implementation: Implemented – Ongoing. Please see response to recommendation 21 regarding the statutory Duty of Candour. See also recommendation in relation to PSIRF (including 26, 40 and 44) and LFPSE (including recommendation 36,40,99 and 102)

Published Evidence

Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.

Reasonable Progress
26 Nov 2024
DHSC - Duty of Candour Review

DHSC published findings of call for evidence on statutory duty of candour. 261 responses received. Key finding: 52% of respondents said CQC had not adequately enforced the duty. Many reported it had become a "tick-box exercise". Only 40% thought the purpose was clear and well understood. Final government response still pending.

Findings of the Call for Evidence on the Statutor… View Source
Reasonable Progress
06 Feb 2023
Academic Review - Ten Years After Francis

Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.

University of Birmingham: Ten years after Francis View Source
Good Progress
11 Feb 2015
UK Government - Culture Change in the NHS

Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.

Confirmed Completed
27 Nov 2014
Legislation - Duty of Candour (Regulation 20)

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: statutory duty of candour came into force for NHS trusts November 2014, extended to all CQC-registered providers April 2015. Requires providers to notify patients/families of notifiable safety incidents and apologise.

Health and Social Care Act 2008 (Regulated Activi… View Source
Good Progress
19 Nov 2013
UK Government - Hard Truths Vol 1 & 2

Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.

Source
Report Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 06 Feb 2013
Responsible Bodies
Healthcare providers Primary
Recommendation age 13.5 yrs
Last formal update 484 days ago