R69 Response Accepted AI-assessed

Explanation to relatives on CDI death

Recommendation

Health boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
According to the Scottish Government, 1 April 2018, the Scottish Government established a statutory Duty of Candour under the Health (Tobacco Nicotine etc. and Care) (Scotland) Act 2016, with the Duty of Candour Procedure (Scotland) Regulations 2018 requiring organisations to inform families, apologise, and provide explanations for safety incidents, including when CDI contributes to death. According to the Scottish Government Oversight Board, 1 March 2021, the Queen Elizabeth University Hospital (QEUH) Oversight Board found in March 2021 that the Duty of Candour was not formally activated for specific infection instances at QEUH, despite deaths linked to the hospital environment, indicating a gap in practical application.
How was this assessed?
Assessed by gemini-2.5-flash on 19 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.gov.scot, www.legislation.gov.uk, hansard.parliament.uk
This recommendation requires implementation across many organisations. The assessment reflects central policy response, not adoption in individual organisations.
Jurisdiction
Scotland
Response
Accepted
Accepted Scottish Government
18 Jun 2015

Section 4.2 of the Scottish Government's response emphasizes person-centred care, with a key aim to ensure people have sufficient knowledge and understanding of their health care. The "Must Do with Me" elements of person-centred care include ensuring people receive the information they need and personalized contact, with services organized around their needs. This framework supports providing clear explanations to relatives, particularly when a patient dies with CDI.

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Published Evidence

Published assessments of implementation progress from inspectorates, select committees, official progress reports, and other sources. Check the source type badge to see whether each assessment is independent or government self-reported.

limited_progress
01 Mar 2021
Scottish Government Oversight Board Other

QEUH Oversight Board found that Duty of Candour was not formally activated for any of the specific infection instances at QEUH despite deaths of children linked to hospital environment. This directly contradicts Vale of Leven recommendation for clear explanations to families about infection-related deaths.

View detailed findings

The failure to activate Duty of Candour within NHS GGC for infection-related incidents is a significant implementation gap given the Vale of Leven Inquiry's emphasis on family communication.

QEUH/NHS GGC Oversight Board Final Report, March … View Source
Good Progress
01 Apr 2018
Scottish Government Other

Statutory Duty of Candour established under Health (Tobacco Nicotine etc. and Care) (Scotland) Act 2016. Duty of Candour Procedure (Scotland) Regulations 2018 require organisations to inform families about safety incidents, apologise and provide explanations including when CDI contributes to death.

View detailed findings

Non-statutory guidance revised March 2025. However, QEUH failures (2015-2019) showed Duty of Candour was not formally activated for infection incidents within the same health board (NHS GGC) where the Vale of Leven outbreak occurred.

Duty of Candour Procedure (Scotland) Regulations … View Source
Source
Inquiry Vale of Leven Inquiry
Report The Vale of Leven Hospital Inquiry Report 24 Nov 2014
View Source
Responsible Bodies
NHS Health Boards (Scotland) Primary
Themes & Tags
Coroner family information gaps Duty of Candour implementation Bereavement Communication C.difficile
Recommendation age 11.3 yrs
Last formal update 3932 days ago