Duty of Candour implementation
118 items
2 sources
Identified shortcomings in the practical operation and implementation of duties of candour within healthcare systems.
Cross-Source Insight
Duty of Candour implementation has been flagged across 2 independent accountability sources:
81 inquiry recs
37 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (81)
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
BRIS-113 — Make reporting of sentinel events easy using all communication means
Recommendation: The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Unknown
BRIS-114 — Grant immunity for NHS staff reporting sentinel events within 48 hours
Recommendation: Members of staff in the NHS should receive immunity from disciplinary action by the employer or by a professional body if they report a sentinel event to the trust or to the national database within 48 hours, except where they …
Unknown
BRIS-115 — Discipline NHS staff who cover up or fail to report sentinel events
Recommendation: Members of staff in the NHS who cover up or do not report a sentinel event may be subject to disciplinary action by their employer or by their professional body.
Unknown
BRIS-116 — Provide opportunity to report sentinel events in confidence
Recommendation: The opportunity should exist to report a sentinel event in confidence.
Unknown
BRIS-117 — Require contractual stipulation for confidential, non-disciplinary reporting of sentinel events.
Recommendation: There should be a stipulation in every healthcare professional’s contract that sentinel events must be reported, that reporting can be confidential, and that reporting within a specified time period will not attract disciplinary action.
Unknown
BRIS-118 — Integrate sentinel event reporting into all NHS trust staff training and communications.
Recommendation: The process of reporting of sentinel events should be integrated into every trust’s internal communications, induction training and other staff training. Staff must know what is expected of them, to whom to report and what systems are in place to …
Unknown
BRIS-119 — Abolish clinical negligence system, establish expert group for alternative patient compensation.
Recommendation: In order to remove the disincentive to open reporting and the discussion of sentinel events represented by the clinical negligence system, this system should be abolished. It should be replaced by an alternative system for compensating those patients who suffer …
Unknown
BRIS-191 — Require healthcare professionals to be honest with parents about child's condition
Recommendation: Healthcare professionals should be honest and truthful with parents in discussing their child’s condition, possible treatment and the possible outcome.
Unknown
BRIS-23 — Endorse and implement DoH consent guide across all NHS healthcare professional practice
Recommendation: We note and endorse the recent statement on consent produced by the DoH: ‘Reference guide to consent for examination or treatment’, 2001. It should inform the practice of all healthcare professionals in the NHS and be introduced into practice in …
Unknown
BRIS-24 — Treat patient consent as an ongoing process, not a single signature event
Recommendation: The process of informing the patient, and obtaining consent to a course of treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient’s signature on a form.
Unknown
BRIS-25 — Extend consent process to all clinical procedures involving touching, focusing on communication
Recommendation: The process of consent should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication.
Unknown
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
BRIS-33 — Establish a duty of candour for all NHS staff regarding adverse events
Recommendation: A duty of candour, meaning a duty to tell a patient if adverse events2 have occurred, must be recognised as owed by all those working in the NHS to patients.
Unknown
BRIS-34 — Ensure patients receive acknowledgement, explanation, and apology when care goes wrong
Recommendation: When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology.
Unknown
BRIS-4 — Provide treatment and care information in varied forms, stages, and reinforced
Recommendation: Information about treatment and care should be given in a variety of forms, be given in stages and be reinforced over time.
Unknown
BRIS-5 — Tailor patient information to individual needs, circumstances, and wishes
Recommendation: Information should be tailored to the needs, circumstances and wishes of the individual.
Unknown
CR17 — Protocol for duty to assist referrals
Recommendation: HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold for making a referral on a potential breach by a …
Response Pending
DM-17 — Statutory duty of candour for law enforcement
Recommendation: The Panel recommends the creation of a statutory duty of candour, to be owed by all law enforcement agencies to those whom they serve, subject to protection of national security and relevant data protection legislation.
Gov response: The Panel agreed with other independent inquiries, such as Bishop James Jones' report on the experiences of the Hillsborough families, about the need for a duty of candour for public services, including the police. The …
Accepted in Part
No update 2+ yrs
14 — Board apologies
Recommendation: We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Gov response: Accepted. Duty of Candour regulations require healthcare providers to be open when things go wrong. NHS Resolution promotes early apology and has clarified that sincere apologies do not constitute admission of liability. Professional Standards Authority …
Accepted
No update 2+ yrs
7 — UHB patient recall
Recommendation: We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen.
Gov response: Accepted and implemented. University Hospitals Birmingham has undertaken extensive patient recall programmes. Over 12,000 patients were recalled for review. Ongoing support is provided to affected patients. Trust has confirmed all identifiable patients have been contacted …
Accepted
Delivered
8 — Spire patient recall
Recommendation: We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in …
Gov response: Accepted and implemented. Spire Healthcare has undertaken comprehensive patient recall. All identifiable former patients of Paterson have been contacted and offered clinical review. Spire has provided ongoing treatment plans and support to affected patients, consistent …
Accepted
Delivered
IBI-4a(i) — Duty of Candour - Northern Ireland
Recommendation: Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.
Gov response: The Northern Ireland Executive committed to proposing an organisational duty of candour, considering consultation findings and broader Hillsborough Law developments.
Accepted
In progress
IBI-4a(ii) — Duty of Candour - Scotland and Wales Review
Recommendation: Duty of candour: The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it is being in England, to assess how effective its operation has been in practice. Since the duty was …
Gov response: Scottish Government The organisational duty of candour provisions of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 and the Duty of Candour Procedure (Scotland) Regulations 2018 set out the procedure that organisations providing …
Accepted
In progress
IBI-4a(iii) — Duty of Candour - England Review
Recommendation: Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.
Gov response: A November 2024 call-for-evidence found inconsistent application of the duty. Government is preparing consultation response with final review report to follow manager regulation consultation conclusions.
Accepted
In progress
IBI-4a(iv) — Individual Duty of Candour for Leaders
Recommendation: Statutory duty of candour: The statutory duties of candour in England, Scotland, Wales (and Northern Ireland, when introduced) should be extended to cover those individuals in leadership positions in the National Health Service, in particular in executive positions and board …
Gov response: UK Government consultation (November 2024 - February 2025) sought views on whether a professional duty of candour should apply to NHS leaders. Response being prepared considering broader manager regulation proposals.
Accepted in Part
In progress
IBI-4a(v) — Leadership Accountability for Safety
Recommendation: Statutory duty of candour: Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being …
Gov response: Government acknowledges the importance of this principle but notes implementation complexity and potential employment law implications. Exploring whether professional standards and manager regulation could achieve accountability without unintended consequences.
Accepted in Part
In progress
IBI-4b — Organisational Culture Change
Recommendation: Cultural Change: That a culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns about patient safety be addressed both by taking the steps set out in (a) above, and also by making leaders accountable …
Gov response: Scotland established an Independent National Whistleblowing Office and introduced Non-Executive Whistleblowing Champions in all Health Boards. Wales enacted the 2020 Act. Northern Ireland is implementing a Being Open Framework.
Accepted in Part
In progress
IBI-5a — Civil Service Statutory Duty of Candour
Recommendation: The Government should reconsider whether, in the light of the facts revealed by this Inquiry, it is sufficient to continue to rely on the current non-statutory duties in the Civil Service and Ministerial Codes, coupled with those legal duties which …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
In progress
IBI-5b — Monitoring Non-Statutory Duties
Recommendation: If, on review, the Government considers that it is sufficient to rely on the current non-statutory duties in the Civil Service Code, it should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
In progress
IBI-5c — Ministerial Duty of Candour
Recommendation: The Government should consider the extent to which Ministers should be subject to a duty beyond their current duty to Parliament under the Ministerial Code.
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
In progress
IHRD-1 — Statutory Duty of Candour
Recommendation: A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public. (ii) Where death …
Gov response: The Department of Health is taking forward legislation for a statutory duty of candour. Public consultation was held in 2020-2021. Legislation is being prepared as part of broader healthcare reforms.
Accepted
No update 2+ yrs
IHRD-2 — Criminal Liability for Candour Breach
Recommendation: Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Gov response: Under review as part of wider duty of candour and accountability framework development.
Accepted in Part
No update 2+ yrs
IHRD-3 — Guidance on Statutory Duty of Candour
Recommendation: Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.
Gov response: Being considered alongside duty of candour legislation development.
Accepted in Part
No update 2+ yrs
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes. Patient Advocacy Service being developed.
Accepted
No update 2+ yrs
IHRD-4 — Trust Awareness of Duty of Candour
Recommendation: Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of healthcare.
Gov response: Reviewed in context of workforce planning. Some concerns raised by Royal Colleges about potential de-skilling impacts. Implementation being balanced against training needs.
Accepted in Part
No update 2+ yrs
IHRD-41 — Publication of External Investigation Reports
Recommendation: Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.
Gov response: Publication policies for external investigation reports implemented.
Accepted
No update 2+ yrs
IHRD-42 — Sharing New Investigation Information
Recommendation: In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
Gov response: Procedures established for sharing new information with families after investigation completion.
Accepted
Delivered
IHRD-5 — Employment Contracts and Duty of Candour
Recommendation: Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
Gov response: Trusts reviewing employment contracts and policies for consistency with duty of candour requirements.
Accepted
No update 2+ yrs
IHRD-6 — Support for Candour Compliance
Recommendation: Support and protection should be given to those who properly fulfil their duty of candour.
Gov response: Support mechanisms established for staff raising concerns. Being Open Framework includes protections.
Accepted
Delivered
IHRD-69 — Executive Director Responsibilities
Recommendation: Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.
Gov response: Executive Director responsibilities assigned for candour, child healthcare and SAI learning.
Accepted
Delivered
IHRD-7 — Monitoring Candour Compliance
Recommendation: Trusts should monitor compliance and take disciplinary action against breach.
Gov response: Compliance monitoring mechanisms being developed as part of duty of candour framework.
Accepted
No update 2+ yrs
IHRD-72 — Candour in Trust Communications
Recommendation: All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.
Gov response: Non-executive Director oversight of Trust communications implemented.
Accepted
No update 2+ yrs
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Gov response: Trust disciplinary procedures updated to address professional code breaches independently.
Accepted
Delivered
IHRD-86 — Expand RQIA Remit and Resources
Recommendation: The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity to investigate and review individual cases or groups of cases, …
Gov response: RQIA remit and resources under review. Some expanded oversight implemented.
Accepted
No update 2+ yrs
IHRD-94 — Clinical Negligence Litigation Reform
Recommendation: The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical negligence litigation as it presently operates might be abolished or …
Gov response: Under consideration. No government committee established to date to examine clinical negligence litigation reform.
Accepted in Part
No update 2+ yrs
IHRD-95 — Legal Privilege Protocol
Recommendation: Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing how and when legal privilege entitlement might properly be asserted by Trusts.
Gov response: Protocol development for legal privilege assertions by Trusts progressing.
Accepted
No update 2+ yrs
IHRD-96 — Healthcare Litigation Standards
Recommendation: The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and legal advisors in this connection should be audited.
Gov response: Standards for healthcare litigation management under development.
Accepted
No update 2+ yrs
L15 — Power to Direct Remedies
Recommendation: In relation to complaints, the Board should have the power to direct appropriate remedial action for breach of standards and the publication of corrections and apologies. Although remedies are essentially about correcting the record for individuals, the power to require …
Gov response: The Prime Minister stated on 29 November 2012 that he accepted "the principles that Lord Justice Leveson has laid out" for independent self-regulation, including "an independent board, a standards code, an arbitration service and the …
Accepted in Part
F109 — Effective complaints handling
Recommendation: Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally …
Gov response: 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" …
Accepted
F110 — Lowering barriers
Recommendation: Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential litigation to agree to a stay of proceedings pending the …
Gov response: 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" …
Accepted
F111 — Lowering barriers
Recommendation: Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the …
Gov response: 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" …
Accepted
F112 — Lowering barriers
Recommendation: Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as a formal complaint, whether or not the informant has indicated …
Gov response: 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" …
Accepted
F173 — Principles of openness transparency and candour
Recommendation: Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open …
Gov response: 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" …
Accepted
F174 — 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 …
Gov response: 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" …
Accepted
F175 — Candour about harm
Recommendation: Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative).
Gov response: 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" …
Accepted
F176 — Openness with regulators
Recommendation: Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.
Gov response: 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" …
Accepted
F177 — Openness in public statements
Recommendation: Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
Gov response: 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" …
Accepted
F178 — Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and …
Recommendation: The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly …
Gov response: 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" …
Accepted in Part
F179 — Restrictive contractual clauses
Recommendation: "Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient …
Gov response: 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" …
Accepted
F180 — Candour about incidents
Recommendation: Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.
Gov response: 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" …
Accepted
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform …
Gov response: 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" …
Accepted in Part
F182 — Statutory duty of openness and transparency
Recommendation: There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory …
Gov response: 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" …
Accepted
F183 — Criminal liability
Recommendation: It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct another in the performance of these statutory duties; To provide …
Gov response: 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" …
Not Accepted
F184 — Enforcement by the Care Quality Commission
Recommendation: Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by …
Gov response: 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" …
Accepted
F21 — Responsibility for regulating and monitoring compliance
Recommendation: The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. The regulator must be willing to consider individual cases of …
Gov response: 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" …
Accepted in Part
F26 — Responsibility for regulating and monitoring compliance
Recommendation: In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake …
Gov response: 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" …
Accepted
F27 — Responsibility for regulating and monitoring compliance
Recommendation: The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, unless there is evidence showing that suspicions are ill-founded or …
Gov response: 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" …
Accepted
F273 — Information to coroners
Recommendation: The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified …
Gov response: 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" …
Accepted in Part
F274 — Information to coroners
Recommendation: There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness over any perceived …
Gov response: 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" …
Accepted
F28 — Sanctions and interventions for non-compliance
Recommendation: Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals are …
Gov response: 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" …
Accepted
F280 — Appropriate and sensitive contact with bereaved families
Recommendation: Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may …
Gov response: 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" …
Accepted
F281 — Appropriate and sensitive contact with bereaved families
Recommendation: It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner least likely to cause additional and unnecessary distress.
Gov response: 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" …
Accepted
F29 — Sanctions and interventions for non-compliance
Recommendation: It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has …
Gov response: 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" …
Accepted
F290 — Experience on the front line
Recommendation: The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level …
Gov response: 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" …
Accepted
F37 — Use of information about compliance by regulator from: Quality accounts
Recommendation: Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to …
Gov response: 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" …
Accepted
F5 — Clarity of values and principles
Recommendation: In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; They will do everything in their power to protect patients from avoidable harm; They will be honest and …
Gov response: 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" …
Accepted
1 — Admit problems and apologise to affected families
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
11 — Raise awareness of incident reporting and duty of candour
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
24 — Involve patients and relatives in incident investigation
Recommendation: We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking …
Gov response: 37. We accept this recommendation. A duty of candour has been introduced. 38. A lack of openness and honesty at Morecambe Bay was a fundamental cause of both the distress of the families, and of …
Accepted
R69 — 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.
Gov response: 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 …
Accepted
PFD Reports (37)
Lee Eustace
Concerns: An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information to the Coroner.
Response: The Trust has implemented a new jejunostomy feeding protocol and, following a review, sent a Duty of Candour letter to the family. They have also improved their learning from deaths …
Responded
Amber Walker
Concerns: Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Response: The Department of Health and Social Care noted the concerns, referencing existing NICE guidance on epilepsies and the Clive Treacey Checklist for systematic SUDEP risk assessment. It also explained that …
Responded
William King
Concerns: Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a risk of recurrence.
Response: The Royal College of Surgeons of England plans to update its guidance on consent, develop a practical toolkit and a short set of principles on shared decision-making by Spring 2026, …
Response: The Association of Anaesthetists and Royal College of Anaesthetists are shortly publishing a Good Practice guide on Rapid Sequence Induction (RSI) that addresses NG tube considerations, and will update their …
Response: The Trust accepts failures in explaining risks and documenting discussions, and plans to introduce a new electronic form in the New Year. This form will act as an aide-memoire for …
Responded
Mabel Williams
Concerns: The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow and reactive.
Overdue
Darren Turner
Concerns: Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.
Responded
Cynthia Gilbert
Concerns: Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and the efficacy of post-death investigations.
Responded
Denise Johnson
Concerns: The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
Responded
Janet Seddon
Concerns: A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.
Responded
Sophie Dean
Concerns: Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
Responded
Olayemi Kehinde
Concerns: Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into the incident.
Responded
Benjamin Leonard
Concerns: The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.
Responded
Sarah Chappell
Concerns: Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Responded
Samantha Shillito
Concerns: A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.
Responded
Robert Murray
Concerns: There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order should not be applied.
Responded
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
Concerns: There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Responded
Susan Roberts
Concerns: There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.
Responded
Peter Cole
Concerns: Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Responded
John Long
Concerns: Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.
Overdue
Agnes Sansom
Concerns: Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
Responded
Ifeoma Onwuka
Concerns: An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.
Overdue
Andrew Wells
Concerns: The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.
Overdue
Emma Langley
Concerns: The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.
Responded
Elisa Fuller
Concerns: Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.
Responded
David Smith
Concerns: Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.
Responded
Emmett Gillah
Concerns: Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. Staff were also unaware of KMPT's discharge policies.
Overdue
Rose Ball
Concerns: A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the doctor's fitness to practice and highlighting wider public safety implications of such practices.
Overdue
David Lindsey
Concerns: The Trust failed to adhere to both NICE guidelines and its own internal policies concerning cancer screening, referrals, diagnosis, and treatment.
Overdue
Patricia Forshaw
Concerns: The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Responded
Francesca Whyatt
Concerns: Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.
Overdue
Helen Cannon
Concerns: Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.
Overdue
Geraldine Butterfield
Concerns: Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.
Overdue
Sally Froggatt
Concerns: There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.
Overdue
Jack Susianta
Concerns: Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Overdue
Frank Mellers
Concerns: There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to attempted resuscitation despite a DNAR order. Policies for DNAR issuance and communication require urgent review.
Responded
Hilda Haughton
Concerns: Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of increased fire-door closing times in hospitals.
Responded
James Withers
Concerns: Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.
Overdue