Duty of Candour implementation
Identified shortcomings in the practical operation and implementation of duties of candour within healthcare systems.
83 items
1 source
12 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
95match
F178 - Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour
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 include and are consistent with above principles and these recommendations.
Matched on
terms: candour, duty, implementation
Inquiry recommendation
91match
F181 - Enforcement of the duty Statutory duties of candour in relation to harm to patients
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 that patient or other duly authorised person as soon as is practicable of that fact and thereafter to...
Matched on
terms: candour, duty
Inquiry recommendation
90match
IBI-4a(ii) - Duty of Candour - Scotland and Wales Review
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 introduced in 2023 in Wales, the review there need not be immediate, but should be no later than...
Matched on
terms: candour, duty
Inquiry recommendation
87match
R104 - Statutory duty of candour
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 service users and the public. (ii) Where harm has been or may have been caused to a service user by an act or omission of...
Matched on
terms: candour, duty
Inquiry recommendation
87match
IHRD-4 - Trust Awareness of Duty of Candour
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.
Matched on
terms: candour, duty
Inquiry recommendation
87match
IHRD-1 - Statutory Duty of Candour
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 or serious harm has been or may have been caused to a patient by an act or omission...
Matched on
terms: candour, duty
Inquiry recommendation
83match
BRIS-33 - Establish a duty of candour for all NHS staff regarding adverse events
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.
Matched on
terms: candour, duty
Inquiry recommendation
83match
11 - Raise awareness of incident reporting and duty of candour
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 the duty of candour of professional staff, and incorporate into the programme compliance with the refreshed policy. This...
Matched on
terms: candour, duty
Inquiry recommendation
83match
IHRD-5 - Employment Contracts and Duty of Candour
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.
Matched on
terms: candour, duty
Inquiry recommendation
82match
IBI-5a - Civil Service Statutory Duty of Candour
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 occur on the occasions when civil servants and ministers interact with courts, inquests and inquiries, as securing candour.
Matched on
terms: candour, duty
Inquiry recommendation
82match
IBI-4a(iv) - Individual Duty of Candour for Leaders
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 members.
Matched on
terms: candour, duty
Inquiry recommendation
82match
IBI-4a(i) - Duty of Candour - Northern Ireland
Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.
Matched on
terms: candour, duty
Inquiry recommendation
78match
IBI-5c - Ministerial Duty of Candour
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.
Matched on
terms: candour, duty
Inquiry recommendation
78match
IHRD-3 - Guidance on Statutory Duty of Candour
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.
Matched on
terms: candour, duty
Inquiry recommendation
78match
IBI-4a(iii) - Duty of Candour - England Review
Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.
Matched on
terms: candour, duty
Inquiry recommendation
78match
DM-17 - Statutory duty of candour for law enforcement
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.
Matched on
terms: candour, duty
Inquiry recommendation
78match
F173 - Principles of openness transparency and candour
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 and truthful.
Matched on
terms: candour, duty
Inquiry recommendation
74match
IHRD-6 - Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
Matched on
terms: candour, duty
Inquiry recommendation
69match
IHRD-2 - Criminal Liability for Candour Breach
Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Matched on
terms: candour, duty
Inquiry recommendation
66match
F182 - Statutory duty of openness and transparency
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 obligation on the organisation to provide it.
Matched on
terms: duty
Inquiry recommendation
64match
IBI-5b - Monitoring Non-Statutory Duties
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 of advice given to Permanent Secretaries and Ministers, and the candour and completeness of their response to concerns...
Matched on
terms: candour, duty
Inquiry recommendation
64match
IBI-4a(v) - Leadership Accountability for Safety
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 provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done...
Matched on
terms: candour, duty
Inquiry recommendation
62match
F175 - Candour about harm
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).
Matched on
terms: candour
Inquiry recommendation
62match
F174 - Candour about harm
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...
Matched on
terms: candour
Inquiry recommendation
62match
IHRD-7 - Monitoring Candour Compliance
Trusts should monitor compliance and take disciplinary action against breach.
Matched on
terms: candour
Inquiry recommendation
60match
24 - Involve patients and relatives in incident investigation
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 and to receive personal feedback on the results. Action: the Care Quality Commission, NHS England.
Matched on
terms: candour, duty
Inquiry recommendation
57match
F180 - Candour about incidents
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.
Matched on
terms: candour
Inquiry recommendation
53match
F184 - Enforcement by the Care Quality Commission
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 monitoring undertaken by commissioners and others.
Matched on
terms: duty
Inquiry recommendation
53match
CR17 - Protocol for duty to assist referrals
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 vessel of the duty to render assistance, the information to be communicated and how the numbers of referrals...
Matched on
terms: duty
Inquiry recommendation
49match
F183 - Criminal liability
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 information to a patient or nearest relative intending to mislead them about such an incident; Dishonestly to make...
Matched on
classifier match
Inquiry recommendation
45match
F177 - Openness in public statements
Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
Matched on
classifier match
Inquiry recommendation
45match
F176 - Openness with regulators
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.
Matched on
classifier match
Inquiry recommendation
41match
92 - Apologies to former child migrants
The Chair and Panel have recommended that institutions involved in the child migration programmes who have not apologised for their role should give such apologies as soon as possible. Apologies should not only be made through public statements but specifically to those child migrants for whose migration they were responsible.
Matched on
classifier match
Inquiry recommendation
41match
BRIS-34 - Ensure patients receive acknowledgement, explanation, and apology when care goes wrong
When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology.
Matched on
classifier match
Inquiry recommendation
40match
BRIS-117 - Require contractual stipulation for confidential, non-disciplinary reporting of sentinel events.
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.
Matched on
classifier match
Inquiry recommendation
40match
IHRD-37 - Family Involvement in SAI Investigations
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 opportunity to become involved in setting the terms of reference for an investigation. (iii) Families should, if they...
Matched on
classifier match
Inquiry recommendation
40match
IBI-4b - Organisational Culture Change
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 for how the culture operates in their part of the system, and for the way in which it...
Matched on
classifier match
Inquiry recommendation
36match
BRIS-26 - Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
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 and about the likely outcome, to enable them to make a choice about how to proceed.
Matched on
classifier match
Inquiry recommendation
36match
BRIS-24 - Treat patient consent as an ongoing process, not a single signature event
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.
Matched on
classifier match
Inquiry recommendation
36match
14 - Board apologies
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.
Matched on
classifier match
Inquiry recommendation
36match
IHRD-42 - Sharing New Investigation Information
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.
Matched on
classifier match
Inquiry recommendation
36match
1 - Admit problems and apologise to affected families
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 also for the length of time it has taken to bring them to light and the previous failures...
Matched on
classifier match
Inquiry recommendation
36match
BRIS-23 - Endorse and implement DoH consent guide across all NHS healthcare professional practice
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 all trusts.
Matched on
classifier match
Inquiry recommendation
32match
BRIS-115 - Discipline NHS staff who cover up or fail to report sentinel events
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.
Matched on
classifier match
Inquiry recommendation
32match
BRIS-114 - Grant immunity for NHS staff reporting sentinel events within 48 hours
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 themselves have committed a criminal offence.
Matched on
classifier match
Inquiry recommendation
32match
BRIS-113 - Make reporting of sentinel events easy using all communication means
The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Matched on
classifier match
Inquiry recommendation
32match
BRIS-107 - Create open, non-punitive NHS environment for reporting sentinel events
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.
Matched on
classifier match
Inquiry recommendation
32match
BRIS-25 - Extend consent process to all clinical procedures involving touching, focusing on communication
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.
Matched on
classifier match
Inquiry recommendation
32match
R69 - Explanation to relatives on CDI death
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.
Matched on
classifier match
Inquiry recommendation
32match
IHRD-75 - Independent Disciplinary Action
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.
Matched on
classifier match